Multidisciplinary Quality Improvement Initiative Research Articles

Sleeping Safe and Sound: A Multidisciplinary Hospital-wide Infant Safe Sleep Quality Improvement Initiative

IntroductionPromoting Safe Sleep to decrease sudden unexpected infant death is challenging in the hospital setting. Local ProblemConcern for adherence to Safe Sleep practice across inpatient units at a large pediatric hospital. MethodsUtilized Quality improvement (QI) methodologies to promote Safe Sleep across all units. InterventionsDevelopment of a multidisciplinary expert group, hospital-wide guidelines, targeted interventions, and bedside audits to track progress. ResultsAdherence to Safe Sleep practices improved from 9% to 53%. Objects in the crib were a major barrier to maintaining a Safe Sleep environment. Safe Sleep practices were less likely to be observed in infants with increased medical complexity (p=.027). ConclusionsQI methodology improved adherence to infant Safe Sleep guidelines across multiple units. Medically complex infants continue to be a challenge to Safe Sleep. Therefore, ongoing education for staff and further research into best practices for the most complex infant populations are necessary.

Achieving optimal cord management: a multidisciplinary quality improvement initiative

Optimal cord management (OCM), defined as waiting at least 60 seconds (s) before clamping the umbilical cord after birth, is an evidence-based intervention that improves outcomes for both term and...

Improving Nurse-Physician Bedside Communication Using a Patient Experience Quality Improvement Pilot Project at an Academic Medical Center.

Introduction Patient experience is a crucial aspect of healthcare delivery, and it encompasses various elements that contribute to a patient's perception of the care they receive. Patient satisfaction and patient experience are related but distinct concepts. Patient experience focuses on whether specific aspects of care occurred, while patient satisfaction gauges whether patient expectations were met. It goes beyond mere satisfaction and delves into the broader aspects of how patients interact with the healthcare system and the quality of those interactions, with health plans, doctors, nurses, and staff in various healthcare facilities. Other aspects highly valued by patients include elements such as timely access to care and information, good communication with the healthcare team, and friendly staff. Patient experience can influence both the healthcare and financial outcomes of healthcare facilities. It is well understood that positive patient experiences may lead to better care adherence, improved clinical outcomes, enhanced patient safety, and better care coordination. Payers, both public and private, have recognized the importance of patient experience. Improving patient experience benefits healthcare facilities financially by strengthening customer loyalty, building a positive reputation, increasing referrals, and reducing medical malpractice risk and staff turnover. Methodology A multidisciplinary retrospective quality improvement initiative was initiated to effectively improve nurse-physician communication and organizational outcomes in several hospital units. Results Using an innovative staff-developed and driven acronym, IMOMW (I'm on my way), the study demonstrated significant positive outcomes such as increased Epic documentation (Epic Systems Corporation, Verona, Wisconsin, United States) of physician and nursing rounding by 13%, a 10.5% rise in recommend facility net promoter score (NPS) patient experience survey scores, 13.4% increase in physician and nurse team communication, 5.4% increase in nursing communication, and a 5.3% increase in physician communication. Moreover, pilot units outperformed the control group consisting of medical-surgical units located in newer portions of the hospital. Conclusion This quality improvement study demonstrates improved interdisciplinary nurse-physician communication, Epic documentation, and patient experience scores. Further investigation is necessary to better understand the specific factors and/or processes that influence the sustainability of interventions that improve nurse-physician communication and patient experience.

Where’s my med? Improving patient-specific medication storage for emergency department boarders

BackgroundThere have been an increased number of patients boarding in the emergency department (ED) who often experience delays in receiving nonurgent medications not typically stocked in the ED automated dispensing cabinets (ADC). ObjectivesTo describe a quality improvement project designed to decrease the amount of time it takes nursing staff to obtain patient-specific medications for patients boarding in the ED at a community hospital. Practice descriptionPrior to this quality improvement project, standard practice was for pharmacy staff to send all medications to the ED based on inpatient cart fill lists, resulting in a 24-hour supply being sent at 1 time. Medications that were not immediately due were often misplaced by ED staff as there was no standard location to store them. Practice innovationA separate location for each examination room in the ED was created in 1 central ADC to store patient-specific medications. Pharmacy staff were instructed to load medications directly into the ADC for expected long-term behavioral health boarders. Nursing staff were instructed to place future doses in the newly created locations and were educated on how to locate medications utilizing the electronic medication administration record. Evaluation methodsED nursing staff timed how long it took them to obtain medications for 40 boarding patients before and after implementation of the quality improvement initiatives. ResultsThe postimprovement intervention decreased the amount of time it took to obtain medications for forty ED boarding patients by 66%, from an average of 37.7 minutes at baseline to 12.9 minutes postintervention. This was a statistically significant improvement via an unpaired t-test (P < 0.0001 with a 95% CI from 15.3 to 34.47). This was rechecked after 1 year and the improvement was sustained. ConclusionA multidisciplinary team-based quality improvement initiative was successful in reducing the time it took to obtain medications for ED boarding patients.

Implementation of a health system intervention to reduce time from presentation to surgical intervention for pediatric testicular torsion

Testicular salvage rates for torsion are time-dependent1. Door to detorsion time has been identified as an independent testicular survival factor2. We describe an initiative to reduce door to incision (DTI) time for pediatric testicular torsion. An institutional multidisciplinary quality improvement initiative with a primary outcome of reducing DTI time for pediatric testicular torsion was developed with multidisciplinary stakeholders. Several process and balancing measures were used as secondary outcomes to help interpret and verify the observed change in DTI time. Interventions were implemented in cycles. Initial interventions standardized assessment of suspected torsion by Emergency Medicine utilizing a validated scoring system. A threshold Testicular Workup for Ischemia and Suspected Torsion (TWIST) score led to parallel notification of essential services for rapid assessment and case prioritization3. Subsequently, bedside ultrasound in the Emergency Department was implemented. Progress was tracked in a live dashboard and analyzed with X-mR process control charts and Nelson rules. These tools are used in quality improvement and process control to demonstrate the significance of changes as they are being implemented, prior to when traditional hypothesis testing would be able to do so. We aimed to increase the proportion of cases with DTI times under 4h from 64% to >90% within one year. We observed 22 torsion cases prior to and 62 following initial implementation. The percentage of cases with DTI times under 4h improved from 64% to 95%. At week 29, a shift identified a significant change on the X chart, with reduction in mean DTI time from 221 to 147min. At the same time, a shift on the mR chart identified reduction in patient-to-patient variation. Mean time from arrival to Urology evaluation decreased from 140 to 56min, mean time from arrival to scrotal ultrasound decreased from 70 to 36min, and mean time from scrotal ultrasound to surgical incision decreased from 128 to 80min. These improvements highlight the two key successes of our project: application of the TWIST score and bedside ultrasound for rapid assessment of suspected testicular torsions, and parallel processing of the evaluation and management. Implementation of a protocol for pediatric testicular torsion increased the proportion of cases with DTI time <4h to 95%, decreased mean DTI time, and decreased variation. Our protocol provides a model to improve timeliness of care in treating pediatric testicular torsion.

Decreasing Antibiotic Use in a Community Neonatal Intensive Care Unit: A Quality Improvement Initiative.

In view of the excessive use of antibiotics in our neonatal intensive care unit (NICU), we launched a 5-year multidisciplinary quality improvement (QI) initiative in our NICU in 2018. We had set our aim of decreasing the antibiotic use rate (AUR) from 22 to 17%. The QI initiative was conducted in our 53-bed level 3B NICU. We used the core elements of antibiotic stewardship and focused on improving gaps in knowledge by using updated standards of care and a multidisciplinary approach. Outcome measures included overall AUR in NICU. Statistical control chart (P chart) was used to plot the AUR data quarterly. The AUR demonstrated a decline at the onset, and at the end of the initiative the AUR demonstrated a sustained decline to 13.18%, a 40% decrease from the baseline AUR of 22%. The changes that were implemented included development of evidence-based guidelines for babies less than and greater than 35 weeks, daily antibiotic stewardship rounds, sepsis risk calculator, antibiotic stop orders (48-hour stop, 36-hour soft stop, and 36-hour hard stop), and periodic reviews. Our multidisciplinary approach using all the core elements of an antibiotic stewardship program significantly decreased AUR in our NICU. · Excessive use of antibiotics may cause harm to the infant's health.. · Indiscriminate use of antibiotics can lead to antibiotic resistance.. · Stewardship programs can significantly decrease AUR in NICUs..

Improving Early Colostrum Administration to Very Low Birth Weight Infants in a Level 3 Neonatal Intensive Care Unit: A Quality Improvement Initiative

To increase early oral immune therapy (OIT) with colostrum administered to the buccal mucosa in order to improve our human milk practices for very low birth weight (VLBW) infants admitted to a level 3 NICU. Using the Institute for Healthcare Improvement's (IHI) Model for Improvement, several interventions aimed at increasing early OIT administration were implemented. Four key drivers included: optimizing evidence based OIT guidelines, personnel alignment and engagement, optimal electronic health record (EHR) use for ordering practices, and timely lactation consultant involvement. The primary outcome measure was early OIT administration, while secondary outcome measures examined all OIT administration and human milk at discharge. Process measures included the percentage of staff members who were compliant with OIT protocol. Early OIT administration increased from a baseline mean of 6% to 55% in the 12-month study period. Percentage of total (early and late) OIT administration to VLBW infants increased from a baseline of 21% to 85%. Average human milk at discharge for VLBW infants remained at 44%, without significant improvement. A multidisciplinary quality improvement initiative led to significant improvement in OIT administration to infants at a level 3 NICU.

Reducing MRSA Infection in a New NICU During the COVID-19 Pandemic

Methicillin-resistant Staphylococcus aureus (MRSA) is prevalent in most NICUs, with a high rate of skin colonization and subsequent invasive infections among hospitalized neonates. The effectiveness of interventions designed to reduce MRSA infection in the NICU during the coronavirus disease 2019 (COVID-19) pandemic has not been characterized. Using the Institute for Healthcare Improvement's Model for Improvement, we implemented several process-based infection prevention strategies to reduce invasive MRSA infections at our level IV NICU over 24 months. The outcome measure of invasive MRSA infections was tracked monthly utilizing control charts. Process measures focused on environmental disinfection and hospital personnel hygiene were also tracked monthly. The COVID-19 pandemic was an unexpected variable during the implementation of our project. The pandemic led to restricted visitation and heightened staff awareness of the importance of hand hygiene and proper use of personal protective equipment, as well as supply chain shortages, which may have influenced our outcome measure. Invasive MRSA infections were reduced from 0.131 to 0 per 1000 patient days during the initiative. This positive shift was sustained for 30 months, along with a delayed decrease in MRSA colonization rates. Several policy and practice changes regarding personnel hygiene and environmental cleaning likely contributed to this reduction. Implementation of a multidisciplinary quality improvement initiative aimed at infection prevention strategies led to a significant decrease in invasive MRSA infections in the setting of the COVID-19 pandemic.

Pseudomonas infection reduction in the ICU: a successful multidisciplinary quality improvement project.

Pseudomonas aeruginosa infection causes high morbidity and mortality, especially in immunocompromised patients. Pseudomonas can develop multidrug resistance. As a result, it can cause serious outbreaks in hospital and intensive care unit (ICU) settings, increasing both length of stay and costs. In the second quarter of 2020, in a community hospital's 15-bed ICU, the P. aeruginosa-positive sputum culture rate was unacceptably high, with a trend of increasing prevalence over the previous 3 quarters. We performed a multidisciplinary quality improvement (QI) initiative to decrease the P. aeruginosa-positive rate in our ICU. We used the Define, Measure, Analyze, Improve, and Control model of Lean Six Sigma for our QI initiative to decrease the P. aeruginosa-positive sputum culture rate by 50% over the following year without affecting the baseline environmental services cleaning time. A Plan-Do-Study-Act approach was used for key interventions, which included use of sterile water for nasogastric and orogastric tubes, adherence to procedure for inline tubing and canister exchanges, replacement of faucet aerators, addition of hopper covers, and periodic water testing. We analyzed and compared positive sputum culture rates quarterly from pre-intervention to post-intervention. The initial P. aeruginosa-positive culture rate of 10.98 infections per 1,000 patient-days in a baseline sample of 820 patients decreased to 3.44 and 2.72 per 1,000 patient-days in the following 2 post-intervention measurements. Environmental services cleaning time remained stable at 34 minutes. Multiple steps involving all stakeholders were implemented to maintain this progress. A combination of multidisciplinary efforts and QI methods was able to prevent a possible ICU P. aeruginosa outbreak.

2213. Increased Early Syphilis Detection and Treatment in an Urban Emergency Department During the COVID-19 Pandemic

Abstract Background Many people at risk for sexually transmitted infections (STIs) utilize the emergency department (ED) for evaluation and treatment of STI-related complaints. Syphilis testing rates in the ED have historically been low. Following the implementation of a joint ED and Infectious Disease (ID) multidisciplinary quality improvement initiative designed to increase syphilis testing in this setting, we sought to evaluate the demographics and clinical outcomes for patients diagnosed with early syphilis in the ED. Methods A retrospective chart review of patients with positive syphilis test results from ED encounters at the Ohio State University Wexner Medical Center East Hospital between 1 January 2019 and 31 December 2021 was performed. Demographic and clinical information was obtained for patients diagnosed with early syphilis (primary, secondary or early latent syphilis). Results Since 2019, we have observed a significant increase early syphilis cases identified in our ED despite stable rates of testing (Figure 1). There were 55 cases of early syphilis, 3 with neurosyphilis (NS) at the time of diagnosis (Figure 2). Most cases were men (38/55; 69%), Black/African American (44/55; 80%), and symptomatic (48/55; 87%). Nine of 55 patients (16%) had HIV co-infection, 2 were new diagnoses at time of syphilis diagnosis. Most patients (44/55; 80%) completed appropriate treatment. Of the symptomatic patients, 17/45 (37%) received presumptive treatment in the ED (3 cases of NS excluded). Of those who received treatment after discharge from the ED, the median time to treatment completion was 3 days (range 0-30), with 11/24 (46%) returning to the ED for treatment. Figure 1.Figure 2. Conclusion As a result of a collaborative ED/ID STI testing initiative established at our institution, we have observed a significant increase in the number of symptomatic early syphilis cases identified in our ED between 2019 and 2021, with most patients completing treatment in a timely manner. This data show that the ED is an important and feasible setting for syphilis diagnosis and treatment when appropriate support systems are in place, including established communications with ID colleagues. Disclosures Carlos Malvestutto, MD MPH, Gilead Sciences: Advisor/Consultant|Viiv Healthcare: Advisor/Consultant Susan L. Koletar, MD, Gilead Sciences: Grant/Research Support.

Quality care for patients with tenosynovial giant cell tumor: A multidisciplinary quality improvement initiative.

56 Background: Tenosynovial giant cell tumor (TGCT) is a rare soft tissue sarcoma that is difficult to treat due to location, high risk of recurrence, and potential for significant morbidity. Recent approvals of novel systemic therapies provide new options for patients who may not be candidates for surgery. However, clinical teams may encounter challenges that inhibit prompt referral, quality of life assessment, and effective multidisciplinary care coordination between surgeons and oncologists. Methods: In September 2020, we surveyed multidisciplinary oncology health teams (n = 25) to assess gaps in TGCT diagnosis, clinical care, and multidisciplinary care coordination. To address identified gaps, teams participated in audit-feedback sessions to develop action plans for improvement. To better understand identified gaps, surveys and education were extended to a nationwide audience of providers caring for patients with TGCT (n = 553). Results: In the health teams survey, top challenges identified included differentiating among appropriate treatment management strategies (46%), coordinating care/transitions of care for patients with TGCT (25%), and making a proper TGCT diagnosis (13%). Confidence gaps echoed these challenges, with less than half of providers indicating high/very high confidence (5-point Likert scale) in their ability to distinguish between nodular and diffuse types of TGCT (47%), align treatment decisions with evidence-based guidelines (47%), and recognize and manage adverse events associated with novel therapies (47%). During audit-feedback sessions, teams developed action plans to improve collaboration between interprofessional teams, improve adverse event management, increase education for supportive care, and facilitate earlier referrals to medical oncologists. When healthcare providers nationwide were surveyed, only 13% reported high or very high confidence in differentiating available treatment options for TGCT. Additionally, the top challenges in coordination care for patients with TGCT included poor follow-up/monitoring for disease recurrence (23%), ineffective communication between multidisciplinary team members (20%), and lack of time for patient-centered measures (19%). Conclusions: These findings reveal important challenges in diagnosis, treatment, and multidisciplinary care of TGCT patients. The methods and findings from this study offer key opportunities for scalable interventions to improve care for patients with TGCT.

Spreading routine serious illness conversations at a single cancer center using a multidisciplinary and patient-family advisory approach.

367 Background: ASCO Guidelines recommend oncologists conduct serious illness conservations (SIC) for all patients with advanced cancer. We describe the spreading of a multidisciplinary and patient-family advisor (PFA) quality improvement (QI) initiative to conduct routine SIC at a NCI-designated comprehensive cancer center. Methods: This single center study describes the second phase of a learning health system initiative to conduct routine SIC for all seriously ill patients with cancer. Prior work completed included defining patient eligibility (e.g. two-year surprise question), and deploying a SIC template in the electronic health record (EHR) to capture SIC in a centralized location. Phase II can be categorized into three steps: a) increasing communication coach and PFA capacity; b) refining EHR tools to automate tracking and reporting of outcomes; and c) adoption of the Model for Improvement as the QI methodology to guide testing and implementation. For the first three months, each team engaged in preparatory work including: process mapping, key driver diagram development, and SIC Guide training. In the last six months, each team met weekly to set their own team goals, conducted iterative PDSAs, and reviewed run charts of their performance. Patient-level data on SIC documentation was collected through automated EHR tools and provided to the teams on a weekly basis. Results: Over nine months (3/1/2021 to 12/31/21), four teams screened 510 patients with cancer, identified 272 (53%) patients as eligible for SIC, and 178 (65%) of those eligible had a documented SIC from a baseline of 0%. The breakdown of this combined SIC patient count by clinician author is as follows: team A 40 (22%); team B 45 (25%); team C 9 (5%); team D 14 (8%) and specialty palliative care 70 (39%). Each team set modest, initial SIC documentation goals (range 5-15%), and attainment of first SIC documentation goal varied (range 2 to 4 months). We retained all clinician team members during the study period, but 2 out of 3 PFAs left by study period end. Noted challenges with PFA recruitment and retention included: lengthy recruitment, integration into clinical teams, and resistance to change by teams. Conclusions: The multidisciplinary approach, inclusive of specialty palliative care, increased SIC documentation. PFA involvement, as implemented, met with challenges and yielded mixed results. Additional follow-up will be required to assess if gains can be sustained and/or increased.

Head and neck cancer readmission reduction (HANCARRE) project: Reducing 30-day readmissions.

ObjectiveUnplanned 30‐day readmissions result in increased costs and decreased patient satisfaction. The objective of this study was to compare readmission rates before and after a multidisciplinary quality improvement initiative that focuses on patient and staff education, use of targeted skilled nursing facilities, and appropriate use of patient observation status.MethodsThis was a quality improvement study of all unplanned admissions to the Head and Neck Oncology service at a tertiary care facility during a 3‐year period between October 2015 and September 2018. In October 2016, when the Head and Neck Oncology service revised its discharge practices for patients undergoing extirpative and/or reconstructive surgery. These changes included enhancing patient education, increasing the use of a skilled nursing facility with directed staff education and patient handoffs by advanced practice nurses, and appropriate utilization of 23‐h observation status for returning patients. The readmission rate from the pre‐intervention era (October 2015 through September 2016) was compared to the readmission rate from the post‐intervention era (October 2016 through September 2018). Secondary outcomes were the rates of 23‐h observation within 30 days of the discharge as well as emergency room visits within 30 days of discharge.ResultsIn this sample of 449 patients, 161 (35.9%) were observed before the change‐in‐practice (before October 2016), and 288 (64.1%) were observed following the change‐in‐practice (after September 2016). On univariable analysis, the risk of readmission declined by approximately 41.4% from the pre‐intervention era, though this conclusion was not statistically significant (P = 0.06). On multivariable analysis, patients at moderate or high risk of death were 2.31 times more likely than those at minor risk of death to readmit within 30 days (P = 0.03). Similarly, those with recurrent or persistent cancer were 3.33 times more likely than those undergoing initial curative surgical management of cancer to readmit within 30 days (P = 0.001). No patient characteristics were associated with a 23‐h observation following discharge (all P > 0.05). Conclusions were similar for emergency room visits following discharge.ConclusionsA three‐part quality improvement strategy resulted in a clinically important decrease in 30‐day readmissions, though the decline was not statistically significant. There were no significant changes in 23‐h observation within 30 days of discharge or emergency room visits within 30 days of discharge.

Timely completion of spinal fusion: A multidisciplinary quality improvement initiative to improve operating room efficiency.

Failure to complete surgery within the scheduled timeframe impairs operating room efficiency leading to patient dissatisfaction and unplanned labor costs. We sought to improve timely completion (within 30 min of scheduled time) of first-case spine fusion surgery (for idiopathic scoliosis) from a baseline of 25%-80% over 12 months. We also targeted timely completion of perioperative stages within predetermined target completion times. The project was conducted in three overlapping phases over 16 months. A simplified process map outlining five sequential perioperative stages, preintervention baselines (N=24) and time targets were defined. A multidisciplinary team conducted a series of tests of change addressing the aims. The key drivers included effective scheduling, team communications, family engagement, data collection veracity, standardized pathways, and situational awareness. Data collected by an independent data collector and from electronic medical records were analyzed using control charts and statistical process control methods. Post-intervention, timely case completion increased from 25% to 68% (N=49) (95% CI 15.1-62.7), (p=0.003) and was sustained (N=14). Implementation of prediction model for case-scheduling decreased difference between scheduled and actual case end-time (33 vs. 53 min [baseline]) and variance [lower/upper control limits ([-26, 51] vs. [-109, 216]min [baseline]). Average start time delay decreased from 6 to 2min and on-time surgical starts improved from 50% to 70% (95% CI 3.2-41.6%). Timely completion increased for anesthesia induction (60% to 85%), surgical procedure (26% to 48%) and emergence from anesthesia (44% to 80%) but not for intraoperative patient preparation (30% to 25%) perioperative stages. Families reported satisfaction with preoperative processes (N=14), and no untoward intraoperative safety events occurred. Application of QI methodology reduced time variation of several tasks and improved timely completion of spine surgery. Beyond the study period, sustained team behavior, adaptive changes, and vigilant monitoring are imperative for continued success.

Cumulative sum learning curves guiding multicenter multidisciplinary quality improvement of EUS-guided tissue acquisition of solid pancreatic lesions.

Background and study aims  In this study, we evaluated the performance of community hospitals involved in the Dutch quality in endosonography team regarding yield of endoscopic ultrasound (EUS)-guided tissue acquisition (TA) of solid pancreatic lesions using cumulative sum (CUSUM) learning curves. The aims were to assess trends in quality over time and explore potential benefits of CUSUM as a feedback-tool. Patients and methods  All consecutive EUS-guided TA procedures for solid pancreatic lesions were registered in five community hospitals between 2015 and  2018. CUSUM learning curves were plotted for overall performance and for performance per center. The American Society of Gastrointestinal Endoscopy-defined key performance indicators, rate of adequate sample (RAS), and diagnostic yield of malignancy (DYM) were used for this purpose. Feedback regarding performance was provided on multiple occasions at regional interest group meetings during the study period. Results  A total of 431 EUS-guided TA procedures in 403 patients were included in this study. The overall and per center CUSUM curves for RAS improved over time. CUSUM curves for DYM revealed gradual improvement, reaching the predefined performance target (70 %) overall, and in three of five contributing centers in 2018. Analysis of a sudden downslope development in the CUSUM curve of DYM in one center revealed temporary absence of a senior cytopathologist to have had a temporary negative impact on performance. Conclusions  CUSUM-derived learning curves allow for assessment of best practices by comparison among peers in a multidisciplinary multicenter quality improvement initiative and proved to be a valuable and easy-to-interpret means to evaluate EUS performance over time.

Totally Excited about Moving Mobility and Exercise (TEAM Me): A Successful Multidisciplinary Exercise Quality Improvement Initiative for Pediatric and Young Adult Oncology and Stem Cell Transplant Inpatients.

Background: Pediatric, adolescent and young adult (PAYA) patients are less active than their healthy counterparts, particularly during inpatient stays. Methods: We conducted a quality improvement initiative to increase activity levels in patients admitted to our pediatric oncology and cellular therapy unit using a Plan-Do-Study-Act (PDSA) model. An interdisciplinary team was assembled to develop an incentive-based inpatient exercise and activity program titled Totally Excited About Moving Mobility and Exercise (TEAM Me). As part of the program, patients were encouraged by their care team to remain active during their inpatient stay. As an additional incentive, patients earned stickers to display on TEAM Me door boards along with tickets that could be exchanged for prizes. Activity was assessed by documentation of physical therapy participation, tests of physical function, and surveys of staff perceptions of patient activity levels, motivations, and barriers. Results: Compared to baseline, patient refusals to participate in physical therapy decreased significantly (24% vs. 2%) (p < 0.02), and staff perceptions of patient motivation to stay active increased from 40% to 70% in the post implementation period. There were no changes in physical function tests. Conclusions: An incentive-based exercise program for young oncology inpatients greatly improved patient activity levels, participation in physical therapy and influenced professional caregivers’ beliefs.

61. A Multidisciplinary Quality Improvement Initiative to Promote Penicillin Allergy Delabeling

BackgroundPenicillin (PCN) allergies are reported in up to 10% patients and are associated with adverse clinical and antimicrobial stewardship outcomes. Here we describe a multidisciplinary quality improvement (QI) initiative to facilitate PCN delabeling at a large urban hospital.MethodsStarting in August 2020, the departments of Allergy and Infectious Diseases (ID) began a joint QI effort to employ a part time allergist nurse practitioner (ANP) for PCN allergy assessment and delabeling. The ANP used a daily system generated list to identify and assess adult patients with PCN allergy and contact teams to request a consult. An ID fellow also assisted with identifying patients and contacting care teams. The ANP then offered skin/oral PCN challenge or direct label removal based on history after discussion with an allergist physician. Baseline, clinical, and allergy characteristics were compared between patients delabeled and not delabeled using Chi-square and Mann-Whitney U test. Primary endpoints were antibiotic utilization outcomes from index admission post ANP assessment to 30-days post discharge. Secondary endpoints included readmission, length of stay (LOS), mortality, and sustained removal of the PCN allergy at 30-days. ResultsBetween 30 August 2020 and 6 May 2021 (250 days), 139 PCN allergic patients were assessed (81 delabeled versus 58 not delabeled) (Figure 2). Some patients (37%) were delabeled via history alone, while 63% had further skin/oral testing. Baseline characteristics were similar between groups (Table 1). In the delabeled group, we observed increased narrow-spectrum PCN use (p< 0.001), and decreased vancomycin (p< 0.001), fluoroquinolone (p=0.013), carbapenem (p< 0.011), and overall restricted antimicrobial use (Table 2). Rates of 30-day readmission, LOS, and mortality were comparable. Four (5%) of delabeled patients had had PCN allergy re-entered in the chart at 30-days. Patients were similar between groups on all baseline clinical and allergy characteristics except for more patients with infection classified as “other” in the non-delabeled group. In the delabeled patients, we observed increased narrow-spectrum PCN use and decreased vancomycin, fluoroquinolone, carbapenem, and overall restricted antimicrobial use. Use of first and second generation cephalosporines was comparable between groups. Rates of 30-day readmission, LOS, and mortality were comparable.ConclusionThis QI effort between the departments of Allergy and ID to employ an ANP increased narrow spectrum antibiotic use and reduced use of restricted antimicrobials. Challenges included the part time position of the ANP unable to see every patient, reemergence of allergy in the chart, and clinical or other exclusions for delabeling (Fig 3). Disclosures All Authors: No reported disclosures

Increasing Rates of Prone Positioning in Acute Care Patients with COVID-19.

BackgroundProne positioning improves mortality in patients intubated with acute respiratory distress syndrome and has been proposed as a treatment for nonintubated patients with COVID-19 outside the ICU. However, there are substantial patient and operational barriers to prone positioning on acute floors. The objective of this project was to increase the frequency of prone positioning among acute care patients with COVID-19.MethodsThe researchers conducted a retrospective analysis of all adult patients admitted to the acute care floors with COVID-19 respiratory failure. A run chart was used to quantify the frequency of prone positioning over time. For the subset of patients assisted by a dedicated physical therapy team, oxygen before and after positioning was compared. The initiative consisted of four separate interventions: (1) nursing, physical therapy, physician, and patient education; (2) optimization of supply management and operations; (3) an acute care prone positioning team; and (4) electronic health record optimization.ResultsFrom March 9, 2020, to August 26, 2020, 176/875 (20.1%) patients were placed in prone position. Among these, 43 (24.4%) were placed in the prone position by the physical therapy team. Only 2/94 (2.1%) eligible patients admitted in the first two weeks of the pandemic were ever documented in prone position. After launching the initiative, weekly frequency peaked at 13/28 (46.4%). Mean oxygen saturation was 91% prior to prone positioning vs. 95.2% after (p < 0.001) in those positioned by physical therapy.ConclusionA multidisciplinary quality improvement initiative increased frequency of prone positioning by proactively addressing barriers in knowledge, equipment, training, and information technology.

Geriatric Recovery and Enhancement Alliance in Trauma (GREAT) multidisciplinary quality improvement initiative: improving rates of successful resuscitation, rehabilitation and reintegration of geriatric trauma patients across the trauma spectrum of care

Geriatric Recovery and Enhancement Alliance in Trauma (GREAT) multidisciplinary quality improvement initiative: improving rates of successful resuscitation, rehabilitation and reintegration of geriatric trauma patients across the trauma spectrum of care. Sandy Widder, Kristin E. Morch, Nori L Bradley, Lauren Ternan, Ni Thuyen Lam Background: Traumatic injuries are a significant cause of morbidity and mortality in the elderly, with the risk of poor outcomes increasing with advanced age. Using a multidisciplinary geriatric trauma care approach, led by a dedicated nursing coordinator, standardized order sets were implemented to reduce in-hospital complications and screening tools applied early to identify patient specific care needs. Specifically, early trauma consult, identification of injuries, appropriate opioid ordering, polypharmacy avoidance, delirium prevention, mental health issues, and mobility needs were addressed The goal was to improve geriatric trauma awareness, decrease in-hospital complications and improve the likelihood of return to home and baseline function Implementation: Through stakeholder consultation process, it was recognized that the hospital needed a coordinated, geriatric trauma team process. The geriatric trauma navigator (GTN) role was created to lead these quality improvement initiatives. This included the development of educational strategies for frontline staff and physicians to highlight the unique challenges of trauma patient management and to introduce the GREAT study for optimized patient care. Patients 65 years of age or older with a traumatic mechanism were enrolled. GREAT patients then followed a protocol designed for tracking and implementing standardized processes, including early ED and in-patient order sets, engagement of trauma services, and the application of screening tools and specialty consultations. Screening tools (Identification of Seniors At Risk (ISAR), Confusion Assessment Method (CAM), Mini-Cog, Patient Health Questionnaire (PHQ-2), Geriatric Depression Scale (GDS-15), Alcohol Use Disorders Identification Test- Concise (AUDIT-C), Canadian Nutrition Screening Tool (CNST), Clinical Frailty Scale, ADL/IDLs) were administered to identify at-risk patients and to inform consultation with geriatrics and psychiatry, and allied health services (occupation therapy, physical therapy, nutrition services, pharmacy). The study team evaluated data on a monthly basis and met quarterly to evaluate and implement changes. Evaluation Methods: Data was prospectively collected and compared to control data from the Alberta Trauma Registry and Trauma Quality Improvement Program (American College of Surgeons). Data tabulation and statistical analysis was performed using Stat59 (STAT59 Services Ltd, Edmonton, AB, Canada). Outcome measures-provision of timely and comprehensive care: rates of trauma team activations, emergencydepartment and in-hospital length of stay-reduction of hospital complications: UTI, DVT/PE, pneumonia, pressure ulcers, ICUadmission, unexpected readmission to hospital-improvement of functionality upon discharge: in-hospital and 30 day mortality rates,return to function, disposition (home versus long term care) Process measures-time to diet and ambulation-tracking of number of days of urinary catheter in situ-compliance with GOC discussions-use of assessment screening tools-spinal clearance &lt;24 hours Results: Enrollment of patients into GREAT based on study criteria lowered the threshold for triggering a trauma team consult, improving the recognition rate of geriatric trauma. This was reflected in the decreased average ISS scores and higher rate of trauma consults. Ground level falls, which previously did not typically activate a trauma consult, are now be recognized as major trauma. With the GTN, we determined that gaps exist in the current monitoring of key performance measures. Through the GREAT data collection process, we were able to establish baseline data and target PDSA changes to address these gaps. Advice and Lessons Learned: This quality initiative was designed as a proof of concept model for early identification of the geriatric trauma patient and a collaborative team approach to optimize care processes, and in turn minimize complications. The GTN role was vital to identify patients, implement screening tools, and coordinate care. With limited resources and increasing work loads for all programs, the additional GTN role required site leadership and stakeholder support. Ideally, a protocolized geriatric trauma team activation and admission process would ensure all patients receive screening tools as part of their in-patient orders for early assessments and interventions. Further educational campaigns will need to be developed to increase awareness of the importance of geriatric trauma. Additionally, processes need to be streamlined for data gathering and monitoring of performance measures. Access to screening tools and order sets need to be user friendly, built into currently existing workflows, and evaluated for optimization.

Assessing Adherence to Audiologic Parameters of Care for Children With Cleft Palate: A Quality Improvement Initiative.

To evaluate and increase adherence to an evidence-based audiologic management protocol for children with cleft palate. Prospective, multidisciplinary quality improvement initiative. Tertiary pediatric hospital. Children with cleft palate (with or without cleft lip) between the ages of 0 and 5 years (n = 205). A multidisciplinary team identified key drivers for nonadherence to recommended audiological follow-up and implemented interventions to improve adherence. Key drivers included provider practices and preferences, clinic logistics and flow, and patient/family awareness and education. Several interventions were implemented between 2016 and 2020, including developing an evidence-based audiologic protocol, maximizing access to audiologic clinic visits across multiple departments, cleft team education, and improved team communication. Completion of recommended audiologic assessment at 5 separate care milestones. After implementation of interventions between 2016 and 2020, adherence to recommended audiologic follow-up increased from 59% to 84%. Analysis of individual care milestones revealed that increased access to audiologic testing during team clinics resulted in the largest increase in adherence to recommended follow-up. Additionally, cause-effect analysis revealed that nonadherence due to provider-related causes decreased over the project period to a greater extent than patient/family-related causes. Implementation of an evidence-based audiologic care protocol and improvements in access to early hearing care are feasible in a high-volume multidisciplinary cleft clinic. Adherence to recommended audiologic management can be improved by establishing strategies to improve access to care, team member and family education, and enhanced team communication.