Interdisciplinary Quality Improvement Research Articles

Optimizing Utilization of SGLT2 Inhibitors in Patients With Type 2 Diabetes Mellitus and Chronic Kidney Disease in a VA Primary Care Clinic: An Interdisciplinary Quality Improvement Project.

Optimizing Utilization of SGLT2 Inhibitors in Patients With Type 2 Diabetes Mellitus and Chronic Kidney Disease in a VA Primary Care Clinic: An Interdisciplinary Quality Improvement Project.

Reducing NICU Unplanned Extubations From Tube Dislodgement.

Unplanned extubations (UEs) can be a frequent problem and are associated with adverse outcomes. This quality improvement initiative sought to reduce UEs from tube dislodgement in a level IV NICU utilizing methods applicable to other ICUs and performed with minimal monetary funds. From January 2019 to July 2023, an interdisciplinary quality improvement team used the Model for Improvement and performed sequential interventions to improve the outcome measure of UEs per 100 ventilator days. Process measures included adherence to a modified, site-specific UE care bundle derived from the Solutions for Patient Safety network, whereas the number of endotracheal tube-related pressure injuries was used as a balancing measure. Statistical process control charts and established rules for special cause variation were applied to analyze data. Sequential interventions reduced the rate of UEs from a baseline of 2.3 to 0.6 UEs per 100 ventilator days. Greater than 90% adherence with the UE care bundle and apparent cause analysis form completion occurred since December 2020. There were no endotracheal tube-related pressure injuries. A sustained reduction in UEs was demonstrated. Leveraging a multidisciplinary team allowed for continuous UE analysis, which promoted tailored consecutive interventions. UE care bundle audits and the creation of a postevent debrief guide, which helped providers share a common language, were the most impactful interventions. Next steps include disseminating these interventions to other ICUs across our hospital enterprise. These low-cost interventions can be scalable to other NICUs and PICUs.

Impact of Implementing Serious Illness Conversations Across a Comprehensive Cancer Center Using an Interdisciplinary Approach.

Gaps in communication of end-of-life care preferences increase risk of patient harm. Adoption of oncology practice guidelines advocating serious illness communication for patients with advanced cancer is limited. (1) Increase Serious Illness Conversation (SIC) use across oncology teams via an interdisciplinary quality improvement (QI) approach and (2) assess patient reported shared decision making (SDM) experiences with clinicians engaged in SIC implementation. QI methodology was applied to spread the implementation of SIC across 4 oncology teams. CollaboRATE scores were used to evaluate patient reported outcomes of SDM for patients with advanced cancer. The SIC QI initiative was a component of the Promise Partnership Learning Health System (PPLHS) piloted in the Dartmouth Cancer Center, Lebanon, NH, USA. (1) The percentage of eligible patients with documented SIC and (2) a comparison of a patient reported measure of SDM (CollaboRATE) among SIC eligible patients in encounters with providers who took part in the implementation versus those who did not. Oncology teams screened a total of 538 patients, identified 278 eligible patients, and completed 144 SIC conversations. The teams improved the proportion of documented SIC among eligible patients from near 0% to a collective frequency of 52%. For clinicians' top-box CollaboRATE scores, a chi-squared test demonstrated a statistically significant association between providers implementing SIC into practice and patient reported shared decision making (.16, p = .031). This approach allows for tailoring of iterative improvement cycles to mitigate barriers and improve the practice of SIC among oncology teams.

Synergizing Safety: A Customized Approach to Curtailing Unplanned Extubations through Shared Decision-making in the NICU.

Unplanned Extubation (UE) remains an important patient safety issue in the Neonatal Intensive Care Unit. Our SMART AIM was to decrease the rate of UE by 10% from the baseline from January to December 2022 by emphasizing collaboration among healthcare professionals and through the use of shared decision-making. We established an interdisciplinary Quality Improvement team composed of nurses, respiratory therapists, and physicians (MDs). The definition of UE was standardized. UE was audited using an apparent cause analysis form to discern associated causes and pinpoint areas for improvement. Interventions were implemented in a step-by-step fashion and reviewed monthly using the model for improvement. A shared decision-making approach fostered collaborative problem-solving. Our baseline UE rate was 2.3 per 100 ventilator days. Retaping, general bedside care, and position change accounted for over 50% of the UE events in 2022. The rate of UE was reduced by 48% by the end of December 2022. We achieved special-cause variation by the end of March 2023. The sole education of medical and nursing providers about various approaches to decreasing unnecessary retaping was ineffective in reducing UE rates. Shared decision-making incorporating inputs from nurses, respiratory therapists, and MDs led to a substantial reduction in the UE rate and underscores the potential of systematic evaluation of risk factors combined with collaborative best practices.

Implementation of a Patient-Reported Outcome Measure: A Quality Improvement Project.

Patient-reported outcome measures (PROMs) are seen as increasingly beneficial to patient-centered clinical practice, but implementation of routine collection and utilization into clinical care can be challenging. Our interdisciplinary quality improvement (QI) team used the Institute for Health Care Improvement Model for Improvement methodology to address this problem in our outpatient neurorehabilitation program. We used a participatory approach to identify the PROM rehabilitation stakeholders found to be most appropriate to implement in the outpatient settings; chart audits were conducted to determine the extent to which clinicians implemented the PROM and documented a PROM-related goal. Opportunistic clinician feedback was collected to determine single PROM usefulness and acceptability. Our 4-month initiative demonstrated increased collection of a PROM, the Patient-Specific Functional Scale (PSFS), and incorporation into patient-centered goal. Use of QI methodology was beneficial when planning and executing our initiative. Future work is needed to examine factors to sustain PSFS use, incorporation into patient-centered goal setting, and maximize meaningful patient outcomes.

Improving Employee Safety Through a Comprehensive Patient Behavioral Program.

Health care workers in the United States are facing increasing rates of exposure to aggressive behavior, resulting in an increase in employee injuries related specifically to patient behavioral events. By leveraging interprofessional collaboration and system-level innovation, we aimed to reduce the rate of employee injuries related to patient behavioral events at a children's hospital by 50% over a 3-year period. An interdisciplinary quality improvement team comprising physicians, behavior analysts, nursing, and other key stakeholders developed a comprehensive behavior program in our children's hospital. The team developed 5 key pillars: aggression mitigation tools, clinical resources, advanced training, screening and management, and behavior emergency response. The outcome measure was rate of reported employee safety events related to patient behavioral events. This was tracked via prospective time series analysis statistical process control chart using established rules to detect special cause variation. The average rate of employee injuries resulting from patient behavioral events decreased from 0.96 to 0.39 per 1000 adjusted patient-days, with special cause variation observed on a statistical process control U-chart. This improvement has been sustained for 16 months. Staff members who experienced injuries included nurses and patient technicians, with common antecedents to injuries including medical interventions or patient requests that could not be safely met. A unified and multimodal system aimed to address pediatric patient behavioral events can reduce employee injuries and foster a culture of employee safety in the pediatric inpatient setting.

Improving Adolescent Psychosocial Assessment through Standardized Patient Simulation: An Interdisciplinary Quality Improvement Initiative.

Adolescent suicide and mental illness have increased at alarming rates. Healthcare professionals report a lack of skill and confidence in obtaining adolescent histories and managing confidential care due to limited training in residency. Nursing professional development practitioners face challenges of adequately preparing interdisciplinary healthcare providers to assess, identify, and intervene at all points of contact with adolescents. To increase the confidence in clinical communication skills and clinical competency, and to increase the number of social work referrals related to modifiable risk factors for adolescent patients, a Texas pediatric tertiary care center utilized standardized patient (SP) methodology to supplement traditional clinical experiences with communication-focused education based on the Home, Education, Eating, Activities, Drugs, Sexuality, Suicidality, and Safety (HEEADSSS) interviewing. This quality improvement (QI) pilot demonstrated the benefits of utilizing standardized patient methodology in communication-focused education based on the HEEADSSS interviewing. Following the SP simulations, confidence in clinical communication skills increased by 13%, clinical competency in performing comprehensive psychosocial interviews increased by 11%, use of HEEADSSS increased by 64%, and social work referrals increased by 89%. This interdisciplinary SP interviewing simulation pilot was beneficial in improving the 36 physician and nursing residents' ability to conduct psychosocial assessments for risk factors of suicidality among adolescents.

GJ Express: an improvement initiative to decrease sedation and anesthesia for gastrojejunostomy tube exchanges.

Overuse of sedation and anesthesia causes delays in gastrojejunostomy tube (GJ) exchanges, increased risk of complications, unnecessary use of resources, preventable hospital admissions, and an adverse impact on patient and family experience. Our hospital was over-utilizing sedation and anesthesia, and we aimed to decrease this use from 78% to 20% within two years. An interdisciplinary quality improvement team comprehensively evaluated current processes for GJ tube exchanges through a retrospective chart review for baseline data with prospective time series analysis after improvement implementation. The primary outcome measure was the percentage of pediatric patients that utilized sedation or anesthesia for routine GJ tube exchanges. A statistical process control p-chart was used to calculate and show changes over time for patients (n = 45 patients average). The median percent of pediatric GJ tube exchanges performed with sedation or anesthesia decreased from 77.8% to 11.3%. Most patients (76%) were covered by Medicaid programs; with low reimbursement rates, decreased anesthesiologist billing revenue does not have a negative financial impact. An interprofessional improvement initiative that engaged patients and families, incorporated pediatric-specific staff services, and developed systematic weaning was associated with a significant decrease in the overuse of sedation and anesthesia for GJ tube exchanges. We believe that this work is highly relevant and impactful for medical centers caring for children who require gastrojejunostomy tubes, an increasingly common approach to management of children with feeding issues. There is very little literature available on the use of sedation or anesthesia for changing these tubes. While large children's medical centers in the USA usually do not utilize sedation or anesthesia, there are likely many serious outliers, especially when children receive care outside of a pediatric specific institution. This paper brings awareness to this serious issue and provides information about how we changed care to achieve higher patient safety and lower medical costs.

Metabolic bone disease of prematurity screening and individualized enteral mineral supplementation in high-risk neonates: a quality improvement initiative.

Prompted by an alarmingly low screening rate for metabolic bone disease of prematurity (MBDP), we aimed to increase MBDP screening with serum calcium, phosphorous, and alkaline phosphatase at four to six weeks of life in infants born at <1500 g and <32 gestational weeks from a baseline of 27.37% to 90% within one year. We used the Institute for Healthcare Improvement's Model for Improvement as a framework. A key driver diagram informed the interventions which were carried out through four Plan-Do-Study-Act cycles. There were 129 and 130 neonates in the pre-intervention baseline group and post-intervention MBDP bundle group, respectively. MBDP bundled primary screening rates increased from 27.37% to 95.56% (p < 0.001). Furthermore, 20% of infants had an individualized change in their enteral mineral supplementation after the initiative. An interdisciplinary team-based quality improvement approach was effective in altering clinical practice to improve screening and subsequent treatment for MBDP.

Patient perception of service quality to preanesthetic oral examination: a cross-sectional study using the SERVQUAL model.

A phase-III interdisciplinary quality improvement program, the preanesthetic oral examination (PAOE), was implemented as a new program in an academic medical center to prevent perioperative dental injuries. This study was aimed at surveying the perceived service quality and satisfaction of patients who had undergone PAOE based on the SERVQUAL model. This cross-sectional survey was conducted at the Kaohsiung Medical University Hospital using convenience sampling. Patients referred for PAOE (PAOE group) and those who had voluntarily availed dental services (control group) were recruited. A modified SERVQUAL questionnaire was used to assess the perceived service quality and patient satisfaction with dental services. Cronbach's alpha for SERVQUAL was 0.861. We enrolled 286 (68.8%) and 130 (31.2%) participants in the PAOE and control groups, respectively. The path analysis revealed that the PAOE group scored lower in dimensions of reliability (β = -0.074, P = 0.003), responsiveness (β = -0.148, P = 0.006), and empathy (β = -0.140, P = 0.011). Furthermore, reliability (β = 0.655, P < 0.001) and responsiveness (β = 0.147, P = 0.008) showed a direct effect on patient satisfaction. Overall, participants were highly satisfied with the dental services. The PAOE group showed lower satisfaction and perceived quality of dental services compared to the control group. Although implementing an interdisciplinary program reduces the perceived service quality, its influence is limited. Employing an interdisciplinary teamwork is a win-win strategy encouraged to improve patient safety and reduce malpractice claims. Future suggestions should focus on establishing waiting times that are considered reasonable by patients. Patient-centered education related to the risk of perioperative dental injuries should be provided, and awareness of oral conditions for patient safety should be improved. Moreover, interprofessional education in continuous and undergraduate programs is necessary to improve professional quality.

Nurses' and Physicians' Experiences After Implementation of a Quality Improvement Project to Improve Sepsis Awareness in Hospitals.

Previous research has explored nurses´ experience with the implementation of early detection alert systems, and nurses and physicians' perceptions of sepsis management and use of sepsis triage. As one of the first, this study aims to investigate the perceived usefulness of an interdisciplinary quality improvement project including standardized sepsis patient pathway to improve the early identification and treatment of sepsis patients. This study was a qualitative study that employed semi-structured interviews with thirteen ward nurses and five ward physicians recruited by convenience and respondent-driven sampling, respectively. The interviews explored the perceived usefulness of mutual training in sepsis care in medical hospital wards. We applied Systematic Text Condensation to analyze the experiences and knowledge of professional identification and cooperation in early identification of sepsis patients. The results revealed three main themes: Awareness of sepsis, collaboration between nurses and physicians, and clinical assessment and judgement. The findings highlighted the positive impact of the project in terms of raising awareness, improving communication, and enhancing the ability to detect and treat sepsis. The study also identified the importance of repetition and reminders to maintain awareness, the need for ongoing training for new healthcare professionals, and the challenges of collaboration and decision-making processes. The sepsis intervention seemed successful in improving awareness of sepsis and enhancing interprofessional collaboration between nurses and physicians. Health professionals continued to rely on their clinical judgment but increased the use of objective measurements and communication of vital signs. Continuous repetition and education for new colleagues were identified as important factors for the sustainability of the intervention. Overall, the study highlights the importance of standardized protocols and training for early detection and management of sepsis in healthcare settings.

Interventions to Reduce Inappropriate Physical Therapy Consultation in the Inpatient Setting: A Quality Improvement Initiative.

Physical therapy (PT) in inpatient settings is a limited and valuable resource. Inappropriate PT consultation is costly and can lead to delays in care and discharge planning. Baseline data at an academic hospital revealed that approximately one in four PT consults were inappropriate (n = 29,230) across all services, as defined by an activity measure post-acute care "6-Clicks" basic mobility score of >22. Our interdisciplinary quality improvement team used the Six Sigma methodology to address this problem. We performed a root-cause analysis that identified high-impact root causes and implemented two targeted interventions: (1) A modified electronic health record PT order with clinical-decision support, and (2) nursing role change to assume PT-ordering responsibility. The rate of inappropriate PT consults decreased from 23.9% to <10% postintervention across all inpatient units, with the nursing role change reaching statistical significance (p < .0019). Our multifaceted intervention contributed to a significant reduction in unnecessary PT consults, expediting evaluation of patients qualifying for skilled inpatient therapy.

Improving Handoffs After Osteoporotic Fractures

Osteoporotic fractures among long-term care residents have substantial economic and human costs. After a fracture, many older adults do not receive an osteoporosis diagnosis or evidence-based treatment, which leads to increased risk of recurrent fractures. Optimal processes are well defined for transitioning medical care after a hip or vertebral fracture for osteoporosis evaluation, but the handoff process from the specialist back to a primary care practitioner (PCP) or to a rehabilitative setting is not well defined. Our interdisciplinary quality improvement team developed and evaluated a program for transitioning care from a hospital-based fracture liaison clinic (FLC) to PCPs caring for older adults across the care continuum. To understand the current process of postfracture care transitions, we analyzed the postfracture patient experience. We surveyed PCPs to assess barriers to osteoporosis treatment, and retrospectively conducted a baseline analysis of 87 patients who had sustained an osteoporotic fracture in 2020. This preliminary work showed several opportunities for practice improvement and helped us develop a practical multicomponent intervention aimed at improving care transitions from the FLC to PCPs. The intervention (June-September 2021) comprised a standardized documentation template in the electronic health record (EHR) for FLC clinicians, a structured handoff process, and an engagement tool for patients outlining the roles and responsibilities of each care team member. We compared care transition measures before and after intervention. EHR documentation of an osteoporosis diagnosis increased from 56% (49 of 87 patients) before intervention to 92% (48 of 52) after intervention (P < .001). Additionally, increases were observed in documentation of treatment recommendations, associated risk factors, and PCP discussions with patients regarding osteoporosis and related treatment. This practical, commonsense intervention established clear roles for each care team member. The intervention addressed systemwide barriers in facilitating a safe transition from a subspecialty care team to PCPs providing care to older adults with osteoporosis.

Improving Neurology Inpatient Fall Rate: Effect of a Collaborative Interdisciplinary Quality Improvement Initiative

ObjectiveTo reduce unwitnessed inpatient falls on the neurology services floor at an academic medical center by 20% over 15 months. Patients and MethodsA 9-item preintervention survey was administered to neurology nurses, resident physicians, and support staff. Based on survey data, interventions targeting fall prevention were implemented. Providers were educated during monthly in-person training sessions regarding the use of patient bed/chair alarms. Safety checklists were posted inside each patient’s room reminding staff to ensure that bed/chair alarms were on, call lights and personal items were within reach, and patients’ restroom needs were addressed. Preimplementation (January 1, 2020, to March 31, 2021) and postimplementation (April 1, 2021, to June 31, 2022) rates of falls in the neurology inpatient unit were recorded. Adult patients hospitalized in 4 other medical inpatient units not receiving the intervention served as a control group. ResultsRates of falls, unwitnessed falls, and falls with injury all decreased after intervention in the neurology unit, with rates of unwitnessed falls decreasing by 44% (2.74 unwitnessed falls per 1000 patient-days before intervention to 1.53 unwitnessed falls per 1000 patient-days after intervention; P=.04). Preintervention survey data revealed a need for education and reminders on inpatient fall prevention best practices given a lack of knowledge on how to operate fall prevention devices, driving the implemented intervention. All staff reported significant improvement in operating patient bed/chair alarms after intervention (P<.001). ConclusionA collaborative, multidisciplinary approach focusing on provider fall prevention education and staff checklists is a potential technique to reduce neurology inpatient fall rates.

Defining and implementing meaningful advance care planning.

e18708 Background: Advance Care Plans (ACP) capture a patient’s preferences for care before the patient becomes unable to make their own decisions. Our center (SKCC) participates in external quality programs, including the ASCO Oncology Medical Home model and CMS’ Oncology Care Model, that require ACP among cancer patients. Evidence from other centers suggest ACP, as defined by these external programs, do not impact patient outcomes. In an effort to increase the rate of “meaningful” ACP our interdisciplinary team completed an iterative quality improvement (QI) project to define an internal, more rigorous standard of ACP. Methods: Clinicians at SKCC developed a standardized Personalized Care Discussion (PCD) appointment conversation template to guide meaningful, goals-based care discussions with cancer patients. Our project assessed the rate at which different patients completed a scheduled PCD appointment between 6/2/2021 and 7/1/2022. The objectives of our QI project were to: identify a sub-population of cancer patients with the highest expected value from PCD; and define an evidence-based metric to hold care teams accountable for completing PCD. Our interdisciplinary QI project team monitored and evaluated 5 cycles of plan-do-study-act (PDSA) over the course of 1 year to meet the project objectives. Each PDSA included either an adjustment to the patient population or an adjustment to the workflow. The key performance indicator in each PDSA was the % of patients with a scheduled PCD appointment who completed the appointment. Results: Of the all the PDSA cycles, the ones with the highest completion rate of a scheduled PCD appointment were cycles in which: the patient’s oncologist introduced the patient to PCD (as opposed to automated scheduling); and the patient was introduced to PCD early on in their care at SKCC. Conclusions: The results of this project led us to develop an internal quality metric that requires oncology providers (OP) facilitate PCD with all new cancer patients within 9 months of the new patient visit. This metric exceeds expectations of external programs by requiring OPs complete goals-based ACP with patients and introducing ACP as a universal standard of cancer care for all new patients. Operational support for OPs is critical for success in this initiative. Patient education that manages sensitivities and stigma about ACP enhances successful OP-patient collaboration. SKCC continues to monitor the impact of this metric on patient outcomes. [Table: see text]

Effect of Single-Unit Transfusion Guideline on Red Blood Cell Transfusion for Obstetric Patients [ID: 1375663

INTRODUCTION: The American Red Cross recently declared a national blood crisis. We aimed to evaluate the effect of a single-unit transfusion guideline on the transfusion rate. METHODS: An interdisciplinary quality improvement initiative to reduce blood transfusion for postpartum hemorrhage (PPH) was conducted in a tertiary obstetric hospital with approximately 5,000 births annually. Opportunities for improvement were prioritized including antepartum anemia treatment, early recognition and treatment of PPH, and blood stewardship. The baseline period was January 2019 to December 2020. The intervention period was July 2021 to April 2022. We recommended transfusions begin with an order for a single unit of blood (“Start with One”). Plan-do-check-act cycles were initiated. The clinical outcome was units of blood transfused per 1,000 deliveries. Relative risks, t tests, and control charts were used for analysis. The quality improvement project was IRB exempt (HUM00213652). RESULTS: Incidence of PPH decreased between baseline and intervention periods (relative risk 0.83, 95% CI 0.77–0.90). The baseline transfusion rate was 79.3 units of blood per 1,000 births. During the intervention period, this decreased by 32.8% to 53.2 units per 1,000 births (P=.004). Special cause variation was found after introduction of the “Start with One” campaign: 8 consecutive months in the intervention period have been above the mean proportion for single-unit transfusions. CONCLUSION: A single-unit transfusion guideline, as part of a multimodal strategy to reduce PPH, was associated with a significant decrease in red cell transfusion. The current national blood shortage should be a call to action for all obstetric providers to safely reduce the volume of blood transfusions.

INTERDISCIPLINARY DEMENTIA CARE WORKFORCE TRAINING AND QI IMPLEMENTATION: LEARNINGS FROM 25 HOSPICES

Abstract To build and sustain a dementia-capable clinical workforce and care delivery organizations, it is essential to systematically disseminate evidence-based, interdisciplinary dementia care programs. The outbreak of COVID-19, clinical staff shortages, and competing priorities experienced by healthcare organizations including staff vaccination and other regulatory requirements, pose significant challenges to the continuation of agency-wide, interdisciplinary dementia care workforce training and quality improvement. In this symposium, we present our experience Implementing Aliviado Dementia Care, a comprehensive, interdisciplinary dementia care workforce training and quality improvement program amid COVID-19 across 25 U.S. hospice agencies, as part of an embedded pragmatic clinical trial. Aliviado Dementia Care consists of interdisciplinary dementia care workforce training, treatment algorithms, assessments, care plans, caregiver education, and clinical workflow changes. The symposium begins with a discussion of the training, knowledge improvement, turnover, and replenishing strategies of hospice champions during COVID-19. We then discuss how we tailored dementia care training for each of the skilled hospice disciplines (i.e., medicine, nursing, social work, spiritual care) and provide two case studies elucidating how additional tailoring was performed to fit local agency culture and needs during COVID-19. Furthermore, we discuss how we developed and iterated training for home health/hospice aides, the usability and training results, and specific considerations for training aides during COVID-19. Lastly, we conclude the symposium with a discussion of salient strategies and technologies that help sustain our nationwide implementation despite the ongoing COVID-19. Throughout each of these abstracts we also discuss how COVID-19 affected, and created differential implementation of components of the intervention.

Improving Documentation of Postdischarge Issue Mitigation during Postdischarge Phone Calls

An interdisciplinary quality improvement team used the Model for Improvement to perform planned sequential interventions over 16 months. The outcome measure was documentation of postdischarge issue mitigation. Process measures included PDPC template use and completion and postdischarge issue identification. Balancing measures included call attempts and caller perceptions of ease of documentation. Interventions included creating a flowsheet note template, creating caller template training sessions, and sharing team data and feedback. We gathered data via reports generated from the electronic medical record, chart review, and survey. Data were analyzed using statistical process control charts and established rules for detecting special cause variation. The postdischarge issue mitigation documentation increased from 65% to 91% over 16 months. Template use and completion increased from 0% to 100% and 98%, respectively. The number of postdischarge issues identified remained unchanged. Call attempts increased from 40% to 59%. Caller perceptions remained unchanged. Documentation of postdischarge issues and issue mitigation promotes adequate communication with the patient's care providers, improving the quality and safety of care. Data sharing to promote team engagement was the key factor in improving documentation of postdischarge issue mitigation.

Interdisciplinary Quality Improvement Project Increases Vitamin D Supplementation in Infants.

American Academy of Pediatrics guidelines recommend 400 IU of vitamin D supplementation daily for certain infants <1 year of age. We aimed to increase the proportion of reported appropriate vitamin D supplementation for infants born at our institution and those who followed up in our resident clinic through 6 months from 49% to 80% over 24 months. Our interdisciplinary quality improvement effort included vitamin D medication delivery before nursery discharge and family and staff education. The process measure was the percentage of families discharged from birth hospitalization with vitamin D and teaching. The outcome measure was the percentage of families reporting appropriate vitamin D supplementation at 2-, 4-, and 6-month well child visits. The balancing measure was the percentage of infants discharged from the nursery by 2 pm. Data were displayed on Statistical Process Control p charts and established rules for detecting special causes were applied. Baseline and improvement data were collected for 587 hospital discharges and 220 outpatient encounters. The percentage of families discharged with vitamin D increased from 24.8% to 98% from 2016 to 2018. Percent of families reporting appropriate vitamin D supplementation at well child visits increased from 49% to 89% from 2016 to 2018. Overall, the percentage of discharges by 2 pm remained stable at 60%. Bedside medication delivery and education in the newborn nursery improved reported vitamin D supplementation rates in the first 6 months of life. The intervention did not delay newborn hospital discharge.

Improving Caregiver Understanding of Liquid Acetaminophen Administration at Primary Care Visits

Liquid medication dosing errors are common in pediatrics. Our outpatient clinic identified gaps in caregiver education based on a 2015 American Academy of Pediatrics policy statement on prescribing liquid medications. This quality improvement (QI) initiative sought to improve caregiver's understanding of liquid acetaminophen administration at the 2-month well-child visit from 30% to 70% over a 32-month period. A resident-led interdisciplinary QI team performed sequential interventions to improve our outcome measure: the percentage of caregivers with an adequate understanding of 4 essential components of liquid acetaminophen administration (name, indication, dose, and frequency). Outcome data were collected via a 4-item verbal assessment of caregiver's understanding by nursing staff, with correct answers to all items considered adequate understanding. Process measures (medications prescribed and education provided), and balancing measures (anticipatory guidance items discussed) were gathered via electronic health record review. Shewhart "P" charts and established rules for detecting special cause variation were used to analyze data. Scatter plots assessed the association between the provision of syringes and caregiver understanding of medication administration. In 636 caregivers, overall understanding of medication use improved from 39.8% to 74%. Knowledge of accurate dosage improved from 50.9% to 76.8%. Correlation between syringe provision and caregiver understanding was strong (R = .84). Resident-led QI improved caregiver's understanding of liquid acetaminophen administration in infants. The most impactful interventions were implementation of English and Spanish pictograms and provision of dose-demarcated oral syringes, coupled with teach-back. Future interventions will examine generalizability to other medications and expansion to other services.