Bundle Of Interventions Research Articles

P-308. Impactful Implementation of “HAPPI MRSA” - Hospital Onset Pneumonia Prevention and Reduction of Methicillin-Resistant Staphylococcus aureus Bloodstream Infections at a Large U.S. Health System

Abstract Background Hospital onset (HO) Methicillin-Resistant Staphylococcus aureus (MRSA) bloodstream infection is one of the key performance metrics for the CMS Hospital-Acquired Condition (HAC) reduction payment program. MRSA bacteremia is a serious preventable infection associated with increased morbidity and mortality. The goal of our intervention was to implement process changes to reduce MRSA bacteremia and HO pneumonia, improve patient safety, quality of care and decrease healthcare costs associated with treatment.Figure 1:Most Common Sources of All Cases HO MRSA Bacteremia at JHS (Baseline Period: January 2019- September 2021) Methods Jackson Health System (JHS) is a 2,289-bed nonprofit academic health system located in Florida, USA. Utilizing a PDSA cycle for process improvement, we implemented a bundle of interventions focused on Hospital Onset Pneumonia Prevention (HAPPI) as the leading cause of MRSA bacteremia across JHS (Figure 1). Planning included focus groups and process mapping to assess barriers to an ideal oral care universal practice (Figure 2). Policies were updated; education and compliance monitoring were incorporated at each hospital. Managers were empowered by hospital leadership to hold staff accountable for each of the metrics within the bundle: universal oral care with kits tailored to independent, dependent, and ventilated patients, universal skin bathing with chlorhexidine gluconate (CHG), nasal decolonization, early mobility, and aspiration precautions.Figure 2:Barriers to Universal Oral Care in Hospitalized Patients at JHS (Focus Groups with Frontline Staff and Infection Prevention Leadership) Results During the pre-intervention period Jul 2021-Jun 2022, we identified 46 HO MRSA bacteremias that were secondary to HO pneumonia. System wide education occurred Jul-Dec 2022. During our post-intervention period Jan-Dec 2023, 20 HO MRSA bacteremias were identified that were secondary to HO pneumonia, a 57% reduction (Figure 3). Estimating $60,000 to treat MRSA bacteremia secondary to pneumonia, we identified a $1.5 million dollars in cost savings by preventing 26 infections.Figure 3:Most Common Sources of All Cases HO MRSA Bacteremia at JHS (Post-Intervention Period: January-December 2023) Conclusion We reduced HO MRSA bacteremias and subsequently HO pneumonia after implementing and actively monitoring compliance with a bundle of interventions. Facilities considering pneumonia and MRSA prevention should include strategies that reduce organism bioburden with bathing, nasal decolonization, and oral care along with early mobility and aspiration precautions. Disclosures All Authors: No reported disclosures

P-1725. A Cluster Randomized Trial of Bundled Interventions to Reduce Inappropriate Antibiotic Use in the Outpatient Setting

Abstract Background Antibiotics are often inappropriately prescribed in the outpatient settings. Among the most common reasons for inappropriate antibiotic prescriptions are upper respiratory tract infections (URI) which are known or highly likely to be viral in origin. Our aim was to test a bundle of complementary interventions to reduce inappropriate antibiotic prescriptions in the outpatient setting for patients presenting with various URIs. Here we present preliminary data from the cluster randomized trial using pre-intervention baseline data (August to October 2023) and after implementation of interventions (December 2023 to March 2024).Figure 1.Comparison of inappropriate antibiotic prescriptions for URTIs between the intervention and control groups during the pre-intervention (Aug 2023 – Oct 2023) and post-intervention phases (Dec 2023 - Mar 2024). Methods We randomly assigned 2 Primary Healthcare Centers (PHCC) in Qatar to receive a 4 component intervention: 1) extensive provider education; 2) providing an algorithm driven decision support tool based on professional society recommendations for appropriate use of antibiotics for various URIs; 3) option for deferred prescription; and 4) monthly feedback to all physicians regarding their prescription patterns including anonymized comparison with their peers. Two PHCCs in the control group received a single intervention which was randomly chosen. For this study, we identified 4 common URIs for which professional society guidelines do not recommend use of antibiotics (acute bronchitis, acute laryngitis, common cold, influenza without mention of pneumonia). Prescriptions written and corresponding diagnoses were retrieved from the electronic medical records. Children < 2 years of age, and individuals with any immune compromising condition or medications were excluded.Table. 1Appropriate and Inappropriate use of antibiotics in URTIs Results A total of 7,246 antibiotic prescriptions were written for 4 included URIs during the study period. The percentage of inappropriate prescriptions in the intervention group decreased from 67.7% to 62% in the first 4 months after the intervention (p-value >0.05). The proportion of inappropriate prescriptions in the control groups remained steady at 70% before and after the intervention. Conclusion While not statistically significant in this early stage, our preliminary results indicate a trend in reduction in inappropriate prescriptions of antibiotics for URIS in the outpatient setting. Disclosures Adeel A. Butt, MD, MS, Gilead Sciences: Grant/Research Support

P-1740. Impact of a System Wide Antimicrobial Stewardship Intervention Bundle to Improve Guideline Directed Antibiotics for Urinary Tract Infections

Abstract Background Urinary tract infections (UTIs) are one of the common reasons for antibiotic use across healthcare settings. Across an eleven-hospital system, common urinary pathogens (E. coli, Proteus species, and Klebsiella species) had greater than 80% coverage with cefazolin, which was within 0-8% of ceftriaxone coverage based on the local antibiograms. With increased risk of C. difficile infection and resistance development seen with ceftriaxone, cefazolin was promoted as first line for empiric UTI coverage.Table 1:Outcomes Methods An interrupted time series analysis was performed comparing a pre-intervention group to two phases of stewardship intervention (figure 1). The first intervention included an updated guideline, education, and pharmacist intervention upon order verification recommending guideline directed therapy. Guideline directed options and guideline non-compliant options are highlighted on green and red respectively, on figure 3. The second intervention was cascade reporting (figure 2) for urine culture Enterobacterales susceptibility, which was implemented across sites between 9/2023-1/2024. A generalized linear model with Poisson link was fit to the data. Compliant orders were regressed vs. the denominator of all UTI orders. Multiple models were considered, and the final model selection was based on likelihood ratio testing and the rule of parsimony.Figure 1:Interrupted Time-SeriesWhite = pre-intervention; light gray = intervention 1; dark gray = intervention 2 Results In the four pre-intervention months, guideline compliance across the system was 38.1% (1674/4393), compared to 61.9% (6749/10,903) after intervention 1 was implemented (table 1). The final model suggested that intervention 1 was associated with a nearly 1.5-fold increase in compliance which was sustained over time and suggested that the compliance rate over time increased modestly at around 5% per quarter (figure 1). There was no change in length of stay, risk adjusted length of stay, or 30-day all-cause readmission (table 1).Figure 2:Microbiology Cascade Reporting Workflow Conclusion Guideline update, education, and frontline pharmacist intervention were significantly impactful in improving guideline directed treatment for UTIs. Cascade reporting on urine cultures may help reinforce guideline directed therapy but did not result in substantially different compliance rates from education with frontline pharmacist intervention.Figure 3:Percent of Patients with Empiric Guideline Directed Therapy Orders Disclosures Nathaniel J. Rhodes, PharmD MS, Apothecademy, LLC: Advisor/Consultant

Epidemiology and outcomes of carbapenem-resistant Klebsiella pneumoniae infections in patients with hematological malignancies from 2014 to 2022.

We aimed to describe the epidemiology, cross-transmission, interventions, and outcomes of carbapenem-resistant Klebsiella pneumoniae (CRKP) infections in the hematological malignancies (HM) department of a hospital in China. This prospective study was divided into three stages from 2014 to 2022: Period 1 (from 1 January 2014 to 4 March 2021), Period 2 (from 5 March 2021 to 31 December 2021), and Period 3 (from 1 January 2022 to 31 December 2022), with different measures implemented at each stage to evaluate the rate of new infections. The risk factors, epidemiological characteristics, data from all patients with CRKP, NGS gene sequencing molecular epidemiology analysis, and cross-transmission were described. A total of 217 patients with K. pneumoniae isolates, including 38 (17.5%) patients with CRKP isolates, were confirmed in the HM department. The total rate of CRKP in KP isolates was 17.5%. The predominant clone in the HM department was ST11 CRKP producing the KPC-2 enzyme (21, 70.0%). A total of 23 cases of HM department-acquired CRKP infections were identified, and five hospital cross-transmission events were observed. Four instances of CRKP dissemination were primarily related to clone ST11. Only one outbreak occurred at the end of Period 1, involving four cases of CRKP healthcare-associated infections (HAIs). After the implementation of outbreak intervention bundles at the end of Period 2, no cross-transmission occurred. The rate of CRKP in KP isolates decreased to 12.9% (only four CRKP isolates) in Period 3, down from a peak of 46.7% in Period 2 (including 14 CRKP isolates). Only one new carrier (0.9%) was identified during the two cross-sectional active screenings of the rectal swab. The 28-day mortality rate was 38.7% (12/31) in CRKP-infected patients. The prevalence of CRKP in the HM department was relatively low in the studied hospital. We found that interventions, including single-room isolation, enhanced disinfection, and skin decolonization, played a pivotal role in controlling the spread of HM-acquired CRKP infections.

Ensuring drug safety in the outpatient department of a tertiary care hospital in Sri Lanka

Background: Medication safety is a fundamental component of patient safety, as highlighted by the World Health Organization (WHO). The Colombo South Teaching Hospital (CSTH), a major tertiary care institution in Sri Lanka, recently transitioned from a paper-based to a computer-based health information management system in its Outpatient Department (OPD) to improve medication safety and operational efficiency. This study evaluates the impact of these interventions on drug safety. Methods: This interventional study employed a pre- and post-implementation analysis at CSTH. The study combined qualitative methods, including focus group discussions (FGDs), key informant interviews, and direct observations. Participants included medical officers, pharmacists, patients, and hospital administrators. Data collection focused on challenges in the previous paper-based system, the features of the new computer-based system, and improvements in medication safety. Results: The previous paper-based system exhibited several challenges, such as illegible handwritten prescriptions, limited access to prior patient records, and lack of continuity in treatment plans. Pharmacists faced difficulties interpreting prescriptions, which affected patient counseling and drug dispensing efficiency. The newly implemented computer-based system addressed these issues effectively. Key improvements included: Accurate and Clear Prescriptions: Standardized and comprehensive prescriptions minimized errors. Patient Record Accessibility: Enhanced access to medical histories and allergy information facilitated safer prescribing practices. Medication Safety Initiatives: Pre-packed drugs, detailed labeling, and alert systems for look-alike and sound-alike drugs significantly reduced medication errors. These interventions improved patient safety, operational efficiency, and adherence to clinical governance principles. Discussion: The e-based system has demonstrated measurable benefits, aligning with global patient safety objectives. Enhanced prescription accuracy, reduced drug-related errors, and improved patient satisfaction underscore the system's effectiveness. Recommendations: Scaling these interventions across other healthcare institutions in Sri Lanka and integrating them into national policies is recommended. Regular updates to alert systems, ongoing staff training, and periodic evaluations will ensure sustainability and continued improvements. Conclusion: This study highlights the significant improvements in medication safety achieved through a comprehensive bundle of interventions in the CSTH OPD. These findings offer a framework for enhancing drug safety and patient care in broader healthcare settings.

Implementation of Surgical Site Infection Prevention Bundle in Gynaecological Surgeries: A Quality Control Initiative

Background: Surgical site infection (SSI) is the most common post operative morbidity after gynaecological surgeries. There can be multiple risk associated that may or may not be modifiable. Therefore, perioperative bundled approach are designed to reduce surgical site infections. Aim/Objective: To determine whether surgical site infection (SSI) prevention bundle reduces the risk of SSI by 30 days postoperatively compared with the standard hospital protocol. Methods: A randomized control trial was conducted on women who underwent elective gynaecologic surgery from January 2019 to May 2020. The subjects were divided into intervention and control group. The primary outcome was the rate of SSI by 30 days postoperatively. Results: Total 192 women were randomized. the intervention group included 94 and 98 were assigned to the control group. The SSI rate at 30 days after surgery was 8 /85 (9.5%) in intervention group and 22/85 (25.8%) in control group (p value=0.005; RR=0.36;95% confidence interval [CI], 0.17-0.77). The relative risk reduction of SSI was 64% (p value=0.005) after the bundle was implemented. In subgroup analysis, the primary outcomes were affected by the subgroups like age, co morbidities and operative characteristics. Conclusion: SSI prevention bundle intervention led to significant decrease in overall SSI rate in electively planned gynecological surgeries.

Extending the Calgary Audit and Feedback Framework into the virtual environment: a process evaluation and empiric evidence

BackgroundThe Calgary Audit and Feedback Framework (CAFF) is a pragmatic, evidence-based approach for the design and implementation of in-person social learning interventions using Audit and Group Feedback (AGF). This report describes extension of CAFF into the virtual environment as part of a multifaceted intervention bundle to reduce redundant daily laboratory testing in hospitals. We evaluate the process of extending CAFF in the virtual environment and share resulting evidence of participant engagement with planning for practice change.MethodsWe describe an innovative virtually facilitated AGF intervention based on the CAFF. The AGF intervention was part of an intervention bundle which included individual physician laboratory test utilization reports and educational tools to reduce redundant daily laboratory testing in hospitals. We used data from recorded and transcribed virtual AGF sessions, post AGF session surveys and detailed field notes maintained by project team members. We used simple descriptive statistics for quantitative data and analyzed qualitative data according to the elements of CAFF.ResultsEighty-three physicians participated over twelve virtual AGF sessions conducted across four tertiary care hospitals during the study period. We demonstrate that all prerequisite activities for CAFF (relationship building, question choice and data representation) were present in every virtual AGF session. Virtual facilitation was effective in supporting the transition of participants through different steps of CAFF in each session to lead to change talk and planning. All participants contributed to discussion during the AGF sessions. The post AGF session surveys were filled by 66% of participants (55/83), with over 90% of respondents reporting that the session helped them improve practice. 46% of participants (38/83) completed personal commitment to change forms at the end of the sessions.ConclusionsVirtual AGF sessions, developed and implemented with fidelity to the CAFF approach, successfully engaged physicians in a group learning environment that led to change planning. Further studies are needed to determine the generalizability of our findings and to add to the literature on evidence-based virtual facilitation techniques.

Reducing severe intraventricular haemorrhage rates in

To assess staff adherence to a 'Preterm Brain Injury Prevention Bundle', and its effectiveness in reducing severe intraventricular haemorrhage (IVH) rates and risk factors in extremely preterm infants born at <26 weeks' gestation. Adherence to the bundle was assessed using a novel bedside assessment tool, with immediate feedback to bedside staff post-assessment. Data on IVH rates and associated risk factors were stratified by IVH severity, and compared between pre- and post-bundle implementation. Of 203 bedside assessments, good adherence was observed in 12/28 items (43%), while the remaining items required improvement. Rates of grade 3/4 IVH reduced (39.2% pre-bundle vs. 19.0% post-bundle, p = 0.13). Thermoregulation and base excess improved (p = 0.02 and p = 0.04 respectively) after bundle implementation. Reduced severe IVH rates post-bundle implementation may be attributed to staff education and improved clinical parameters. Adherence to the bundle interventions varied which highlighted target areas for future education.

Bundle compliance patterns in septic shock and their association with patient outcomes: an unsupervised cluster analysis.

Adhering to bundle-based care recommendations within stringent time constraints presents a profound challenge. Elements within these bundles hold varying degrees of significance. We aimed to evaluate the Surviving Sepsis Campaign (SSC) hour-one bundle compliance patterns and their association with patient outcomes. Utilizing the Medical Information Mart for Intensive Care-IV 1.0 dataset, this retrospective cohort study evaluated patients with sepsis who developed shock and were admitted to the intensive care unit between 2008 and 2019. The execution of five hour-one bundle interventions were assessed. Patients with similar treatment profiles were categorized into clusters using unsupervised machine learning. Primary outcomes included in-hospital and 1-year mortality. Four clusters were identified: C#0 (n = 4716) had the poorest bundle compliance. C#1 (n = 1117) had perfect antibiotic adherence with modest fluid and serum lactate measurement adherence. C#2 (n = 850) exhibited full adherence to lactate measurement and low adherence to fluid administration, blood culture, and vasopressors, while C#3 (n = 381) achieved complete adherence to fluid administration and the highest adherence to vasopressor requirements in the entire cohort. Adjusting for covariates, C#1 and C#3 were associated with reduced odds of in-hospital mortality compared to C#0 (adjusted odds ratio [aOR] = 0·83; 95% confidence interval [CI] 0·7-0·97 and aOR = 0·7; 95% CI 0·53-0·91, respectively). C#1 exhibited significantly better 1-year survival (adjusted hazard ratio [aHR] = 0·9; 95%CI 0·81-0·99). We were able to identify distinct clusters of SSC hour-one bundle adherence patterns using unsupervised machine learning techniques, which were associated with patient outcomes.

Redesigning the Hospital Environment to Improve Restfulness

Hospital wards are often not conducive to patient sleep, negatively affecting patient health and experience. To assess determinants of in-hospital restfulness and to design and test rest-promoting interventions on the wards in partnership with clinicians, staff, and patients. This rapid-sequential mixed-methods quality improvement study was performed at a large urban academic hospital in St Louis, Missouri, from May 1, 2021, to December 31, 2022, with follow-up through hospitalization. Mixed-methods activities involved purposively selected hospitalized adults on the wards, nurses, hospitalists, and hospital staff. Interventions included all adult hospitalizations on the study wards. Sequential stacked bundles of multimodal rest-promoting interventions (general education, focused education on light or noise, safely reducing overnight monitoring or testing, and environmental personalization). Pre-post comparisons of perceived nighttime quietness (via surveys) and sleep opportunity (coprimary outcomes) as well as clinical interruptions overnight, environmental noise, and adoption and satisfaction. Nine patients (4 female) and 14 staff members (10 female; 3 nurse managers or administrators, 10 nurses, and 1 physician) were interviewed, 38 surveys were collected, and more than 100 hours of observation were performed. Interventions were evaluated for 671 patients (mean [SD] age, 60 [16] years; 336 [50%] female). Determinants of in-hospital rest included infrastructure, staff attitudes, priorities, culture, and patient experiences of anxiety, uncertainty, and loss of control. Informed by these determinants, codesign workshops yielded 39 potential interventions, from which 9 were selected for testing. Related interventions were organized into bundles, which were tested in sequential 2-week sprints. Perceived nighttime quietness improved nonsignificantly during the project (wards "always" quiet at night: 51% preintervention vs 86% postintervention; P = .09), with excessive noise events decreasing from 0.65 (95% CI, 0.53-0.77) to 0 per 100 patient-nights before the intervention (P = .02). Sleep opportunity improved significantly (mean, 4.94 [95% CI, 4.82-5.06] hours per patient-night before the intervention vs 5.10 [95% CI, 5.00-5.20] hours per patient-night after the intervention; P = .01). In this quality improvement study, a set of feasible, acceptable, and beneficial rest-promoting interventions were developed. After implementation of these interventions on the wards, a significant improvement in nighttime quietness and sleep opportunity was observed. These results demonstrate how human-centered design methods can generate practical and effective strategies for improving an important patient-related outcome and a core element of patient experience.

Integrating Stakeholder Priorities for the Optimization of Care of the Preterm Infant in a Safety-Net NICU.

This study aimed to engage clinical and community stakeholders to create a prioritization matrix of interventions to reduce neonatal brain injury and improve neurodevelopmental outcomes. We collaborated with our community partner to establish a Lived Experience Advisory Group (LEAG). Faculty performed a literature review to identify neonatal neuroprotective interventions; additional priorities from the LEAG were also included. Project leaders scored and presented intervention bundles for impact. Stakeholder priorities for value/feasibility were obtained via questionnaire. Mean values were incorporated into a prioritization matrix. Themes from discussions with LEAG members included the role of the neonatal intensive care unit (NICU) parent, the experience of trauma, shared decision-making, communication and trust with the health care team, and bias in medical care. Five interventions were placed in the highest priority quadrant of the prioritization matrix: thermoregulation, maternal antepartum steroids, delayed cord clamping, optimized oxygen delivery, and optimized glucose regulation. It is feasible to incorporate community and parent values into clinically oriented neuroprotective intervention bundles for preterm infants. This clinical-community collaboration is vital to ensure that our project objectives meet the needs and priorities of the population it is intended to serve. · Including input from parent advisory groups supports interventions that meet the needs of families.. · Collaboration between clinical and community stakeholders can improve neuroprotective and neurodevelopmental strategies.. · Incorporation of clinical interventions into a prioritization matrix improves resource utilization.. · Five perinatal interventions were ranked highly for impact and feasibility in the prioritization matrix..

CO76 The Effectiveness, Safety, and Cost-Reductions of an Intervention Bundle for Reducing Length of Stay in Laparoscopic Cholecystectomy Patients

CO76 The Effectiveness, Safety, and Cost-Reductions of an Intervention Bundle for Reducing Length of Stay in Laparoscopic Cholecystectomy Patients

Clinicians' and Patients' Experiences and Perceptions on the Prevention and Management of Surgical Site Infections: A Mixed-Methods Systematic Review.

To explore clinicians' and patients' perceptions of implementing evidence-based practice to improve clinical practice for preventing and managing surgical site infections within hospital acute care settings. A convergent integrated mixed-methods systematic review using the Joanna Briggs Institute approach. Included studies reported (i) acute care hospital clinicians' and patients' experiences and preferences for preventing and managing surgical site infections and (ii) barriers and facilitators to implementing surgical site infection prevention and management guidelines. The Mixed Methods Appraisal Tool and the Quality Improvement Minimum Quality Criteria Set were used for critical appraisal. Quantitative data was transformed into qualitised data, then thematically synthesised with qualitative data and coded all findings into themes. Clinicians' and patients' views were also compared. English language peer-reviewed studies published from 2009 to March 2023 were identified from Medline, EMBASE, CINAHL, PsycINFO and Cochrane Central Library. Thirty-seven studies (16 quantitative, 17 qualitative, 3 mixed-methods and 1 quality improvement) met the inclusion criteria. Five main themes represent key factors believed to influence the implementation of evidence-based surgical site infection prevention and management guidelines: (1) Intentional non-adherence to insufficiently detailed and outdated guidelines, (2) Knowledge deficits on evidence-based SSI care bring about inconsistent clinical practice, (3) Collaborative interdisciplinary and patient-provider relationship to enhance guideline uptake, (4) Infection surveillance to improve patient safety and quality of life and (5) Negative physical and psychological impacts on patients. The five themes reflect a need for updated hospital guidelines as a medium to improve surgical site infection knowledge and ensure consistent and evidence-based clinical practice. This review also highlights the significance of interdisciplinary and patient-provider collaboration and infection surveillance to facilitate guideline uptake. The effectiveness of intervention bundles designed to improve these aspects of care will need to be evaluated in future research. A future intervention bundle that includes (1) ensuring up-to-date hospital guidelines/policies; (2) fostering collaborative interdisciplinary teamwork culture between physicians, nurses, podiatrists, pharmacists and allied health professionals; (3) encouraging patient or carer involvement in shared decision-making and (4) implementing audit and feedback mechanism on infection surveillance is proposed to improve SSI prevention and management in acute care settings. This paper followed the PRISMA 2020 checklist guideline for reporting systematic reviews. This mixed-methods systematic review collates evidence of clinicians' and patients' experiences and preferences for preventing and managing surgical site infections. The inclusion of hospital patients' perspectives supports the development of patient-centred interventions. The review protocol is registered on the International Prospective Register of Systematic Reviews (PROSPERO 2021 CRD42021250885). Available at: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021250885.

Consumer and multidisciplinary clinician experiences after implementation of the Drug Burden Index intervention bundle to facilitate deprescribing in older inpatients: A mixed method study.

The Drug Burden Index (DBI) measures exposure to anticholinergic and sedative drugs, which are associated with harm in older adults. To facilitate deprescribing in older Australian inpatients, we piloted an intervention bundle integrating the DBI in Electronic Medical Records, clinician deprescribing guides, consumer information leaflets and a stewardship pharmacist. To understand (i) hospital clinician experiences of using the bundle and (ii) consumer (patient and carer) and General Practitioner (GP) experiences of in-hospital deprescribing, following bundle implementation. Hospital clinicians from target services (General and Geriatric Medicine) at an Australian metropolitan tertiary-referral hospital, were invited to complete surveys, including the System Usability Scale (SUS), and interviews. Patients aged ≥75 years with high DBI (DBI ≥1) were admitted to target services, and their carers, received interview invitations. Consenting patients' GPs received surveys. Qualitative data was thematically analysed. Hospital clinician interviews were mapped to the Human Organisation Technology-fit Framework. Patient interviews were mapped to an adaptation of the National Health Service Patient Experience Framework. Seventeen hospital clinicians (n = 15 medical, n = 2 pharmacists) and four GPs completed surveys. Eight hospital clinicians (n = 7 medical, n = 1 pharmacist), seven patients and two carers completed interviews. Hospital clinicians reported good usability (SUS score 71.5 ± 12.5). Most themes were around system use and user satisfaction. They reported the intervention was useful for medication review, identified challenges from pre-existing heavy workload and suggested further integration into workflows. Patients and carers reported themes around information, communication and education. Patients reported feeling better or no different post-deprescribing. Patients, carers and GPs described poor communication regarding in-hospital medication changes and their rationale. The intervention was well accepted by hospital clinicians. The bundle requires further integration into workflows for sustainability and assessment of generalisability in other health services. Given patients, carers and GPs reported poor medication-related communication, future interventions may target this.

Decreasing the Use of Cefdinir for Pediatric Urinary Tract Infections in a Rural Health Care System: A Quasi-experimental Study.

There are several antimicrobial options for treating urinary tract infection in children. Although cefdinir is commonly used, better options exist. We developed an intervention bundle to reduce the use of cefdinir in favor of cephalexin. The intervention bundle decreased cefdinir use by 19.1% while use of cephalexin increased by 19.8%.

Characteristics of Diaper Dermatitis in Patients Aged 0-24 Months After Congenital Heart Disease and the Effects of a Diaper Dermatitis Care Bundle: A Comparison of 2 Groups.

The purpose of this study was to examine characteristics of diaper dermatitis (DD) in critically ill patients aged 0 to 24months following surgery for congenital heart disease (CHD), the effects of a diaper dermatitis care bundle (DDCB), and factors associated with the development of DD in this population. Nonrandomized comparison cohort study with a historical comparison group. Convenience sampling was used to identify children aged 0 to 24months undergoing CHD and cared for in a pediatric intensive care unit in central Taiwan (Taichung). The sample comprised 54 participants; 24 were in the historical comparison group and 30 received the DDCB. The rate of DD from the historical comparison group was compared to that in an intervention group managed with a bundle of interventions used to prevent and manage DD, which includes the routine use of a topical skin protectant. The participants in the historical comparison group received usual care to prevent and manage DD including routine cleansing with a moistened, disposable cloth every 3hours and following defecation or urination. The DDCB comprised diaper changes at least every 3hours and as needed after soiling, along with the routine application of a dimethicone and sodium hyaluronate-based skin protectant before diaper changes. Both groups were evaluated for use of an antifungal cream when candidiasis was present. Participants managed with the DDCB have a significantly lower rate of DD than the historical comparison group who received routine care (41.65% vs 6.67%, P =.002). Univariate logistic regression showed an odds ratio of 0.10 (95% confidence interval of 0.019-0.520, P =.006), suggesting that the DDCB acted as a protective factor against the development of DD. Multivariate analysis of the historical comparison group indicated that non-cyanotic heart disease was associated with a lower likelihood of postoperative DD compared to those with cyanotic heart disease (odds ratio=0.01, 95% confidence interval of 0.000-0.946, P =.047). Managing critically ill patients with a DDCB recovering from cardiac surgery significantly decreased the incidence of DD. We recommend routine use of this type of care bundle for preventing DD in this vulnerable population in all children with CHD, with particular attention being paid to this with cyanotic CHD.

Adolescent Focused Intervention Bundle for Institutionalized Adolescents' Health Promotion: A Study Protocol

Adolescent Focused Intervention Bundle for Institutionalized Adolescents' Health Promotion: A Study Protocol

Promotion of breastfeeding in Italian Maternity Hospitals: a pre-intervention study

BackgroundIn Italy, exclusive breastfeeding (EBF) rates at hospital discharge range unsatisfactorily between 20–97%.MethodsIn 2023, the Project for Hospital Policy on Breastfeeding (HPB) has been launched to promote breastfeeding in Italian Maternity Hospitals (MHs) as a joint initiative of the Italian Scientific Societies involved in perinatal care together with the National Midwife (FNOPO) and Nurse (FNOPI) Boards and with Vivere Onlus, a family association. The HBP Project has been designed as an uncontrolled before-after study to increase EBF rate at hospital discharge in the population of healthy, term infant with a normal weight at birth following an intervention bundle comprising: 1) Establishment of a local hospital Working Group; 2) Adoption of a hospital policy; 3) Implementation of breastfeeding monitoring; 4) Training for perinatal care professionals; 5) Enhanced implementation of the practices of skin-to-skin contact (SSC) and mother-baby rooming-in; 6) Development/Improvement of perinatal care protocols.ResultsWe report the pre-intervention assessment of 89 out of the 111 enrolled MHs (80.2%) at the beginning of the Project (Time 1 or T1). Almost all MHs (96.6%) have a multi-professional Breastfeeding Working Group, while a hospital policy on breastfeeding is available only in 48.2%. Moreover, only 56.2% of the 9,777 perinatal health workers have been trained in breastfeeding. Over a 1-month period, SSC has been practiced in the delivery room by 76.9% of 6,304 term healthy newborn infants and rooming-in by 83.4% of 6,735 healthy term newborns of normal weight at birth. Over a 4-month period, 69.1% of 33,367 healthy term newborns of normal birth weight were exclusively breastfed at hospital discharge. Noticeably, EBF rate of MHs ranges from 4% up to 100%, the second quartile being 73%.ConclusionAt T1 of the HPB Project, breastfeeding rates at hospital discharge for healthy, term infants with a normal weight at birth appear to be suboptimal among Italians MHs. Particularly, the range of EBF rates among participating centers is wide, with 50% of the MHs having EBF rate lower than 73%. Therefore, the ongoing HPB Project might represent not only an opportunity to increase the initiation of breastfeeding and to improve quality of health care in the whole study group of MHs, but possibly also to level differences between centers.

Impact of a Bundle of Interventions on the Spectrum of Parenteral Drug Preparation Errors in a Neonatal and Pediatric Intensive Care Unit.

Background/Objectives: This study aimed to evaluate the impact of a bundle of interventions on the error rates in preparing parenteral medications in a neonatal and pediatric intensive care unit (NICU/PICU). Methods: We conducted a prospective interventional study in a NICU/PICU in a tertiary university hospital as a follow-up to a prior study in the same setting. A clinical pharmacist and a pharmacy technician (PT) analyzed the workflow of drug preparation on the ward, identified high-alert medications, and defined a bundle of five interventions, which include the following: Drug Labeling: 1. EN ISO-DIVI labeling; Training: 2. Standardized preparation process on the ward; 3. eLearning Program; 4. Expert Consultations; and Location of Preparation: 5. Transfer of the preparation of high-alert medications and standardized preparations to the central pharmacy. After implementing the bundle of interventions, we observed the preparation process on the ward to evaluate if the implementation of the interventions had an impact on the quality of the drug preparation. Results: We observed 262 preparations in the NICU/PICU. Each single step of the preparation process was defined as an error opportunity. We defined seven error categories with an overall error opportunity of 1413. In total, we observed 11 errors (0.78%). The reduction in the overall error rate from 1.32% in the former study to 0.78% per preparation opportunity demonstrated that the implemented interventions were effective in enhancing medication safety. Conclusions: This study provides evidence that a bundle of interventions, including standardizing drug labeling, enhancing training, and centralizing the preparation of high-alert medications, can reduce medication errors in NICU/PICU settings.

Improvement cycle to act against catheter-related bloodstream infections

Abstract Background Catheter-related bloodstream infections (CRBSI) pose significant risks, causing a prolongation of hospital stay, increasing costs and increasing the risk of complications and mortality. It is the first healthcare-associated infection in many hospitals including our institution. Preventing CRBSI is essential for safety in patient’s care. To achieve this, we’ve adopted improvement cycles as a tool, aiming to decrease CRBSI rates by 50%. Methods Over the period of 2012 to 2023, 9036 pediatric patients were monitored throughout their hospitalizations. We utilized improvement cycles through various interventions: first an intervention bundle, secondly avoiding multipuncture, thirdly improving sampling techniques, fourthly optimizing supply management, and lastly restructuring the vascular access clinic. Each cycle involved resource management and process enhancement. Progress was measured through percentage metrics and the primary outcome indicator was CRBSI rates. Results The first cycle achieved a 90% compliance, the achievements were compliance above 85% of the bundle. In the second cycle we attained an 85% compliance, implement a guideline for catheter insertion with only two punctures in practice. The third cycle saw a 70% compliance rate, involving a multidisciplinary team for taking samples, training and monitoring by a skilled supervisor. The fourth cycle reached a 60% compliance through a techno-vigilance process, it was a pity quickly practical solutions didn´t work in practice. The final cycle achieved a 70% compliance, establishing a functional vascular access clinic. Rates CRBSI decreased by 50% overall and in the pediatric intensive care unit, meeting our objective. However this reduction was not observed in other intensive care units. Conclusion Improvement cycles simplify changes. Their implementation is effective but requires close monitoring, support from resources and authorities, a committed and proactive team, and continuous changes according to results. There is a need to consolidate the strategies to sustain and enhance our achievements.