Multiple PDSA Cycles Research Articles

52 The bag is not always bad: Implementing a two-step method for urine testing on the inpatient paediatric units

Abstract Background Urinary tract infections (UTIs) are a common source of infection in children. Best practice for diagnosis includes interpreting a urinalysis (UA) and urine culture. Urine cultures obtained through bladder catheterization are invasive and time consuming. A two-step approach with noninvasive UA screen, followed by urine culture if positive has previously demonstrated a reduction in unnecessary catheterizations and urine cultures in children 6-24 months with suspected UTIs. Pre-intervention, there was inconsistent use of screening point-of-care urinalysis prior to bladder catheterization for culture. Objectives To decrease the number of bladder catheterizations in children 6-24 months with a negative screen on Point of Care Test (POCT) urinalysis by 25% over 1 year on paediatrics wards at a paediatric tertiary care centre. Outcome measures: 1. Proportion of bladder catheterizations with negative or no UA screen prior 2. Proportion of UA completed as POCT rather than lab sample Process measures: 1. Number of urinary catheterizations performed for UTI screen 2. Number of times pathway is followed Balancing measure: 1. Missed UTIs Design/Methods Baseline data was collected from the paediatric inpatient units at a tertiary paediatric hospital from April 2020 – April 2021. A two-step pathway for collecting urine samples was adopted, including POCT UA screen on a bag sample, followed by bladder catheterization for culture if positive. The pathway was implemented using the Model for Improvement and multiple PDSA cycles. Intervention focused on education, interdisciplinary collaboration, and process standardization. Results Baseline data demonstrated a high rate of urinary catheter cultures despite a negative UA or no UA prior (69%). After pathway implementation, this rate decreased to 23%, with a reduction in initial UA collected by catheter from 14% to 5% (figure 1). The number of POCT UA performed has increased from a median of 64% pre-intervention to 80% post-intervention, resulting in fewer samples processed in the lab (figure 2). Conclusion Variability in practice for specimen choice for collection and investigation contributed to unnecessary catheterizations. Process standardization successfully improved patient-centered care and efficiency. Next steps include broadening pathway inclusion criteria to the 3–6-month age group. Potential competing interests This work was partially supported by the UMC (Utilization Management Committee) Resource Stewardship Grant. The authors declare no additional sources of funding or conflicts of interest.

Quality Improvement Protocol: Improving the Use of Nonpharmacological Pain Management Strategies within the Inpatient Hospital Setting.

Background: There are many nonpharmacological pain management services available to hospitalized youth; however, not all youth are offered these services. Lack of knowledge about resources, difficulty with the referral process, and lack of understanding about nonpharmacological pain management services and when to refer patients are among the main reasons for lack of utilization. Quality improvement (QI) initiatives have grown within hospital settings and can serve to create change in fast-paced environments. Methods: The current QI project aimed to pilot an educational program to increase the use of nonpharmacological pain management interventions. Staff located on one floor of a pediatric hospital on the East Coast were selected because of the wide range of patient presentations and likelihood that these youth may present with pain during the hospitalization. Following several incremental changes and multiple PDSA cycles, utilization of nonpharmacological pain management services was assessed. Results: Education only did not result in increases in nonpharmacological pain management services ordered. A best practice alert for nursing staff, implemented within the electronic medical record, led to a 50% increase in services ordered. Conclusions: These results suggest that to improve use of nonpharmacological pain management strategies, hospital systems may need to consider more than education.

Improving the chemotherapy unit by implementing Medication Early Release Project (MERP).

343 Background: The outpatient oncology infusion suite is a very busy unit and sees an average of 60 to 70 patients per day. A limited number of treatment chairs, one pharmacy hood for biohazardous drug preparation and various other factors have resulted in long waiting times for patients before starting their treatment. To improve the patient experience and to try and alleviate pressure on the preparation pharmacy and nursing services during peak times we investigated the feasibility of an early medication preparation and release program. This would enable rapid admission, assessment and administration of the pre-prepared treatment and in turn have a positive impact on patient flow and equalize the pressure felt by the preparation pharmacy. Methods: In this quality improvement project we formed a committee that met on biweekly basis, this committee included representatives from nursing, quality, pharmacy, data analysis and was led by a consultant physician. We studied the baseline data of patient waiting times from January to March 2019 and factors that caused patient delays in being treated. Patient selection criteria were prepared to identify patients that could safely have their medication released early in the morning at 7 am enabling pharmacy to dispense at 8 am without their actual presence being required in the infusion suite. Multiple PDSA cycles with several process changes and educational interventions were implemented to achieve our goal. Results: Baseline data identified that the average waiting time was 2.27 hrs a with a range of waiting times between 33 minutes to 5.07 hrs. After the first intervention the average waiting time reduced to 1 hr. and 24 minutes through each PDSA cycle we could see small improvements in the average time. The major breakthrough appeared following the intensive patient education program and enforcement of strict compliance with the criteria in selecting patients appropriate for the early release program. team sustained and keep average waiting time within control limit of less than one hour from 8th month of the program until January 2021 to be 33 minutes. We identified drug wastage for patients who did not show up as a balancing measure. We were successful in reducing the drug wastage by applying several changes and patient education measures and reached zero wastages. Patient satisfaction survey were conducted they were satisfied after their enrolment in the program. Conclusions: Positive impact has been seen with a significant reduction in the average waiting time from 2.24 hours to 41 minutes exactly. With further interventions relating to patient education and root cause analysis of any patients who are spending longer than necessary in the waiting area we aim to improve this further, an expansion of the pharmacy's capacity to prepare more than 10–15 preparations between 7–8 am may give rise to a further expansion of the criteria for patients to be included in the MERP pathway.

97 Decreasing invasive urinary tract infection screening in a paediatric emergency department: A quality improvement initiative

Abstract Primary Subject area Emergency Medicine - Paediatric Background Fever is a common presentation among children coming to the Emergency Department (ED) and a urinary tract infection (UTI) often needs to be excluded. Sterile techniques, like catheterization, are invasive, can be traumatizing to children, and are time consuming to complete. A two-step approach has been shown to reduce the catheterization rate in febrile, young children without unintended consequences. Objectives Our aim was to implement a two-step approach for UTI screening in febrile children 6-24 months in order to decrease unnecessary urine catheterizations by 50% without impacting ED length of stay (LOS) or return visits (RVs). Design/Methods After engaging key stakeholders and a nursing champion, we created a process map to understand the current urine collection process in our ED, and areas for targeted improvement. Using the model for improvement, we adopted a 2-step pathway for a suspected UTI in children 6-24 months as our change idea. The pathway involved identifying children who met inclusion criteria for UTI screening, followed by urine bag application and urinalysis (UA) if clinically indicated. Only if the UA was positive, a second urine sample was collected via catheterization, for repeat UA and culture. Through multiple PDSA cycles, our pathway was implemented in the ED along with concurrent staff education. The outcome measure was the rate of ED urine catheterizations. Process measures included the total number of urine cultures sent to microbiology and percent positivity. The balancing measures included ED LOS and RVs. Results Since project initiation in July 2019, the ED catheterization rate decreased from 73% to 53% (Figure 1) and the number of urine cultures sent to Microbiology decreased by 23%. The number of urine cultures sent to Microbiology decreased by 23% with a mild improvement in the positivity rate by 2% (Figure 2). There was no significant change in RVs. There was a slight 10-min increase in ED LOS, most likely confounded by the COVID pandemic. Conclusion Using improvement methodology, we successfully decreased the number of unnecessary catheterizations in children and the number of urine cultures sent to microbiology. Further refinements to our intervention are ongoing and include optimizing urine screening equipment in patient rooms, poster reminders, re-education for providers, and introducing a parent resource explaining the 2-step pathway. This improvement work is also being spread to the paediatric wards and can easily be adopted by other paediatric centres. It has also been adapted by the Choosing Wisely hospital campaign.

A quality improvement initiative to successfully reduce the frequency of hypoglycemia during treatment of hyperglycemic crises at an academic safety-net hospital: Insights and results

BackgroundDiabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are potentially life-threatening complications of diabetes. Many hospitals have developed protocols to guide the management of these conditions and align with best practices. One of the main complications encountered in the treatment of hyperglycemic crises is hypoglycemia. MethodsAt our institution, we undertook a review of our insulin infusion titration protocol, rates of hypoglycemia, and time to clinical resolution for patients with hyperglycemic crises. A multidisciplinary team performed a literature review and analyzed baseline hospital data with the existing protocol. With the input of multiple stakeholders, several changes were made to the titration algorithm over multiple PDSA cycles to refine the protocol. Effectiveness and safety of the protocol, as well as fidelity with the protocol, were assessed after each PDSA cycle. ResultsAfter the initial cycle, chart review showed a reduction in hypoglycemia rates of more than 50% in patients treated with the new protocol without any increase in time to resolution of DKA. A second version of the protocol was implemented to improve usability, and improvement in hypoglycemia was maintained. ConclusionDespite the fact that the initial protocol had been developed based on best practice recommendations, rates of hypoglycemia were initially high. Critical assessment of pitfalls in management allowed changes to the protocol that significantly and sustainably reduced hypoglycemia.

PO504a / #1986: IMPROVING COMMUNICATION WITH LIMITED ENGLISH PROFICIENCY FAMILIES IN THE PICU

AIMS & OBJECTIVES: Children and families with Limited English Proficiency (LEP) have been reported to have worse healthcare outcomes as a result of communication barriers. The objective of this quality improvement study was to increase the frequency and quality of communication with LEP families in the PICU through improved access and functionality of video interpreters. METHODS: Interpretation data from our tertiary PICU were obtained and monitored starting in 2019. A key driver diagram was utilized to develop potential interventions. Multiple PDSA cycles were completed to evaluate interventions including providing written instructions on video interpreter use, obtaining new standardized video interpreter devices, designating standard locations and staff education around effective interpretation. Statistical process control was employed to analyze the number of interpretations per LEP patient per day based on hospital billing data. RESULTS: There were 82 encounters requiring interpretation during the study period, with an average of seven LEP families in the PICU on any given day. During the preimplementation phase (September-December 2019), LEP families received an average of 1.5 interpretations per patient day. After implementation (January-May 2020), LEP families received an average of 2.1 interpretations per patient day. CONCLUSIONS: Targeted efforts towards using interpretation services with LEP families can be an effective way to increase frequency of communication. Technology standardization alone did not increase interpreter use, however standardization along with improved accessibility correlated with an increase in interpreter use. This project was limited by a delay in data of interpretations due to billing processing, and disruption of overall patient census during the COVID19 pandemic.

15. WHO SPEAKS FIRST? PROMOTING SENIOR RESIDENT AUTONOMY ON FAMILY CENTERED ROUNDS: A QI INITIATIVE

Background Graduated resident autonomy is fundamental as a trainee begins to transition to independent practice. Family Centered Rounds (FCR), the leading model of inpatient rounding in pediatrics, is an opportunity for trainees to demonstrate their competence in leading a healthcare team, which is included as an entrustable professional activity for all pediatric residents by the American Board of Pediatrics. At our institution, senior residents (SR) at baseline performed at a novice level based on the SREA-21, a validated tool that assesses SR autonomy during FCR in 4 domains. Aim Statement Our aim was to increase the median percentage of SREA-21 domains where SR perform at a competent level from 38% to 75% within 6 months. Interventions We used the Model for Improvement to identify key drivers and test proposed interventions using serial PDSA cycles. Interventions included: creation of unified inpatient SR expectations agreed upon by the division of pediatric hospital medicine, introduction of a hospitalist-SR pre-FCR huddle, auditing of FCR interruptions, and direct feedback to the hospitalist-SR dyad by the observer after FCR. Run charts were used to track both SR and hospitalist scores based on the SREA-21 tool. Measures Researchers observed 4 FCR encounters weekly, and calculated SREA-21 domain scores based on actions promoting SR autonomy that were performed by the hospitalist-SR dyad. The primary outcome measure was the percentage of SREA-21 domains in which the SR achieved a competent score based on the tool. Results Prior to our interventions, the median percentage of SREA-21 domains in which the SR performed at a competent level was 38%. After multiple PDSA cycles, there was special cause improvement with a desirable shift upward in the median to 75%, which correlated with the project's interventions and met our goal. The creation of unified SR expectations and the addition of a daily hospitalist-SR huddle had the strongest impact on SR autonomy. Conclusions and Next Steps Using quality improvement methodology, we improved senior resident autonomy during FCR, as measured by the SREA-21 tool. Future interventions will be aimed at sustaining this improvement and evaluating the effect of this change on future independent practice, as well as resident well-being.

5. IF YOU SEE SOMETHING, SAY SOMETHING: ENGAGING HOUSESTAFF IN PATIENT SAFETY AND EVENT REPORTING

Background Residents and fellows play a key role in patient care at academic medical centers and have unique insights into quality and safety improvement opportunities. To increase integration of trainees into the quality and safety mission of our hospital, the Housestaff Quality and Safety Council (HQSC) was created in 2018. The HQSC represents a collaboration between the housestaff, Graduate Medical Education, office of Quality and Safety, interprofessional hospital staff, and senior leadership. At our institution, Aim Statement Our objective was to increase the monthly incidence of event reporting by graduate medical trainees by 20% from baseline within 12 months. Interventions We used improvement methodology to identify critical drivers of barriers to submitting event reports, which included 1) education and awareness of the hospital's reporting system, 2) time and effort associated with submitting reports, 3) culture of safety, and 4) lack of feedback and transparency surrounding reports (Figure 1). We used an iterative approach with multiple PDSA cycles to increase knowledge and engagement of event reporting. Tests of change included tip sheets, development of a trainee-run Morbidity, Mortality, and Improvement (MM&I) conference, acknowledgement by senior leadership for submitting reports, and educational interventions. Measures The baseline mean number of safety reports by trainees in the 12 months prior to our project was 24.6 per month. Results The number of safety event reports placed by trainees increased in the initial 5 months of the project, reaching special cause variation in month 2 and 4. Educational interventions and tip sheets were implemented in PDSA #1, the MM&I conference was implemented in PDSA #2, and acknowledgement by senior leadership was implemented in PDSA #3. Conclusions and Next Steps Engaging trainees in patient safety concepts through education, interactive conferences, and appreciation can increase safety event reporting by trainees. Future planned PDSA cycles include implementing changes to increase timely feedback, developing patient safety faculty and resident experts, and increasing audit and feedback of reporting data to trainees.

51. INCREASING PEDIATRIC RESIDENT LOGGING OF PROCEDURES THROUGH DEVELOPMENT OF A MOBILE APP

Background Learning to perform common medical procedures is one of many elements of Pediatric residency training. In our program, we have observed great proficiency of residents’ procedural skills, but an unfortunate deficiency in completion of procedural logs. Incomplete procedure logs make it difficult to ensure each resident is receiving adequate procedural skills training and to certify competency to future employers. At our institution, the biggest barrier to timely completion of procedure logs was a cumbersome, tedious, and time-consuming logging system (New Innovations). Using QI methodology and technology, we aimed to improve the procedure logging process. Aim Statement To increase the number of procedures logged per resident, from 14 per year to 20 per year (1.66 per month), by March 31, 2020. Interventions We used the model for improvement to perform multiple PDSA cycles to create a simpler, quicker, and more efficient process for logging procedures. After analyzing failures in our legacy process, we tested multiple commercially available apps and web-based platforms as potential replacements. Based on our learning, we opted to design and create our own “NYU Peds App”. The app was iteratively tested using small groups of Pediatric residents, allowing us to modify the design and maximize efficiency, prior to implementation across the full program. Following the launch of the app, the program created a new policy, specifying the number of procedures to be completed each year. Results Since its launch, 1192 procedures have been logged using the NYU Peds App. The number of procedures logged per resident per month has increased from 0.9 to 3.2 (see Figure 1). Further, we have improved resident satisfaction. On an anonymous survey, the percent of residents who strongly agree that the logging system is easy to use significantly increased from 3% (New Innovations) to 82% (NYU Peds App). Conclusions and Next Steps We were able to successfully increase the number of procedures logged by our residents. The main driver of the improvement was implementation of a mobile app that is easy, fast, and usable at the time of care.

LO38: Reducing inappropriate urine culture testing in the emergency department

Background: Urinary tract infections (UTI) are a common emergency department (ED) presentation. Urine cultures (UC) are frequently ordered to confirm the diagnosis, however, it can be challenging to differentiate between a true infection and asymptomatic bacteriuria (ASB) which does not generally benefit from antibiotics. This over-treatment of ASB leads to serious adverse side effects, growing antimicrobial resistance and increased healthcare costs. By reducing inappropriate ED urine culture testing, we can concomitantly avoid the false positives that contribute to this large-scale problem. Aim Statement: We aimed to reduce ED urine culture testing at Credit Valley Hospital, a large community hospital based in Mississauga, Ontario by 30%, from a baseline average of 97 cultures per 1000 ED visits in 2017, to 68 cultures per 1000 ED visits by year end 2019. Measures & Design: Multiple PDSA cycles were ran with our multi-disciplinary ED team. Our interventions to encourage rational urine culture testing are three-fold, including (1) medical directive optimization (removal of routine sending of UC), (2) individualized physician feedback and (3) physician education with introduction of a clinical decision aid. Our outcome measure is rate of UC per 1000 ED patient visits with a balance measure of rate of 30-day ED return visit of hospital admission for patients with a UTI. Evaluation/Results: Despite a parallel surge in ED volumes, we observed a significant decrease in urine culture testing, from an annual average of 97 cultures per 1000 ED visits to 60 cultures per 1000 ED visits in 2019 year-to-date. There was no increase in the rate of ED 30-day return visit or admission for UTI or a diagnostic equivalent. Discussion/Impact: Our multipronged approach effectively decreased the rate of UC testing during the study period. ED physicians provide higher quality care with judicious use of resources to guide diagnosis and management. Active ongoing interventions include our transition to a 2-step UC order protocol (uncoupling urinalysis with culture) using BD vacutainer urine collection products, which will allow for 48 hour storage of uncompromised urine. Further work will leverage our knowledge and experience with optimizing urine culture testing to other culture specimens.

30-Day Readmission Reduction for Skilled Nursing Facility Readmissions at an Urban Medical Center (TH323B)

•Describe the factors that impact readmission of patients with chronic illness being managed at Skilled Nursing Facilities.•Recognize the key drivers that improved communication will try to achieve by the warm handoff protocol.•Describe creation of a comprehensive discharge packet with a relevant summary of hospital course. Unplanned 30-day hospital readmissions are an important measure of hospital quality and a focus of national regulations. The readmission rate for patients being discharged to skilled nursing facilities (SNF) has been an area of improvement for all healthcare systems. The vast majority of SNF will receive a penalty on their Medicare payments for fiscal year 2019 for poor 30-day readmission rates back to hospitals. We aim to reduce the 30 day all cause readmission rate at an urban medical center for skilled nursing facility discharges from the collaborative from Accountable Care Unit from 18% in 2018 to 16% from April to December 2019 at the largest teaching campus for the health system. We used our palliative care training to help improve the communication between 2 facilities. Through the discovery phase some potential Key Drivers identified for the readmissions are lack of verbal communication/wound care orders/nutrition and feeding orders/comprehensive discharge summary/advance directives. Change Concepts devised include a warm handoff between the discharging team and receiving team at SNF, creating a comprehensive discharge packet, improve the hospital course in the discharge summary, create a standardized system for discharge to a skilled nursing facility. We are in process of PDSA Cycle 3. Results of PDSA Cycle 1 and 2 for warm handoff and creating a comprehensive discharge packet show a reduction of 40% for the readmissions. PDSA Cycle 1: 10 patients were discharged after a warm handoff was given to SNF and left facility with a comprehensive discharge packet. At end of 30 days of PDSA Cycle 1, only 4 patients were readmitted. Multiple change concepts and PDSA cycles are ongoing. PDSA Cycle 2 is ongoing. By improving communication between 2 facilities, we achieved our aim in the initial PDSA Cycle by implementing our palliative care skills. We aim to continue to discover other factors and decrease readmission for chronically ill nursing home patients at our urban medical center.

Enhancing the Quality of Discharge Counselling and Reducing the Unnecessary Neonatal Follow-Up Visits: A Quality Improvement Initiative

This quality improvement initiative was undertaken in a tertiary care neonatal intensive care unit (NICU) of All India Institute of Medical Sciences (AIIMS), New Delhi to improve the quality of discharge counselling covering all post-natal mothers and reducing the unnecessary follow-up visits of the neonates admitted between June 2016 to December 2016 in the Follow-up clinic. A team was formulated to evaluate the reasons for poor or no discharge counselling and unnecessary neonatal follow-up visits and to plan further strategies for improving the quality of discharge counselling. Multiple PDSA cycles were implemented. The results of the all PDSA cycles were discussed amongst the team members. At the end of the study, all mothers started receiving standardised discharge counselling in 3 months time. Less number of mothers reported with minor neonatal problems. However, no reduction in the number of unnecessary follow-up visits of neonates was observed, but a change was observed in the neonatal problems. Thus, multiple simple feasible interventions led to the improvement in quality of discharge counseling.

Enhancing Appropriate Coagulation Testing at a Large Academic Hospital

Background: With the advent of Choosing Wisely, there has been a greater emphasis on resource stewardship in medicine. However, broad over-utilization of laboratory tests continues to be a problem, resulting in unnecessary costs and may even result in patient harm. Furthermore, overutilization can lead to a cascade of unnecessary laboratory activities with important direct and indirect costs to an already overburdened system. Coagulation testing provides a prime opportunity to make an impact in the reduction of unnecessary laboratory tests as there are clear indications for testing. Despite being validated for specific clinical circumstances, the PT/aPTT are frequently ordered as screening tests and often ordered together, demonstrating a gap in clinician understanding of the appropriate use of these tests. Educational interventions have previously been considered to be a less effective means of instituting sustainable change in lab test ordering practices. We set out to demonstrate if a multi-modal, multi-disciplinary educational intervention, embedded in a larger quality improvement (QI) initiative could enhance the appropriate use of coagulation testing and minimize laboratory resource waste at St. Michael's Hospital in Toronto, Canada. Here we present on the educational materials that were developed with multiple stakeholder involvement to support the QI process changes.Methods: In this prospective, sequential QI study we developed numerous educational materials and Electronic Medical Records (EMR) decision support prompts to facilitate knowledge translation in coagulation test ordering. The materials were developed with the input of medical students, residents, nursing staff, laboratory technologists, hematology and general internal medicine staff. The materials included educational posters and infographics distributed in clinical work areas and sent monthly via email to nurses, nurse practitioners, laboratory staff and physicians (Figure 1). Medical trainees carry out a large proportion of lab test ordering in our academic hospital, therefore we designed educational materials targeting this cohort. There was also an educational decision support prompt embedded in the EMR order system such that if a clinician attempted to order PT/aPTT testing, a message regarding the appropriate use of these tests appeared (Figure 2). Responding to practitioner requests for additional educational materials, we developed a drug- anticoagulant matching chart as well as posters on appropriate and inappropriate indications for direct oral anticoagulant test ordering. To assess the success of the educational materials, we assessed the volume of calls received by the lab's central receiving regarding coagulation testing. We also qualitatively assessed practitioner level satisfaction and modified the materials based on received feedback.Results: Substantial practitioner level satisfaction with the educational materials was evident and feedback was incorporated through multiple PDSA cycles. Following the implementation of the educational materials, central receiving laboratory technicians felt more empowered to field clinician questions regarding the appropriate use of coagulation testing. Moreover, the volume of calls to the central receiving department regarding PT/aPTT testing progressively decreased from 40-50 calls per day to 3-4 calls per day over three months when the initial multi-modal educational intervention was launched. These changes were sustainable and continue to be seen more than 2 years after the implementation of the educational intervention. This was mirrored by a significant decrease in coagulation testing rates in the hospital as part of the larger QI initiative.Conclusion: Our results indicate that a multi-modal, multi-disciplinary educational initiative that complemented a QI intervention resulted in practitioner satisfaction and support towards improved coagulation test utilization practices at a large academic centre. We believe the educational materials on coagulation testing disseminated to clinicians and embedded in the EMR ordering system effectively enhanced appropriate ordering practices and empowered practitioners as shown by the dramatic reduction in questions pertaining to coagulation testing. We believe that this highlights the importance of education to round out medical QI initiatives. [Display omitted] DisclosuresSholzberg:Octapharma: Research Funding; CSL Behring: Research Funding; Amgen: Research Funding; Shire: Research Funding.

Decreasing initiation of chemotherapy time in elective patients admitted to an inpatient hematology malignancy unit.

120 Background: At our institution, we observed that 86% (n = 25) of patients admitted for elective chemotherapy experienced a delay (greater than 6 hours) in initiating their treatment. Methods: We measured time from admission to chemotherapy administration (Defined from time of vital signs taken at admission until time of chemotherapy administration) in patients admitted for elective chemotherapy. Key process measures were identified and monitored (i.e, time from admission to laboratory exam results, time from admission to chemotherapy signed, time from chemotherapy signed to chemotherapy released by nurse from the EMR). We collected data every two weeks. After collecting data and utilizing performance improvement tools such as a pareto chart and PICK chart, we developed multiple PDSA cycles as described in Table 1. Results: At the time of interim analysis, we observed a median decrease in time to chemotherapy administration from 25 hours to 8.85 hours. Median time to lab draws decreased from 2.33 hours to -0.63 hours. There was no change in time from signature to nurse releasing the chemotherapy. We noticed more providers were signing the chemotherapy prior to patient admission and more patients were receiving pre-admission alkalinization strategies. Conclusions: By implementing new admission workflows, optimizing our use of the EMR to communicate among providers, and improving pre-admission planning we were able to reduce our time to chemotherapy for elective admissions by 64.6%. Improvement still needed to meet our goals and fully standardize the processes as part of our daily workflow.[Table: see text]

Decreasing Central Line-associated Bloodstream Infections Through Quality Improvement Initiative

To study the impact of a quality improvement (QI) initiative using care bundle approach on Central-line associated bloodstream infections (CLABSI) rates. A QI team for infection control in NICU was formed in a tertiary-care neonatal intensive care unit (NICU) from June 2015 to August 2016. Baseline data were collected over first 3 months followed by the intervention period of 1 year. Measures with respect to strengthening hand hygiene and central line bundle care were implemented during the intervention period. Audits assessing the compliance to hand hygiene and CLABSI bundle protocols were used as process indicators. Multiple PDSA cycles were used to strengthen the practices of proposed interventions, documentation of data and audits of the processes during the study period. The QI initiative achieved a 89% reduction in CLABSI from the baseline rate of 31.7 to 3.5 per 1000 line-days. The blood stream Infections reduced from 7.3 to 2.3 per 1000 patient-days. The overall mortality showed a reduction from 2.9% to 1.7% during the intervention period. There was a significant improvement in compliance with hand hygiene protocol and compliance with CLABSI protocols. This study demonstrated that simple measures involving hand hygiene and strengthening of the care bundle approach through quality improvement could significantly reduce the blood stream Infections and CLABSI rates.

A Quality Improvement Initiative to Reduce Cast Transitions in a Pediatric Hospital

Consulting Fee: Globus Medical (Samora) Implementation of a quality improvement (QI) protocol in a pediatric setting will reduce the rate of transitions from emergency department (ED)-applied casts to another form of immobilization (waterproof cast, removable orthosis, or sling) by 50%. Creating a multidisciplinary team to change local non–evidence based practices will decrease health care costs, decrease wait times in both the ED and orthopedic clinic, and reduce potential harm from cast complications. We initiated a QI project in a large tertiary care pediatric hospital to change the current local standard of care, which involved applying long-arm casts in the ED for children presenting with upper-extremity injuries not requiring a reduction. Baseline data showed that 60% of these casts were removed and transitioned to another form of immobilization at the first follow-up in the orthopedic clinic, which led to increased health care costs and risks associated with cast application. We created a multidisciplinary QI team with orthopedic and ED providers, as well as cast technicians, with the aim of reducing the transition rate of ED-applied casts in clinic by 50%. Multiple PDSA cycles were performed and data were evaluated monthly. Charge fees were determined to assess differences in costs between receiving a cast or an orthosis. An independent samples t test for equality of means was used to determine the ED length of stay of each group. Baseline data over 9 months determined a cast transition rate of 60.2%. After implementing the QI protocol, the cast transition rate was reduced to 28.0%, a 54% reduction. The length of stay in the ED for a patient receiving an orthosis as opposed to a cast was 25±7.9 (P < .001) minutes shorter. The charge to a patient receiving an orthosis rather than the ED-applied cast was $291.25 less, which resulted in an overall health care savings of $132,263.50 for these families over 1 year. •Implementation of a multidisciplinary QI protocol resulted in a more than 50% reduction in the transition rate of ED-applied casts in clinic.•Wait times were 25 minutes shorter in theED for patients receiving an orthosis as opposed to a cast.•Health care charges to families were reduced by over $132,000 annually after implementation of the QI protocol.

P151: Occupational therapy in the emergency department: sustaining results

Introduction: An emergency department visit may represent a sentinel event for someone who is older and frail, signalling a slide into dependence and functional decline. The gold standard for the treatment of frail older adults is a comprehensive geriatric assessment, involving consideration of multiple domains including mobility and function in activities of daily living. Despite this, when a chart audit was conducted in a Canadian metropolitan emergency department, none of the patients age 65 and older had a documented assessment of their function or mobility. In response, an occupational therapy program was implemented. The goals of this program were to reduce the number of unnecessary hospital admissions related to patient functional impairments, and to increase function, safety, and independence for patients upon discharge from the emergency department. Methods: The pilot project, which was completed in 2013, was evaluated using a mixed methods approach. Positive patient outcomes at that time included a reduction in avoidable admissions and better support for patients upon discharge from the emergency department. A survey of emergency department staff indicated that occupational therapy consultation added value to the diagnostic and discharge planning processes. However, due to changes in administrative priorities, several service redesigns were required. Multiple PDSA cycles were completed, and the development of a logic model guided and focused program development. Results: A reassessment of program objectives was conducted using 2015 data, which found that the number of patients seen by the occupational therapist remained the same, as did the percentage of patients discharged with support of occupational therapy intervention, such as provision of adaptive equipment or referral to community rehabilitation referrals. The percentage of patients discharged due to occupational therapy as a primary contributing factor rose slightly, and staff satisfaction with the program remained high. Conclusion: This evaluation proves that the provision of occupational therapy services in the emergency department is sustainable, benefits patients, and can be incorporated into the emergency department workflow and culture.

MP23: A collaborative quality improvement initiative to improve the time to electrocardiogram in patients with chest pain presenting to the emergency department

Introduction: For patients with chest pain, the target time from first medical contact to obtaining an electrocardiogram (ECG) is 10 minutes, as reperfusion within 120 minutes can reduce the risk of death and adverse outcomes in patients with ST elevation myocardial infarction (STEMI). In 2007, Vancouver Coastal Health (VCH) began tracking key indicators including time to first ECG. The Vancouver General Hospital (VGH) Emergency Department (ED) has been troubled with the longest door to ECG times in the region since 2014. In 2016, the VGH ED Quality Council developed a strategy to address this issue, with an aim of obtaining ECGs on 95% of patients presenting to the VGH ED with active chest pain within 10 minutes of presentation within a 6 month period. Methods: The VGH ED Quality Council brought together frontline clinicians, ECG technicians, and other stakeholders and completed a process map. We obtained baseline data regarding the median time to ECG in both patients with STEMI and all patients presenting with chest pain. Root cause analysis determined two main barriers: access to designated space to obtain ECGs, and the need for patients to be registered in the computer system before an ECG could be ordered. The team identified strategies to eliminate these barriers, identifying a dedicated space and undergoing multiple PDSA cycles to change the workflow to stream patients to this space before registration. Results: Our median times in patients with STEMI have gone from 33 minutes to 8 minutes as of June 2017. In all patients presenting with chest pain, we improved from a median of 36 to 17 minutes. As of April 2017 we are obtaining an ECG within 10 minutes in 27% of our patients, compared to 3% in 2016. Given the limitations in our data extraction process, we were not able to differentiate between patients with active chest pain versus those whose chest pain had resolved. Conclusion: By involving frontline staff, and having frontline champions providing real time support, we were able to make significant changes to the culture at triage. We cultivated sustainability by changing the workflow and physical space, and not relying on education only. While we have improved the times for our walk-in patients, we have not perfected the process when a patient moves immediately to a bed or presents via ambulance. Implementing small changes and incorporating feedback has allowed us to identify these new challenges early.

Monitoring long-term oral corticosteroids.

Corticosteroids are synthetic analogues of human hormones normally produced by the adrenal cortex. They have both glucocorticoid and mineralocorticoid properties. The glucocortoid components are anti-inflammatory, immunosuppressive, anti-proliferative and vasoconstrictive. They influence the metabolism of carbohydrate and protein, in addition to playing a key role in the body’s stress response. Mineralocorticoid’s main significance is in the balance of salt and water concentrations. Due to the combination of these effects, corticosteroids can cause many adverse effects. Oral corticosteroids are absorbed systemically and are therefore more likely to cause adverse effects than topical or inhaled corticosteroids. Furthermore, it is assumed that greater duration of treatment will lead to a greater number of adverse effects, and therefore the most at risk group are those taking high dose, long-term oral corticosteroids (LTOC). High dose is defined as a prescription of >5 mg oral prednisolone and long term as duration of treatment >1 month (based on National Institute for Health and Care Excellence guidance for patient’s ’at risk' of systemic side effects). Parameters to be monitored in primary care include weight, blood pressure, triglycerides, glucose and urea and electrolytes. From clinical experience within the general practice setting, the authors propose that these patients do not receive adequate baseline monitoring before starting corticosteroids nor are these markers monitored consistently thereafter. This project intended to evidence this claim, evaluate the adverse effect profile and improve monitoring in this patient group. The initial audit of 22 patients, within a single general practice, detected at least one documented adverse effect in 64% of patients, while 41% reported more than one adverse effect. 45% had recorded weight gain, 18% had recorded osteoporosis, 18% had at least one recorded cataract, 14% had recorded Hypertension, 14% had recorded diabetes mellitus, 9% had recorded dyspepsia and 5% had a recorded psychiatric complaint. All of these recorded conditions were either directly attributed to steroid medication or occurred since LTOC were prescribed. The aim of this project was to increase the percentage of patients on LTOC with complete baseline monitoring to 100%. ’Baseline monitoring' was defined as a measurement taken within the previous 5 years. Although somewhat arbitrary, 5 years was felt to be the maximum timeframe in which monitoring would still be relevant for comparison following introduction of LTOC. Quality improvement methodology was used throughout this project with multiple PDSA (Plan, Study, Do and Act) cycles. Through this, a monitoring system and protocol for patients taking LTOC was developed. As a result of this project, five adverse effects were detected in five different patients. These included two cases of secondary hypertension, one case of diabetes mellitus, one cataract and one case of adrenal insufficiency. 12 out of 20 patients achieved complete baseline monitoring. While this study did not fully achieve its aim, the aim was deliberately ambitious. As not all patients in this study attended for monitoring, a figure of 100% was impossible to achieve. The remaining ’incompletely monitored patients' had some but not all parameters measured. The creation of a staff protocol and increased clinical experience will ensure that complete monitoring takes place in the future. In conclusion, this project has shown that adverse effects from LTOC are prevalent in a single general practice population. It is also shown that monitoring for LTOC adverse effects is inadequate but can be improved relatively easily as skills and competencies from other medication monitoring systems already exist within healthcare settings and are immediately transferable.

Safer transitioning Optimising Frail Elderly Patients Care From Hospital to Home

Safer transitioning Optimising Frail Elderly Patients Care From Hospital to Home