Multidisciplinary Quality Improvement Team Research Articles

Improving door-to-analgesia timing in musculoskeletal injuries in an academic emergency department in India: a quality improvement project

IntroductionPain, more frequently due to musculoskeletal injuries, is a prevalent concern in emergency departments (EDs). Timely analgesic administration is paramount in the acute setting of ED. Despite its importance, many...

Improved Cardiac Rehabilitation Referral Rate Utilizing a Multidisciplinary Quality Improvement Team.

Introduction Cardiac rehabilitation (CR) is an underutilized resource in patients with ischemic heart disease, despite being a Class IA recommendation. In this study, a multidisciplinary quality improvement (QI) team aimed to improve CR referrals by standardizing the ordering process at our hospital system. Method By using a collaborative approach involving the electronic medical record (EMR), medical provider education, and hospital protocols, our two-hospital healthcare system was able to successfully identify barriers to CR referral rates and implement interventions for these barriers. All physicians and medical providers, including ancillary staff, were educated on the EMR order sets to improve compliance by using automated order sets in the EMR. The CR referral order in the EMR included a statement regarding the application of evidence-based medicine, and a computerized provider order entry was included as a reminder to the ordering provider. The use of EMR was monitored monthly by the QI committee. Chi-square test and odds ratios were obtained for statistical analysis. Results Through provider-EMR education and patient education on discharge, CR referral rates significantly improved from 51.2 to 87.1% (p = 0.0001) in a 12-month period. The study included 1,499 patients in total. The improvement was statistically significant regardless of patient gender, race, or insurance coverage. Additionally, subgroup analysis in this study found that prior to standardization of the ordering process, African American patients were significantly less likely to be referred to CR compared to Caucasian patients. (51.2% vs. 41.0%, p=0.01). There was no statistically significant difference in the likelihood of CR referral between Caucasian and African American patients following the intervention (84.0% vs. 78.0%, p = 0.166). Conclusion This study shows that CR is an underutilized resource and that effective QI initiatives may not only increase CR referral rates but also close the gap between racial inequities in referral rates. Future research with multi-center randomized control trials is needed to further enhance its external generalizability to other institutions.

Quality improvement collaborative approach to COVID-19 pandemic preparedness in long-term care homes: a mixed-methods implementation study

BackgroundThe devastating impact of the COVID-19 pandemic on long-term care (LTC) homes underscores the importance of effective pandemic preparedness and response. This mixed-methods, implementation science study investigated how a virtual-based...

Improving appropriate use of intravenous albumin: results of a single-centre audit and multifaceted intervention

BackgroundIntravenous albumin has limited indications supported by randomised controlled trials, yet it is often prescribed for indications not supported by evidence.AimTo reduce unnecessary transfusion of albumin.InterventionsUnder the leadership of a...

Reducing Osteopenia of Prematurity-related Fractures in a Level IV NICU: A Quality Improvement Initiative.

Osteopenia of prematurity (OOP) is often a silent disease in the neonatal intensive care unit (NICU). Despite its association with increased neonatal morbidity, such as fractures, wide variation exists in screening, diagnostic, and management practices. We sought to decrease the rate of OOP-related fractures in our level IV NICU by 20% within 1 year. A multidisciplinary quality improvement team identified inconsistent screening, diagnosis, and management of OOP, as well as handling of at-risk patients, as primary drivers for OOP-related fractures. Using the model for improvement, we implemented sequential interventions, including screening, diagnosis, and a management algorithm as a "handle-with-care" bundle in infants at risk for fractures. 194 at-risk infants were included, 59 of whom had OOP. There was special cause variation in OOP-related fractures, with a reduction from 0.43 per 1000 patient days to 0.06 per 1000 patient days with our interventions. There was also an improvement in days between fractures from 62 to 337 days. We achieved these improvements despite a similar prevalence of OOP throughout the initiative. We showed special cause variation with increased patients between missed OOP documentation and improved collection of OOP screening laboratories at 4 weeks of life without increased blood testing. A multidisciplinary team approach with standardized OOP screening, diagnosis, and management guidelines, including a handle-with-care bundle, reduces OOP-related fractures in a level IV NICU.

Improving management of hyponatraemia by increasing urine testing in the emergency department

Hyponatraemia on hospital admission is associated with increased length of stay, healthcare expenditures and mortality. Urine studies collected before fluid or diuretic administration are essential to diagnose the underlying cause...

Improving timely transfers from acute care to the local palliative care unit for patients at the end of life.

Despite evidence showing that nearly two thirds of the Canadian population prefer to die at home, the majority die in hospital. Honoring a patient's wish for their preferred location of death is an essential component in end-of-life care. Therefore, for those patients admitted to acute care whose choice is to transfer to a palliative care unit for end-of-life care, it is imperative that this occurs in a safe and timely manner. The General Internal Medicine ward at this local tertiary care academic center, did not have a standardized process for transferring patients at the end-of-life to the local palliative care unit. With bed calls made between Monday to Saturday at 8am, weekday and weekend transfer times ranged between 1 to 6 hours. The aim of this project was to establish a standardized, safe and efficient patient transfer from acute care to the palliative care unit for a daily standard arrival time. A multidisciplinary quality improvement team was formed to analyze the transfer process. Several Plan Do Study Act cycles were tested, targeting all steps of the transfer process and turnaround time. An outcome measure aiming for a turnaround time of two hours was set as the target. A total of fourteen patient transfers were included. Average transfer time during the weekday was reduced from a baseline average of 180.2 to 128.3 mins. This change was found to be statistically significant and sustained (P<0.003). The average transfer time on weekends remained stable at 234 mins. The outcome target of a 10:00 am arrival time to the palliative care unit was achieved 42% of the time. This project remains on-going and early data is encouraging as it met the targeted transfer time 42% of the time. Fidelity in the process measures helped to meet the targeted turnaround time of two hours for a safe and efficient transfer to the palliative care unit and ensured patients got to their preferred location for end of life care. The goal is to expand this project to other general internal medicine wards across the organization.

The Intervention Selection Toolbox to improve patient-relevant outcomes: an implementation and qualitative evaluation study in colorectal cancer surgery

BackgroundThe concept of value-based healthcare is being used worldwide to improve healthcare. The Intervention Selection Toolbox was developed to bridge the gap of value-based healthcare, between insights in outcomes and actual quality improvement initiatives. In this study we aimed to evaluate the use of the Intervention Selection Toolbox in daily practice of a quality improvement team in a hospital setting.MethodsA methodological triangulation design was used. The Intervention Selection Toolbox was used by a multidisciplinary quality improvement team for colorectal cancer care in a large teaching hospital. In-depth semi-structured interviews, focusing on the key elements of process evaluation, were conducted after implementation with representatives of the quality improvement team to evaluate the use of the Intervention Selection Toolbox. Quantitative data regarding improvement initiatives and degree of implementation was also collected.ResultsThe use of the Intervention Selection Toolbox initially resulted in 80 potential quality improvement initiatives. Eventually, two high potential improvement initiatives were selected. Some components of the toolbox were successfully implemented in daily practice, although ‘standard monitoring’ and ‘causal chain analysis’ proved more difficult to implement. Qualitative analysis was performed with ten members of the multidisciplinary team before thematic saturation occurred. Interviewed members had a wide range in characteristics: age 28–61 years, clinical experience 6–38 years and educational attainment from vocational program to academic doctorate. The Interviews showed added value in the use of the toolbox, but identified time and organizational management as restricting factors.ConclusionsThe Intervention Selection Toolbox is useful to systematically identify improvement initiatives with impact on health outcomes that matter to patients. However, before implementation organizational structure should be optimized to maximize success and efficiency on integration of the Intervention Selection Toolbox.

Embracing Change: A Quality Improvement Project to Introduce Deferred Cord Clamping.

The aim of this quality improvement (QI) project was to increase deferred cord clamping (DCC) rates in preterm infants (≤36 + 6 weeks) to 50% of eligible infants over an 18-month period. The multidisciplinary neonatal quality improvement team collaboratively developed a driver diagram to address the key issues and tasks to launching DCC. Serial plan-do-study-act cycles were used to implement successive changes and integrate DCC as normal practice. Statistical process control charts were used to track and share project progress. This QI project has increased rates of deferred cord clamping for preterm infants from zero to 45%. Our DCC rates have sequentially increased with each plan-do-study-act cycle and have shown sustained increases without significant compromise in other aspects of neonatal care, such as thermoregulation. DCC is a core element of good quality perinatal care. This QI project encountered several limiting factors to progress, including resistance to change from clinical staff and the impact on staffing and education secondary to the coronavirus disease 2019 pandemic. Our QI team used a range of approaches, such as virtual education strategies and narrative storytelling to overcome these obstacles to QI progress.

Improving Identification of Interpreter Need in the Pediatric Emergency Department.

Patients with limited English proficiency (LEP) benefit from the appropriate use of medical interpreters. A multidisciplinary quality improvement team sought to improve communication with patients with LEP within a pediatric emergency department (ED). Specifically, the team aimed to improve the early identification of patients and caregivers with LEP, the utilization of interpreter services for those identified, and documentation of interpreter use in the patient chart. Using clinical observations and data review, the project team identified key processes for improvement in the ED workflow and introduced interventions to increase identification of language needs and offer interpreter services. These include a new triage screening question, an icon on the ED track board that communicates language needs to staff, an electronic health record (EHR) alert with information on how to obtain interpreter services, and a new template to prompt correct documentation in the ED provider's note. Outcomes were tracked using statistical process control charts. All study measures met special cause for improvement during the 6-month study period and have been sustained during surveillance data collection. Identification rates for patients with LEP during triage increased from 60% to 77%. Interpreter utilization increased from 77% to 86%. The documentation of interpreter use increased from 38% to 73%. Using improvement methods, a multidisciplinary team increased the identification of patients and caregivers with LEP in an ED. Integration of this information into the EHR allowed for the targeted prompting of providers to use interpreter services and to correctly document their use.

Decreasing the Rate of Surgical Site Infection in Patients Operated by Cesarean Section in a Tertiary Care Hospital in India: A Quality Improvement Initiative.

Background Surgical site infections (SSIs) are a substantial cause of maternal morbidity and are associated with a significant increase in hospital stay and cost. The prevention of SSI is complex and requires the integration of a range of measures before, during, and after surgery. Jawaharlal Nehru Medical College (JNMC), Aligarh Muslim University (AMU) is one of the referral centers of India with a huge influx of patients. Methods The project was undertaken by the Department of Obstetrics and Gynaecology, JNMC, AMU, Aligarh. Our department was sensitized to the need for quality improvement (QI) through Laqshya, a Government of India initiative for labor rooms in 2018. We were facing problems like a high surgical site infection rate, poor documentation and records, no standard protocols, overcrowding, and no admission discharge policy. There was a high rate of surgical site infections, leading to maternal morbidity, increased days of hospitalization, more usage of antibiotics, and increased financial burden. A multidisciplinary quality improvement (QI) team was formed comprising obstetricians and gynecologists, the hospital infection control team, the head of the neonatology unit, staff nurses, and multitasking staff (MTS) workers. Results The baseline data were collected for a period of one month and it was found that the rate of SSIwas around 30%. Our aim was to decrease the rate of SSI from 30% to less than 5% over a period of six months. The QI team worked meticulously, implemented evidence-based measures, regularly analyzed the results, and devised measures to overcome the obstacles. The point-of-care improvement (POCQI) model was adopted for the project. The rate of SSI decreased significantly in our patients and the rates are around 5% persistently. Conclusion The project not only helped in decreasing the infection rates but also led to vast improvements in the department with the formulation of an antibiotic policy, surgical safety checklist, and admission-discharge policy.

Respiratory support strategies in the prevention of bronchopulmonary dysplasia: A single center quality improvement initiative.

Bronchopulmonary dysplasia (BPD) continues to be a significant morbidity affecting very preterm infants, despite multiple advancements in therapies to treat respiratory distress syndrome and prevent BPD. Local quality improvement (QI) efforts have shown promise in reducing unit or system-wide rates of BPD. In preterm infants born between 23- and 32-weeks' gestation, our aim was to decrease the rate of BPD at 36 weeks corrected gestational age from 43% to 28% by January 2019. Directed by a multidisciplinary respiratory QI team, we gradually implemented the following interventions to reach our aim: (1) early initiation of non-invasive ventilation in the delivery room, (2) initiation of caffeine prior to 24 h of life, (3) administration of early selective surfactant per a well-defined guideline, (4) continuation of non-invasive ventilation until 32 and 0/7 weeks corrected gestational age (CGA), and (5) a revision of the early selective surfactant guideline. Outcome measures included rates of BPD, and process measures included compliance with the above interventions. A total of 509 infants with an average gestational age of 29 1/7 weeks and birth weight of 1,254 (SD±401) grams were included. The rate of BPD in our unit decreased from a baseline of 43% to 19% from the start of the project in October 2016 until the first quarter of 2022 (p < 0.00001). The greatest reductions in BPD rates were seen after the initiation of the guideline to extend non-invasive ventilation until 32 0/7 weeks CGA. The rate of severe BPD decreased from 22% to 9%. In preterm infants born between 23- and 32-weeks' gestation, our local QI interventions to reduce rates of BPD were associated with a reduction in rates by 56%. Increased use of antenatal steroids and higher birth weights post- vs. pre-intervention may have contributed to this successes.

Keep calm and invert on: Reducing blood recollection rates in the neonatal intensive care unit (NICU)

Abstract Background Minimizing blood specimen recollection due to specimen integrity issues is a continuous quality improvement goal in the neonatal intensive care unit (NICU). Specimen integrity issues, such as clotting or hemolysis, are often the result of improper specimen collection processes and lead to blood loss requiring transfusion, additional painful procedures, and delays in patient care. Data collected from Mayo Clinic Hospital - Methodist Campus NICU at Mayo Clinic in Rochester, MN between January – July 2019 showed that clotted complete blood count (CBC) specimens accounted for one-third of rejected neonatal specimens followed by hemolyzed specimens for direct bilirubin (DBIL) testing. The aim of this project was to reduce the percent of CBC and DBIL tests canceled/specimens rejected due to specimen integrity issues in the NICU from 17% to 10% using the Plan-Do-Study-Act methodology. Methods A multidisciplinary quality improvement (QI) team was formed, inclusive of both NICU and laboratory representatives. Bedside direct observations (n=28) were performed by NICU nurses to help identify inconsistencies in the blood collection processes. A total of three Plan-Do-Study-Act (PDSA) cycles were conducted during the 2020-2021 time period. An assessment card was created and revised with each PDSA cycle. The card was completed by the nurse(s) present during the blood collection and initially identified the lab tests ordered, collection tubes, collection type (venipuncture, venous, capillary), number of tube inversions required, staff present during collection, any delays during collection, and whether the draw was deemed successful. Additionally, staff education videos for nursing and laboratory phlebotomy staff were created to demonstrate correct collection tube inversion technique. Results Direct observation identified inconsistent practices in tube inversion during specimen collection. The first PDSA cycle (n=207 collections, April 1 – July 13, 2021) introduced a verbal inversion count and utilization of the assessment card. The following cycle (n=336 collections, July 14 – October 10, 2021) implemented an educational video and modified the assessment card to include start and end time of the draw. The third cycle (n=243 collections, October 11 – November 30, 2021) used a simplified assessment card including patient label, tests ordered, tube type and inversions. The combined rejection rates for CBC and DBIL tests were 4.3%, 3.8% and 2.8% for the 1st, 2nd and 3rd PDSA cycles, respectively. Conclusions Our QI initiative reduced the specimen rejection rate for clotted CBC and hemolyzed DBIL specimens from 17% to 2.8% in the NICU. Interventions focused on improving tube inversion techniques and promoting collaborative relationships between phlebotomists and nursing staff. The use of educational videos and completion of assessment cards during collections were effective at reducing specimen rejection rates.

Early calcium and phosphorus supplementation in VLBW infants to reduce metabolic bone disease of prematurity: a quality improvement initiative

ObjectiveTo reduce the incidence of metabolic bone disease (MBD) among very low birthweight (VLBW) infants admitted to neonatal intensive care unit from baseline of 35% by 50% over 2 years...

60% Reduction of reoperations and complications for elderly patients with hip fracture through the implementation of a six-item improvement programme

IntroductionHip fractures are common, serious and costly fractures in the elderly population. Several guidelines seeking to ensure best practice have been introduced. Although our institution complied with national guidelines for...

Utilization of an Outpatient Integrated Infusion Suite to Decrease Length of Stay, Increase Revenue, and Improve Patient Experience for Elective Chemotherapy Admissions.

Reduction of chemotherapy start times (CST) and length of stay (LOS) for elective chemotherapy admissions is a priority. The aim of this project was to improve efficiency of patient care while simultaneously increasing revenue by reducing LOS and transitioning high-cost chemotherapy to the outpatient setting. A multidisciplinary quality improvement team proposed building a new outpatient infusion suite in close proximity to the inpatient unit. This suite was then integrated into the flow of elective inpatient chemotherapy admissions and discharges for etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin, and rituximab (EPOCH-R). Quality measures such as CST, LOS, and revenue were used to evaluate the new infusion suite. In the pilot phase of the study, the average CST improved by approximately 1 hour 45 minutes (P = .0218). The mean LOS was reduced from 4.3 to 4.1 midnights (P = .0214). In terms of hours, LOS was reduced from 105.8 to 95.5 hours (P < .0001). A mean quarterly revenue of $309,410 US dollars was noted during the pilot that had not been previously billed. These improvements were sustained throughout the control phase. Delays in CST and prolonged LOS lead to patient dissatisfaction and increased cost to the health care system. Focus groups and patient feedback are important when designing and implementing new workflows. The creation of an outpatient integrated infusion suite allows medical centers to meet patients' expectations of reducing number of visits while also reducing LOS and capturing new revenue. Adherence to scheduling guidelines further reduces the CST for elective chemotherapy administration.

Standardized Scoring Tool and Weaning Guideline to Reduce Opioids in Critically Ill Neonates.

Introduction:Pain impacts brain development for neonates, causing deleterious neurodevelopmental outcomes. Prescription opioids for analgesia or sedation are common; however, prolonged opioid exposure in neonates is associated with neurodevelopmental impairment. Balancing the impact of inadequate pain control against prolonged opioid exposure in neonates is a clinical paradox. Therefore, we sought to decrease the average days of opioids used for analgesia or sedation in critically ill neonates at a level IV Neonatal Intensive Care Unit by 10% within 1 year.Methods:A multidisciplinary quality improvement team used the model for improvement, beginning with a Pareto analysis, and identified a lack of consistent approach to weaning opioids as a primary driver for prolonged exposure. The team utilized 2 main interventions: (1) a standardized withdrawal assessment tool-1 and (2) a risk-stratified opioid weaning guideline.Results:We demonstrated a reduction in mean opioid duration from 34.3 to 14.1 days, an increase in nursing withdrawal assessment tool-1 documentation from 20% to 90%, and an increase in the documented rationale for daily opioid dose in provider notes from 20% to 70%. Benzodiazepine use did not change.Conclusion:Standardized withdrawal assessments combined with risk-stratified weaning guidelines can decrease opioid use in critically ill neonates.

Improving Blood Product Transfusion Premedication Plan Documentation: A Single-institution Quality Improvement Effort.

Introduction:Premedication with acetaminophen and/or diphenhydramine to prevent febrile nonhemolytic transfusion reactions and minor allergic transfusion reactions is a common practice based on historical recommendations. However, recent small randomized-controlled trials showed no benefit of premedication. This inconsistency leads to practice variability, which results in the inefficiency of our institution’s blood product ordering process. This project aimed to improve the number of transfusion encounters with premedication plan documentation from a baseline of 19% to 80% in 12 months.Methods:A multidisciplinary quality improvement (QI) team used QI tools to design interventions to improve the efficiency of the ordering process for blood products. Measures were tracked monthly and analyzed using statistical process control.Results:From September 2018 to January 2021, 5,351 blood product transfusion visits were scheduled. At baseline, 34% of patients received premedication, and 19% had premedication plans documented. Interventions included a passive computerized provider order entry alert, clinical care pathway development, and clinician education. Postimplementation, the average number of encounters with a premedication plan increased from 19% to 87%, whereas encounters receiving premedication decreased from 34% to 25%. There was no change in the average number of transfusion reactions (1.8 per 100 transfusions).Conclusions:Using QI methods, our team successfully standardized the blood product premedication plan documentation despite unclear best practices regarding blood product transfusion premedication. The team added premedication plan documentation training to new employee orientation for sustainability.

The use of patient experience data for quality improvement in hospitals: A scoping review

In this paper we identified what was reported in the literature on qualitative and quantitative approaches used to capture and improve patient experiences in a hospital setting. For inclusion, articles were required to describe an embedded strategy for capturing patient experiences that was used to inform quality improvement in a hospital setting. Articles also had to be published in English between January 2004 and December 2020. Six databases (MEDLINE, EMBASE, PsycINFO, CINAHL, Health and Psychosocial Instruments and Cochrane Library) and grey literature (relevant hospital and government websites) were searched. All articles were screened by two reviewers and any disagreements were resolved through consensus. Data were extracted from the included articles using a study-specific form in Microsoft Excel and synthesized using descriptive qualitative and quantitative approaches. Thirty articles were included in this scoping review. Patient experience data were captured through a variety of methods including surveys, focus groups, patient complaints and informal feedback, with the majority using formal, paper-based surveys. A wide range of quality improvement initiatives were implemented as a result of hospitals’ patient experience data, but there was limited contextual information regarding the hospital settings and population characteristics. Initiatives implemented by a dedicated and multidisciplinary quality improvement team (nurses, administrators, physicians, etc.) generally demonstrated positive outcomes. We conclude that more work is needed to better understand how best to capture and use patient experience data for quality improvement, the contexts in which initiatives are successful and how to integrate patients and families in the ongoing implementation and evaluation processes.

Multidisciplinary Project to Prevent Postoperative Urinary Tract Infection.

Postoperative urinary tract infections (UTIs) are associated with increased lengths of stay, inpatient costs, and mortality. Review of institutional data from the American College of Surgeons (ACS) NSQIP revealed opportunities to improve practices with respect to urinary catheter (Foley) insertion, catheter care, adherence to diagnosis and prevention protocols, and ACS NSQIP reporting. A multidisciplinary quality improvement team convened and implemented interventions based on a literature review and analysis of institutional drivers of postoperative UTI. The team educated the ACS NSQIP surgical clinical reviewers and clinical teams about UTI diagnostic criteria and prevention, trained staff in proper catheterization technique, and provided performance feedback. The team also developed kits with supplies and instructions for patients who were discharged home with catheters, along with an instructional video. The investigators evaluated project effectiveness by comparing pre- and postintervention process measures and rates of postoperative UTI. After interventions, compliance rates improved for hand hygiene (62% to 83%, p = 0.04), precleansing of the periurethral area (66% to 97%, p = 0.001), and catheter positioning (41% to 93%, p < 0.001), and the composite performance (10% to 73%, p < 0.001). Surgery residents' scores on a UTI knowledge assessment improved from 71% to 81% (p = 0.005). The majority of residents and staff strongly agreed that the training sessions would change their practice (57% and 69%, respectively). The unadjusted rate of postoperative UTIs at our institution decreased from 1.55% to 0.69% (p = 0.016), corresponding to an improvement in the ACS NSQIP odds ratio from 1.51 to 0.86. A series of interventions, including provider training, patient education, and audits of practice with performance feedback, are associated with improvements in both practice and the incidence of postoperative UTI.