Interventional Quality Improvement Research Articles

Evaluation of administration-related reactions with subcutaneous daratumumab with and without premedication.

Daratumumab-hyaluronidase-fihj (Dara-SQ) is frequently used in the treatment of plasma cell disorders and is associated with improved outcomes. Dara-SQ was shown to be non-inferior to intravenous daratumumab (Dara-IV) in efficacy, safety, and associated with fewer administration-related reactions (ARRs). Despite the lower ARR risk with Dara-SQ, package labeling still recommends indefinite premedication. In this study, we investigated the safety of premedication discontinuation after one cycle of Dara-SQ. This pre-post interventional quality improvement study included all patients aged 18 years and older diagnosed with multiple myeloma or light chain (AL) amyloidosis who received at least one dose of Dara-SQ. Patients in Arm 1 received Dara-SQ per package labeling, while patients in Arm 2 had premedication omitted (excluding dexamethasone) after cycle 1. The primary endpoint was the incidence of ARR after cycle 1. Overall ARR rate and therapy time saved were also evaluated. A total of 102 patients (63 in Arm 1 and 39 in Arm 2) were included. There were zero reactions in either arm after cycle 1 across 1479 Dara-SQ doses administered over a 30-month period with or without premedication omission. The overall ARR rate was 2.9% (3/102), which all occurred prior to premedication omission. Therapy timed saved from premedication omission was 194 hours in a 6-month period, equating to approximately $140 000 USD. ARRs to Dara-SQ were rare, mild, and occurred during cycle 1 prior to premedication omission. Omission of noncorticosteroid premedication is safe, feasible, and carries substantial time and cost savings for patients and infusion centers.

Expansion of the Fertility Preservation Program to All Newly Diagnosed Prepubertal Patients with Cancer at a Pediatric Hospital.

Background: As the majority of pediatric patients with cancer survive their disease, generating a population of over 500,000 childhood cancer survivors in the United States, it is imperative to minimize the lifelong consequences of treatment, which include temporary or permanent infertility caused by certain cancer treatments. A fertility consultation at diagnosis can provide patients and families with the opportunity to be informed regarding the likelihood of gonadal dysfunction and to consider fertility preservation. Method: After our pediatric hospital started to offer tissue cryopreservation, we initiated this evidence-based interventional quality improvement project. Our primary aim was to ensure that all newly diagnosed prepubertal patients with cancer who met the criteria for fertility tissue preservation were correctly identified and offered an educational consultation and preservation. Results: Between July 15, 2022 and October 30, 2022, 54 patients' treatment plans were evaluated to determine treatment-related infertility risk using the Oncofertility Consortium Pediatric Initiative Network's Risk Assessment tool. Fifteen patients were at a high level of significantly increased risk and 13 were eligible for consultation. Seven (46%) patients and their families received a consultation. Initiation of treatment before referral was the primary reason for lack of consultation. Six of seven patients receiving consultation (86%) elected to undergo preservation. Preservation procedures did not cause a delay in starting treatment for those patients. Discussion: A fertility preservation program with established policies and processes can increase the likelihood that prepubertal patients at high risk for infertility are correctly identified, educated, and offered preservation.

Abstract 18597: Is Sleep Disordered Breathing Optimized in Patients With Bradycardic Rhythm Disorders Prior to Pacemaker Implantation? - A Retrospective Observational Study and a Quality Improvement Project

Introduction: Obstructive sleep apnea (OSA) is associated with cardiovascular (CV) morbidity and mortality ranging from asymptomatic bradycardia to sudden death. Studies have shown that sleep-related bradyarrhythmias, decrease with continuous positive airway pressure (CPAP) and are unlikely to develop symptomatic bradycardia in the long-term. AHA/ACC/HRS recommends to evaluate and treat suspected or documented conduction disorder during sleep including patients who have received or are being considered for permanent pacemaker (PPM). Objective We aim to examine the number of sleep studies and CPAP performed and address the barriers of under-diagnosis and treatment with post intervention quality improvement initiative. Methods: We performed retrospective analysis of patients >18 years admitted for elective PPM placement from 01/10/2021-01/01/2023. Categorical variables were reported as number and percent and numerical variable was reported as mean. Multiple logistic regression was used to identify predictors for compliance and sleep study prescription. All statistical analyses were performed with SAS software, version 9.4. Results Of 423 patients, mean age was 78.1 years, 56.50% were males, 96.9% were Caucasians and mean BMI was 30.1 kg/m 2 . Only 34.75 % (N= 147/423) received sleep study. 93.2% (N=137/147) were diagnosed with OSA and 82.9% (N=122/137) were treated with CPAP. Only 63.1% were compliant with CPAP. Males were more complaint with CPAP [OR 3.13 (95% CI 1.36-7.18, p=0.0072)]. Mean BMI at OSA diagnosis was 33.7 kg/m 2 and 30.1 kg/m 2 at PPM implantation. Weight loss was noted but most patients remained obese. Males, age ≥80 and obesity were significant predictors to get sleep study. After study outcomes, we adopted a standardized algorithm for risk assessment, incorporated EHR reminder and educated doctors. The intervention is currently ongoing. Conclusion Data on underutilization of sleep study helped us to work with administration to produce a protocol for screening high risk patients. Treating sleep apnea not only alleviates apnea-related symptoms but also improves CV outcome by avoiding unnecessary pacemaker implantation and minimizing unnecessary health care cost. If effective, this strategy can be a model for other hospitals.

Expansion of the fertility preservation program to all newly diagnosed prepubertal oncology patients at a pediatric hospital.

10064 Background: As the majority of pediatric oncology patients survive their disease, generating a population of over 500,000 survivors in the United States, it is imperative to minimize the lifelong consequences of treatment, which includes temporary or permanent infertility caused by certain cancer treatments. Fertility preservation (FP), the opportunity to preserve one’s ability to have genetically-related children prior to damaging the reproductive system, is a young but rapidly expanding field and recent scientific advances have led to an expansion of options for prepubertal patients. A fertility consultation at diagnosis can provide patients and families with the opportunity to be informed regarding likelihood of gonadal dysfunction and to consider FP. Methods: After our pediatric hospital started to offer tissue cryopreservation, we initiated this evidence-based interventional quality improvement project. Our primary aim was to ensure that all newly diagnosed prepubertal oncology patients who met criteria for FP were correctly identified and offered an educational consultation and preservation. Inpatient admission lists and provider schedules were reviewed daily to identify patients. Treatment plans were discussed with providers to calculate infertility risk. All procedures were to be completed at the time of another procedure to increase likelihood of insurance coverage and minimize delays. Results: Between 07/15/22 and 11/30/22, 54 newly diagnosed prepubertal patients’ treatment plans were evaluated to determine treatment-related infertility risk using the Oncofertility Consortium Pediatric Initiative Network’s Risk Assessment tool. 15 patients were at a high level of significantly increased risk and were therefore eligible for consultation. 7 patients and their families received an educational consultation and 6 elected to undergo FP (3 TTCs; 3 OTCs). FP procedures did not cause a delay in starting treatment for any of these patients. 8 patients did not receive consultations. Reasons included the provider electing to proceed with treatment without consultation (4), the patient’s comorbidities (1), the inability to bundle FP with another procedure (1), and the family decision to decline consultation (1). Conclusions: Of the patients at high risk of infertility, only 46% received consultation with lack of referral prior to initiating treatment as the primary reason. Of the patients offered preservation methods, 86% elected to preserve their fertility, illustrating patient and family interest. Providers must acknowledge changes in practice and be informed on the impact that high-risk treatment protocols can have on fertility. An FP program with established policies processes can increase the likelihood that prepubertal patients at high risk for infertility are correctly identified, educated, and offered preservation.

Incidence of infusion related reactions of daratumumab-hyaluronidase-fihj: Pre-post intervention study of premedication omission.

6574 Background: Daratumumab-hyaluronidase-fihj subcutaneous (Dara-SQ) is utilized frequently in the treatment of newly diagnosed and relapsed/refractory multiple myeloma (MM). Initially approved as an intravenous formulation, daratumumab (Dara-IV) showed significant infusion related reactions (IRRs), requiring premedication (acetaminophen, diphenhydramine, dexamethasone, and some add montelukast) prior to each dose. Dara-SQ was shown to be noninferior to Dara-IV with significantly fewer IRRs. Despite the reduced IRR risk, indefinite premedication is also recommended in the package insert for Dara-SQ. Given that IRRs are rare after the first dose of Dara-SQ and premedication extends the time for patients in an infusion center, we investigated whether premedication may be safely omitted after the first cycle. Methods: This pre-post interventional quality improvement study included all patients aged 18 years or older diagnosed with MM or amyloidosis that received at least one dose of Dara-SQ between July 1st, 2020 – December 31st, 2022. Omission of premedication (excluding dexamethasone) after four doses of Dara-SQ was introduced June 1st, 2022. The pre-interventional arm followed standard of care with premedication continued (Arm 1) and post-interventional arm included patients with premedication omitted after fourth dose (Arm 2). Patient demographics, prior therapy, Dara-IV exposure, and premedication usage were collected to evaluate the primary endpoint: incidence of IRR after premedication omission. Secondary analysis included any IRR prior to intervention, timing of reaction, reaction management, and post-reaction management. Results: A total of 102 patients (63 in Arm 1 and 39 in Arm 2) were included in the study, with a median age of 69 (38-86) years old; 52% African American and 54% male. IRR prior to fourth dose occurred in 1.6% (1/63) for Arm 1 vs. 5.1% (2/39) for Arm 2 [ p= 0.6], Dara-IV exposure was 52.4% (33/63) in Arm 1 vs. 10.2% (4/39) in Arm 2 [ p= 0.02], and indication was newly diagnosed MM in 21% (13/63) of Arm 1 vs. 41% (16/39) of Arm 2 [ p= 0.03]. For the primary objective, there were zero reactions in both arms. All three reactions prior to fourth dose occurred after the first dose of Dara-SQ, with a median time to reaction of 4.8 hours. These were all grade 2 per CTCAE v5.0, with all patients discharged home after reaction, and all patients received subsequent Dara-SQ without issues. For the two reactions prior to fourth dose in Arm 2, premedication was omitted after 6 doses in one patient and 8 doses in the other with no further issues on subsequent doses. Estimated therapy time saved was 194 hours, with an estimated savings of $145,500 thus far. Conclusions: IRRs to Dara-SQ occur early, are rare, and mild in course. Omitting premedication after a minimum of four Dara-SQ doses is safe and carries substantial time savings for patients and infusion centers.

Time is tissue. Want to save millions in wound care? Start early: a QI project to expedite referral of high-risk wound care patients to specialised care

IntroductionWound care is a multibillion-dollar industry, and most research and treatment are geared towards late-stage or end-stage care. The longer a patient has a wound, the more likely it is...

Driving communication forward: improving communication for palliative care patients around driving and opioids – a quality improvement report

IntroductionThe number of people requiring palliative care is increasing with an ageing comorbid population. Pain is a prevalent symptom for palliative care patients and is often managed with opioids. Opioids...

Early detection and treatment of acute illness in medical patients with novel software: a prospective quality improvement initiative

ObjectiveAn ageing population and rising healthcare costs place healthcare systems at risk of failure. Our goal was to develop a technology that would identify illness early, initiate action and therein...

Improving the quality of family meeting documentation in the ICU at the end of life

Objective:Improve documentation quality of end-of-life family meetings in a tertiary intensive care unit (ICU).Design:Before-and-after interventional quality improvement project between October 2018 and February 2020 utilising an electronic pro-forma record.Setting:Australian, University affiliated, mixed medical-surgical 22 bed adult ICU.Participants:Patients who were admitted to the ICU for active management and subsequently died during that ICU admission. We enrolled 50 patients who died before and 50 patients after the introduction of the electronic family meeting pro-forma record.Intervention:Through collaboration with ICU medical and nursing staff, End-of-life Special Interest Group and Clinical Documentation Committee we developed the ICU Family Meeting Discussion Note as an electronic pro-forma record with multiple key fields of entry.Main outcome measures:Patient records were examined for the presence of documented details around patient’s admission, family meetings and specific elements surrounding the patient’s death.Results:The introduction of a pro-forma record markedly improved the quality of documentation of end-of-life care related family meetings. Documentation increased in recording hospital admission date/time (6% vs 84%), meeting location (14% vs 70%), the reason patients were absent from the meeting (34% vs 72%), the Medical Treatment Decision Maker (MTDM) (10% vs 44%), the patient’s resuscitation status (22% vs 54%), and treatment options discussed (78% vs 94%) (p ⩽ 0.005 for all).Conclusion:Introducing an electronic pro-forma record to facilitate family meeting documentation increased the frequency of important recorded information. Further studies are required to assess whether documentation quality improvements are sustainable and whether they affect patient- or relative-centred outcomes.

I-PASS enhances effectiveness and accuracy of hand-off for pediatric general surgery patients

BackgroundI-PASS is a validated and standardized hand-off protocol shown to reduce medical error and improve hand-off efficiency in the pediatric medical population. Our aim was to evaluate the feasibility, effectiveness, accuracy and resident satisfaction of implementing I-PASS on a pediatric surgery service. MethodsA prospective intervention Quality Improvement (QI approved) study was utilized to evaluate resident written and verbal hand-offs before and after implementation of I-PASS on a pediatric surgery service at a tertiary center. Anonymous surveys were completed by residents following each observation. Results were analyzed using T or Mann-Whitney U Tests and Chi Square. ResultsA total of 49 written tools and 50 verbal hand-offs were compared pre-and post I-PASS implementation. With I-PASS, increased written accuracy was observed in the documentation of the patient summary (p < 0.05). Accuracy in the verbal hand-off of illness severity, patient summary, contingency plan, action list and synthesis also improved (p < 0.05); but duration of hand-off increased (p < 0.01). Post implementation surveys of residents demonstrated an increased understanding of patient management (p < 0.05). ConclusionImplementing I-PASS on a pediatric surgery service with modifications catered to surgical patients, improved the effectiveness and accuracy of written and verbal patient hand-offs and increased provider satisfaction and preparedness. Level of evidenceLevel II.

The impact of implementing a psychiatric emergency hotline on the reduction of acute hospitalizations in a Swiss tertiary hospital

BackgroundInpatient treatment is not the most beneficial treatment setting for many patients with psychiatric disorders and overcrowding is a recurrent problem for psychiatric hospitals. Therefore, it is important to develop strategies to limit avoidable inpatient treatment. This study sought to evaluate the impact of an emergency hotline that was developed to better manage psychiatric patients, particularly for identifying those requiring a hospital admission.MethodsThis pre-post intervention quality improvement study compared changes in the management of psychiatric patients’ admission before and after the introduction of an emergency hotline where a specialist in psychiatry examines all inpatient referral from private practitioners.Main outcomes were the change in proportion of hospital admissions after referral from a private practitioner before and within 3 months after the intervention. Secondary outcomes were the average length of hospital stay, proportion of non-voluntary admission, the time required for triage and the impact of the intervention on treatments’ costs. Fisher’s Exact test was used to test the primary hypothesis of difference in the proportion of hospitalized patients before and after introduction of the emergency hotline. Secondary outcomes were tested with Student’s t-test for continuous variables and Fishers’s Exact test for proportions.ResultsAmong 45 admission requests from private practitioners during the 3 months after introduction of the new emergency hotline, 25 (55.6%) were accepted as inpatient treatment, while 20 (44%) were redirected to more appropriate outpatient treatments. There was a highly significant difference from the baseline period during which all 34 requests were accepted (44% vs 100%, p < 0.001). In addition, for the patients hospitalized after the introduction of the emergency hotline there was a trend-level reduction of the average length of stay (9.32 days vs 17.35 days).ConclusionImplementation of an emergency hotline manage by a specialist in psychiatry for admissions to acute psychiatric wards is feasible and simple to use. Importantly, it allows to significantly decrease the proportion of hospitalizations. Additional studies are needed to assess the generalizability of these exploratory results to other health care settings.

P77. Optimizing the spine surgery instrument trays to immediately increase efficiency and lower costs in the operating room

<h3>BACKGROUND CONTEXT</h3> Spine surgery is increasingly scrutinized in a climate of rising health care costs given its cost per procedure compared to other specialties. Fortunately, there are many sources of inefficiency that can be addressed without compromising patient care. Surgical trays are often poorly configured and have considerable economic implications as they comprise a large portion of perioperative budgets. Instruments are typically added on an ad-hoc basis, based on surgeon request, which can result in excessively large and inefficient trays. A solution must take into account the conflicting issues of clinical need, costs, ease of batching, prevention of adverse clinical events, and minimization of wear-and-tear on instruments. Clinician review and cost-analysis of surgical trays are two methods historically used to address this challenge, although they have shortcomings. We conducted an interventional quality improvement study to determine if a customized mathematical inventory optimization model would result in greater reduction of instruments than a clinician review. <h3>METHODS</h3> This was a single-site quality improvement study conducted at a large academic hospital which performs over 750 laminectomy procedures annually. Two trays are required: 1) Laminectomy Tray (LT) and 2) Basic Neurosurgery Tray (BNT). As such, the focus of our study was to optimize these two trays. A trained observer was present in the operating room (OR) during 25 randomly selected laminectomy procedures. Processes in the MDRD and OR were observed to comprehensively quantify associated costs. The results of the observations were applied to a mathematical model to determine ideal tray configuration. In addition, a clinician review (CR) of the trays was performed for comparison. <h3>RESULTS</h3> The mathematical model produced an ideal tray size of 29 for the LT, representing a reduction of 41% from the original size of 49. For the BNT, the mathematical model produced an ideal tray size of 23 instruments, a reduction of 50% instruments from the original size of 46. Combined, this represented $20,934 in annual savings. In contrast, CR alone suggested an ideal tray size of 35 (29% reduction) for the LT and 37 (19%) for the BNT instruments, and $11,197 in annual savings. <h3>CONCLUSIONS</h3> Superior reduction of surgical trays used for laminectomy was achieved using a mathematical model when compared to CR alone. The mathematical model yielded an additional 10% instrument reduction and $9,737 in savings compared to clinician review alone. Our model comprehensively optimizes the surgical trays by incorporating several cost drivers important to major processes involved in surgical tray assembly, processing and OR utilization. This model may be generalizable to all specialties and hospitals to determine optimal tray configuration. The financial implications are broad; at our institution, application of the mathematical model to all surgical trays would result in projected costs savings of $312,476 annually. Surgeons and managers looking to manage costs should consider this evidence-based approach. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

A Quality Improvement Project to Reduce Antibiotic Utilization and Ancillary Laboratory Tests in the Appraisal of Early-Onset Sepsis in the NICU

BackgroundDiagnosis and treatment of early-onset sepsis (EOS) of the newborn remains a controversial issue among providers due to the non-infectious symptomology which exists in the newborn period. MethodsPre/post interventional quality improvement project in a level III NICU to reduce antibiotic utilization and ancillary laboratory tests with the introduction of an evidence-based guideline for the evaluation of EOS in the NICU. ResultsPrimary outcome measures include mean number of empiric antibiotic treatment days and utilization rate (AUR), number of laboratory tests ordered, and incidence of unwarranted antibiotic therapy beyond the 48-h rule out period. Mean empiric antibiotic treatment days decreased from 2.94 to 1.58 days and overall antibiotic use decreased from 73.7% to 57.1%. Likewise, the mean AUR decreased from 212.5 to 147.6 days of therapy per 1000 patient days. There was an 86% decline in the number of ancillary tests and unwarranted antibiotic use beyond 48- h was reduced by 74%. DiscussionGuidelines for EOS of the newborn should include a thorough baseline evaluation of the drivers of antibiotic use to create an evidence-based foundation. Reducing unnecessary antibiotic use and EOS evaluations in a safe and effective manner have the potential to lower consumer and healthcare expenditures while improving the long-term health of the newborn in the NICU. ConclusionsThese findings emphasize the importance of implementing an evidence-based protocol for antibiotic stewardship in the NICU. With further research there is the potential to improve the healthcare of newborns while reducing expenditures in a safe, effective evaluation of EOS in the newborn population.

Development and implementation of a process evaluation for intervention quality improvement of a community-based behavioral HIV intervention trial in Tanzania.

Process evaluations for social and behavioral interventions are increasingly important as interventions become more complex and multi-faceted. Conducting process evaluations in low-resource international settings can be challenging. Process evaluations in low-resource international settings can help inform and improve quality of ongoing intervention implementation. We conducted a process evaluation of a cluster-randomized controlled trial to assess the efficacy of a microfinance and health leadership program on sexually transmitted infections and intimate partner violence perpetration among young men in Tanzania. Our trial included 1,491 participants and the intervention lasted two years. We collected process data on microfinance loan uptake and repayment, and health leaders' health conversations with peers to monitor intervention reach and dose received. We developed a database system that allowed offline data collection and synced to a central database when internet was accessible. Research staff in the U.S. accessed data from the central database to analyze and create regular implementation reports. Process graphical reports facilitated identification of implementation challenges and enabled us to resolve issues before they worsened. For example, from a group with low microfinance loan repayment we learned area participants perceived the loan to be a grant, and then we clarified the misinformation with participants. The process evaluation helped inform ongoing intervention implementation, including approaches to improve reach and uptake of interventions. Field staff time was protected by systemizing the sharing of data processing and analyses across the global team.

Implementation of a Nurse-Driven Pediatric Bowel Management Algorithm: A Quality Improvement Project

BackgroundIn September 2018, a staff survey on a 16-bed pediatric neuro-rehab care unit (RCU) revealed nurses felt their care was limited with few resources available to treat patients experiencing constipation. Based on guidelines published by the North American and European Societies for Pediatric Gastroenterology, Hepatology, and Nutrition, an evidence-based algorithm was implemented in the RCU. AimsThe aims of this project were to reduce the need for invasive constipation treatment and to improve nurse satisfaction. MethodsAn evidence-based interventional quality improvement project, based on the Plan-Do-Study-Act (PDSA) method, was initiated by RCU's clinical nurse leader. To measure impact on patients, use of invasive treatment was tracked in the electronic medical record. To measure impact on staff, a staff satisfaction survey was completed pre- and post- project implementation. ResultsThere was a statistically significant reduction in average rates of invasive medication administration between pre-intervention (M = 2.23, SD = 0.77) and post-intervention (M = 0.79, SD = 0.52; t (7) = 3.38, p = 0.01). A Wilcoxon Signed Rank Test revealed a statistically significant improvement in post-intervention nurse satisfaction for having tools and resources (z = −5.196, p < 0.001). ConclusionsThe findings of this quality improvement project showed that nurse-driven protocols based on current evidence can improve the prevention and treatment of constipation by reducing the need for invasive constipation treatment and improve nurse satisfaction.

Targeting Missed Care Opportunities Using Modern Communication Methods: A Quality Improvement Initiative to Improve Access to CT and MRI Appointments

To evaluate the impact of automated text and phone call reminder systems on CT (computed tomography) and MRI (magnetic resonance imaging) missed care opportunities. This was an IRB (institutional review board) exempt prospective interventional quality improvement study. The proportion of missed care opportunities (appointment made, no imaging performed) related to scheduled CT and MRI examinations were evaluated over 2 months (Month 1: reminder phone calls by staff 48-96 hours prior and mailed letter 1-2 weeks prior; Month 2: no manual call or letter, automated text message 24 hours prior, automated phone call 72 hours prior, automated patient portal message 7 days prior). The proportion of missed care opportunities was calculated in aggregate and by modality. Process control p-charts were generated. An a priori power analysis was performed. Chi-squared tests were performed. p-value < 0.017 was considered significant after Bonferroni correction. Missed care opportunities occurred for 2.82% (292/10348; 95% CI: 2.51-3.16) of all CT and MRI appointments using traditional communication and 2.44% (262/10719; 95% CI: 2.16-2.75) using automated communication (p = 0.09). Automated messaging did not significantly change the proportion of missed care opportunities for CT (traditional: 2.62% [95% CI: 2.23-3.06] vs. automated: 2.06% [95% CI: 1.70-2.48], p = 0.05) or MRI (traditional: 3.1% [95% CI: 2.60-3.66] vs. automated: 2.83% [95% CI: 2.40-3.30], p = 0.43). Process control p-charts showed dominance of common cause variation. Automated messaging did not meaningfully change the overall proportion of missed care opportunities compared to traditional human-initiated phone calls. Automated communications may reduce cost and improve efficiency without adversely affecting access to care.

The redesign of an advanced practice registered nurse professional evaluation process and tool at a midwest academic medical center: A pilot project.

Inconsistency and a lack of clarity exist regarding the advanced practice registered nurse peer review process in hospitals throughout the country. The current APRN peer review process in place for over a decade at an academic medical center has never been evaluated, and neither fulfills ongoing professional practice evaluation requirements nor meets the expectations of peer review. Pre-post intervention quality improvement project (Standards for Quality Improvement Reporting Excellence checklist). Using current professional standards and guidelines that meet the requirements for ongoing professional practice evaluation and nursing peer review, a redesigned process and tool was created and piloted in three specialty groups of nurse practitioners (NPs) at the medical center. Satisfaction before and after the pilot survey was measured using a Likert-type scale, and results were compared and analyzed following the completion of the pilot survey. The posttest measure revealed a statistically significant improvement in satisfaction with the redesigned professional evaluation tool compared with the prepilot peer review tool. The redesign project demonstrated that using current professional standards and guidelines, a comprehensive process and tool for professional evaluation and peer review is achievable across NP specialties.

A National VA Palliative Care Quality Improvement Project for Improving Intensive Care Unit Family Meetings (ICU-FMs)

BackgroundWe sought to increase intensive care unit–family meeting (ICU-FM) documentation in the electronic health record in Veterans Affairs (VA) hospitals. MeasuresPrimary outcomes were proportion of VA decedents with ICU-FM and Bereaved Family Survey–Performance Measure (BFS-PM) scores of “excellent.” InterventionQuality improvement (QI) project, clinical champion, and ICU-FM templates were implemented in nine participating VA facilities. ICU-FMs and BFS-PM were determined in decedents between 2011 and 2018. OutcomesICU-FM increased from 3% to 28% in participating vs. 5% to 6% in nonparticipating facilities over time. Participating facilities were five-fold more likely to have ICU-FMs among ICU decedents (OR = 5.69, [4.45–7.28]). Facility-wide excellent BFS-PM scores increased by 19% in participating vs. nonparticipating facilities at the end of the observation period (OR = 1.19, [1.10–1.30]), but no difference between groups was observed in patients who died in the ICU. ConclusionsIncreasing ICU-FMs is necessary but not sufficient to improve family-reported satisfaction after an ICU death.

Multi-modal Educational Curriculum to Improve Richmond Agitation-sedation Scale Inter-rater Reliability in Pediatric Patients.

Introduction:The Richmond Agitation-sedation Scale (RASS) is a reliable and valid scale for assessing sedation in critically ill pediatric patients. This investigation evaluates the inter-rater reliability of the RASS in mechanically ventilated pediatric patients before and after an educational intervention.Methods:This prospective, interventional quality improvement study was completed in a 20-bed pediatric intensive care unit from July 2013 to July 2014. Children 0–18 years of age requiring mechanical ventilation and receiving sedative or analgesic medications were eligible. Staff completed simultaneous paired RASS assessments in 3 phases: baseline, after educational intervention, and maintenance.Results:Staff completed 347 paired assessments on 45 pediatric intensive care unit patients: 49 in the baseline phase, 228 in the postintervention phase, and 70 in the maintenance phase. There was a significant increase in the weighted κ after the intervention, from 0.56 (95% CI, 0.39–0.72) to 0.86 (95% CI, 0.77–0.95; P < 0.001). The improvement was maintained months later with weighted κ 0.78 (95% CI, 0.61–0.94). In subgroup analysis, there was an increase in weighted κ in patients less than 1 year of age (0.41–0.87) and those with developmental delay (0.49–0.84).Conclusions:The RASS is a reliable tool for sedation assessment in mechanically ventilated, sedated pediatric patients after implementation of an educational intervention. It is also reliable in patients less than 12 months of age and patients with developmental delay. The ability to easily educate providers to utilize a valid, reliable sedation tool is an important step toward using it to provide consistent care to optimize sedation.

Enhancing recognition of obstetric anal sphincter injuries in six maternity units in Palestine: an interventional quality improvement study

ObjectiveTo explore the impact of a training intervention on obstetric anal sphincter injuries’ (OASIS) detection rate.DesignProspective quality improvement interventional study.SettingSix secondary and tertiary maternity units in Palestine.PopulationWomen having singleton vaginal...