Ongoing Quality Improvement Research Articles

Integrating an AI-powered symptom assessment application (SAA) in a hospital network in Portugal

Abstract Introduction Patients often struggle to understand medical information and healthcare worker shortage strains health systems. Integrating SAAs that guide patients and provide diagnostic decision support (DDS) to doctors can help. This study evaluates the impact of the SAA ‘Ada’, a class IIa medical device, after its integration into the patient portal of a Portuguese hospital network, CUF, on clinical workflow and patient health. Methods This on-going post-market quality improvement study, started in Nov 2023 and has enrolled 664 participants. Participating doctors complete a baseline survey. Consenting patients conduct symptom assessments and answer survey questions within the app. The patient’s symptom report is shared with their physician, who then completes a post-consultation survey. Results After using Ada, 86% of patients could enter all their symptoms, 79% felt more prepared for their consultation, and 39% felt less health anxiety (N = 664). In the baseline survey, most doctors utilize online resources (96%) in the absence of a symptom checker, followed by discussions with colleagues (65%) for challenging cases (N = 26). In the post-consultation survey, 95% of doctors found Ada’s condition suggestions reasonable, with only 10% disagreeing with its triage classification. Doctors reported time saving and increased consultation efficiency (64%), and 59% felt more confidence in their diagnosis. A majority said that Ada provided them with additional information about patients (77%). Ada also improved consultation efficiency (74%), preparation (78%), patient engagement (82%), and health knowledge (77%; N = 22). Conclusions By providing personalized health information, Ada prepares patients for their consultation, resulting in improved patient engagement and facilitation of clinical conversation. Incorporating a SAA into routine patient care enhances quality of consultation, reduces consultation time, increases efficiency, and provides DDS to doctors. Key messages • Digital health enhances patient engagement, clinical efficiency, and diagnostic decision support for doctors in healthcare settings. • Ada’s personalized health information empowers patients, improves consultations, and reduces health-related anxiety.

54 Efficacy of a quality improvement project in paediatric procedural pain management during needle procedures

Abstract Background In paediatric hospital settings, needle procedures significantly contribute to children’s experiences of pain and distress. A structured approach integrating preparation, comfort positions, distraction, relaxation techniques, and topical anesthetics can enhance children’s ability to cope with procedural discomfort. We developed a quality improvement (QI) initiative aiming to alleviate procedural pain and distress through a staggered implementation approach over a 3-year period. Objectives This study aimed to evaluate the impact of the first 2 years of an institutional QI initiative on managing procedural pain and distress in children undergoing needle procedures. The primary objective was to evaluate the use of multimodal strategies to reduce needle-related procedural pain/distress following the QI initiative. The secondary objective was to compare pain scores for needle procedures before and after the QI initiative. Design/Methods This observational study was conducted in a tertiary care university-affiliated paediatric hospital with an ongoing hospital-wide QI initiative aiming to alleviate procedural pain and distress in children undergoing needle procedures. The QI initiative consisted of mandatory sector-by-sector training of healthcare providers (HCP) on procedural pain/distress strategies to increase the use of multimodal pain care. Pain scores were measured during needle procedures (i.e. Numerical Rating Scale (NRS), Faces Pain Scale-R (FPS-R) or the FLACC scales, according to patient age) pre and 3-6 months post implementation of the QI initiative. Scheduled audits were conducted using a standardized questionnaire by a deployment champion nurse during needle procedures to document pain scales and pain/distress strategies used by the HCP during needle procedures in each of the hospital services. Results Throughout the first two implementation years (June 2021-June 2023), 363 audits were conducted on needle procedures for 363 children (Median age 7 yo (0month-18yo□). At this stage, audits took place in 14 different hospital services. The most frequent procedures were IV-line insertions (34%), venous blood draws (27%), and capillary blood sampling (26%). Parental presence and the use of distraction techniques were frequently used (90% and 80% of procedures, respectively). Of the 363 audits, 221 were pre-implementation and 142 post-implementation. Post QI initiative, an increased number of procedures were realized using multimodal strategies (4 or more strategies) to reduce pain/distress (from 60% to 78%). Pain scores were recorded for 203/221 audits pre and 134/142 post with a reduction in severe pain scores (7 or more) from 25% pre to 5% post-implementation. Conclusion The institutional QI initiative demonstrated both an increase in the number of strategies used to prevent pain/distress and a reduction in severe pain scores associated with paediatric needle procedures. This project emphasizes the significance of employing a multifaceted approach to managing procedural pain/distress in children undergoing needle procedures.

Experiences of Newly Qualified Nurses' Engagement with Quality Improvement in Practice: A Qualitative Follow-Up Study.

Nurse education plays an essential role in preparing future nurses to engage with quality improvement (QI) initiatives in their organisations and improve patient care. However, frontline nurses continue to report that a lack of QI knowledge hinders their abilities to engage in improvement work. In the UK, student nurses are now trained in QI within their degree to enable them to contribute to improvements once qualified. This qualitative follow-up study investigated the sustainability of QI engagement in nurses who undertook QI training and a QI project during their degree and explored the factors influencing their engagement in QI once qualified. This paper followed the COREQ criteria to report upon 10 semi-structured interviews undertaken with registered nurses and focuses on their experiences of QI engagement post-registration. The data were investigated using an inductive thematic analysis and Nvivo 14. Five themes emerged: transition to a newly qualified nurse, QI knowledge decline, influencing factors (hierarchy, leadership, COVID-19 pandemic, data access and location), and skill transferability. This study showed that qualified nurses can sustain their QI knowledge and remain engaged with QI where they experience positive QI leadership and were exposed to ongoing QI activity in their preceptorship year. However, a lack of QI opportunities and a culture which does not consider QI a responsibility of new nurses is seen to hinder engagement. Educational institutions and practice partners require careful collaboration to assess and develop ongoing QI learning activities that support new nurses to engage in QI.

Evolution of overall survival (OS) after curative-intent lung cancer surgery in a population-based Mississippi Delta cohort.

278 Background: Surgical resection is the most important curative modality for patients with lung cancer, with long-term OS influenced by both surgical quality and cancer biology. We compared surgical care and outcomes over 4 eras in the population-based Mid-South Quality of Surgical Resection (MS-QSR) cohort, an ongoing regional surgical and pathologic quality improvement (QI) dissemination and implementation project. Methods: We implemented a surgical lymph node collection kit and a novel pathology gross dissection method across 12 hospitals encompassing >95% of lung cancer resections in 5 contiguous Dartmouth Hospital Referral Regions. We analyzed the MS-QSR cohort at 5-year intervals characterized by stepped-wedge implementation of specific QI interventions: Era 1 (2004-2008; baseline, no QI), Era 2 (2009-2013; quality feedback, surgical QI pilot), Era 3 (2014-2018; surgical QI implementation), and Era 4 (2019-2023; combined surgical QI and pathology QI implementation). We used standard statistical methods to compare surgical quality; Kaplan-Meier plot, log-rank test, and Cox proportional hazards model with Era 1 as reference to compare OS across eras. Results: Of 7240 resections, 14%, 31%, 29%, and 26% were performed in Eras 1-4, respectively (Table). Attainment of the stringent International Association for the Study of Lung Cancer (IASLC) definition of complete resection increased from 0% in Era 1 to 32% in Era 4; attainment of the American College of Surgeons Operative Standard 5.8 (ACS_OS 5.8), the current US definition of surgical quality, improved from 4% in Era 1 to 67% in Era 4; 120-day mortality rate decreased from 10% to 4% (p<0.0001 for all comparisons). With median follow-up of 4.7, 5.5, 5.6, and 2 years for Eras 1-4, 3-year OS rates were 60%, 64%, 70%, and 79%; 5-year OS rates were 48%, 52%, 58%, and 70%, respectively (p<0.0001). The Hazard Ratio (HR) for mortality decreased from 0.91 (95% CI: 0.8-0.99) in Era 2 to 0.49 (95% CI: 0.43-0.56) in Era 4. Conclusions: Surgical quality and OS sequentially improved in this diverse, high-risk population-based Mississippi Delta surgical resection cohort. We are evaluating the full range of factors associated with this striking OS improvement. Ongoing work is exploring biologic correlates to this improvement. Variable Era 1 N= 988 Era 2 N=2235 Era 3 N=2107 Era 4 N=1910 Median age (Q1, Q3) 68 (62, 74) 68 (62, 74) 68 (61, 74) 68 (61, 74) Male sex (%) 514 (52%) 1234 (55%) 1082 (51%) 977 (51%) Black race 221 (22%) 416 (19%) 450 (21%) 451 (24%) Attained ACS_OS 5.8 40 (4%) 533 (24%) 1050 (50%) 1272 (67%) IASLC complete resectionUncertain completeness 0 (0%)930 (94%) 194 (9%)1932 (86%) 435 (21%)1594 (76%) 606 (32%)1227 (64%) 120-day mortality 100 (10%) 197 (9%) 139 (7%) 72 (4%) 5-year OS 48 (45-51) 52 (50-55) 58 (56-60) 70 (66-74) HR (95% CI) Reference 0.91 (0.83-0.99) 0.75 (0.69-0.83) 0.49 (0.43-0.56)

Development and Implementation of a Venous Thromboembolism Prophylaxis Protocol in the Rehabilitation Setting – A Completed Audit Cycle

Abstract Background 63% of all Venous Thromboembolic disease (VTE) is hospital-acquired, and 70% of hospital-acquired VTE is potentially preventable with appropriate prophylaxis. NICE recommends a VTE risk assessment for all patients admitted to acute hospitals within 24 hours. Validated risk assessment models for acute hospitals enhance provision of thromboprophylaxis, but no such protocols exist for the rehabilitation setting. The aims of this audit were to determine if VTE risk assessments are occurring on admission and during acute illness in rehabilitation wards, to assess the proportion of rehabilitation inpatients receiving VTE prophylaxis, and to develop and pilot a VTE Prophylaxis Protocol. Methods An initial audit was carried out on three rehabilitation wards in May/June 2023. A VTE Prophylaxis Protocol was developed based on the HSE VTE Prevention Program template, incorporated into the admission booklet on 3 pilot wards in February 2024, and practice re-audited in April 2024. Results Pre-intervention, 41 patient records were assessed. 0 patients (0%) had a documented VTE risk assessment on admission, 23(56%) had therapeutic anticoagulation continued, and 3(7%) commenced appropriate VTE prophylaxis on admission. 8 eligible at-risk patients did not receive prophylaxis. Post intervention, all patients (n=25) on the three pilot wards were re-audited. 10 patients (40%) had a documented VTE Risk assessment within 24 hours of admission, 9(36%) had therapeutic anticoagulation continued, and 5(20%) received appropriate VTE prophylaxis on admission (2 without a documented risk assessment). 3 at-risk patients did not receive prophylaxis (1 with a completed risk assessment), and 1 risk-assessed patient inappropriately received prophylaxis. Conclusion Implementation of a VTE Prophylaxis Protocol improved VTE risk assessment in rehabilitation. This small sample however did not demonstrate an association between prophylaxis prescription and use of the protocol. Further education and feedback is required to increase use of the protocol as part of this ongoing quality improvement project.

“Addressing the Silent Need”

Abstract Background Clinical Specialist Teams (CST) are a foundational component of the Integrated Care Programme for Older Persons (ICPOP) providing care for older adults with complex needs, completing Comprehensive Geriatric Assessments (CGA) and supporting goals until outcomes are optimised (HSE, 2021). WHO (2014) estimates 400 million individuals worldwide are affected by hearing loss, with prevalence increasing with age. The WHO in 2024 recommended targeted hearing screening and interventions in older age. NICE guidelines (2023) issued specific recommendations for adults with suspected or diagnosed dementia or mild cognitive impairment (MCI). The aim of this study was to review current practice of sensory assessment with respect to these recommendations. Methods This is a retrospective audit to evaluate current practice against established standards and to identify areas for improvement to achieve best practice. This will form part of an ongoing quality improvement initiative. Data was collected using a team designed tool gathering information on sensory assessment, interventions and onward referrals. A sample of 65 ICPOP clients was chosen from the last quarter of 2023. Results Preliminary results: Conclusion Screening rates for sensory impairment in the CST is high but needs improvement to reach the target of 100%. Referral onto appropriate services for specialised sensory intervention is actioned adequately, but there is need for the CST to advise timely hearing and vision testing to clients in order to adhere to international guidelines, especially those clients with dementia/MCI.

Association between caseload volume and outcomes in left ventricular assist device implantations-a EUROMACS analysis.

This EUROMACS study was conducted with the primary aim of investigating the association between a centre's annual caseload and postoperative outcomes among patients undergoing left ventricular assist device (LVAD) implantation. A total of 4802 patients identified between 2011 and 2020 from 35 participating centres were dichotomized based on the annual caseload of the treating centre at the time of device implant (≤30 vs. >30 LVAD implantations/year). The primary endpoint was 1-year survival. Secondary outcomes included overall survival analysis, device-related adverse events and readmissions. Cumulative follow-up was 10 003 patient-years, with a median follow-up of 1.54 years (interquartile range 0.52-3.15). Patients from higher volume centres more frequently presented in INTERMACS levels 1 and 2, suffered from right heart dysfunction and needed inotropic support. No difference was observed in adjusted 1-year survival. Adjusted overall survival probability was lower in higher volume centres (p = 0.002). In the subgroup analysis of HeartMate 3 devices only, higher volume centres were associated with decreased odds of 1-year survival (adjusted odds ratio 0.43, 95% confidence interval 0.20-0.97, p = 0.041). Similar findings were observed in the cumulative (i.e. learning curve) caseload analyses. In patients undergoing LVAD implantation, centre volume was not associated with 1-year survival, but was related to device-related adverse events. Patient profiles differed with respect to centre size. These findings underscore the necessity for ongoing quality improvement initiatives in all centres, regardless of their annual caseload. Efforts are needed to standardize patient selection and preconditioning to further improve patient outcome.

Data-driven program adaptation and continuous improvement: A case study of the Adolescents 360 (A360) project in Ethiopia, Nigeria, and Tanzania

Interventions benefit from ongoing continuous quality improvement during implementation to refine and strengthen them in response to changing contexts and emerging opportunities. This article reflects on the experience from the Adolescents 360 (A360) project in implementing user-centered, adaptive programming across Tanzania, Ethiopia, and Nigeria from 2018 to 2020. During this implementation period, A360 progressed through three distinct phases: an ‘optimization’ of project interventions in pursuit of efficiency and preparation for scale; a re-focusing on user-centered programming to go beyond efficiency and pursue greater impact; and a rapid course correction in response to the emerging COVID-19 pandemic. A360’s approach to data-informed adaptation evolved throughout these phases. From a hyper focus on cost-efficiency during optimization to a more expansive use of mixed methods data for adaptation during its second phase and finally iteration in response to an extremely restrictive service delivery environment during the COVID-19 pandemic. In this article we reflect on how these periods of adaptation and course correction contributed to the evolution of the project’s interventions and provided significant lessons which the project has taken into its new investment phase. Balance is key – utilizing a range of mixed methods data instead of a singular focus on cost-efficiency, streamlining interventions while not compromising long-term impact, and retaining a user-focus even while considering sustainability.

Impact of En Route Critical Care Provider Experience on Lung Protective Ventilation Compliance During Air Transport of Combat Wounded.

The primary objective of this study was to evaluate the association between the U.S. Air Force Critical Care Air Transport (CCAT) provider operational experience with compliance for lung protective ventilation (LPV) volumes recommended by Acute Respiratory Distress Syndrome Clinical Network guidelines. We performed a retrospective cohort study of CCAT providers transporting combat casualties requiring mechanical ventilation from the Middle East to Germany from 2007 to 2012. We reviewed CCAT medical records from 2007 to 2012 for the total number of patient transports by CCAT physicians and respiratory care practitioners (RCPs). Center for Sustainment of Trauma and Readiness Skills Cincinnati process improvement questionnaire data described provider demographics and clinical backgrounds. We linked these data to patient demographics and in-flight ventilation management from a prior CCAT cohort study. Patient inclusion criteria included transport by CCAT from the Middle East to Germany for traumatic injury requiring mechanical ventilation between 2007 and 2012. We excluded patients with no documented height or tidal volume. LPV compliance was defined as tidal volumes ≤8 mL/kg of predicted body weight during en route critical care transport. We performed a logistic regression analysis. This study was reviewed and approved by the 59th Medical Wing institutional review board (IRB). We analyzed 491 patient transports conducted by 71 (RCPs and 84 physicians. Patients had a median age of 25 years (IQR 22-30), 98% were male, median injury severity score was 24 (IQR 17-34), and median preflight PaO2/FiO2 was 285 (IQR 220-365). Median experience was 26 missions (IQR 13-40) for RCPs and 23 missions (IQR 12-38) for physicians. All in-flight tidal volumes were LPV compliant in 58.3% of missions. Unadjusted analysis showed higher LPV compliance for RCPs with in-garrison critical care experience. Multivariate models did not find an association between missions flown and LPV compliance but did demonstrate a positive association with physician specialty of medical intensivist (OR 3.0, 95% CI 1.6-5.7) and a negative association with flights in 2008 (OR 0.4, 95% CI 0.2-0.7) for LPV compliance. No association was found between number of missions flown by CCAT providers and lung protective tidal volume compliance. Linkage of multiple data sources enabled investigation of clinical and operational currency associations with a care quality metric compliance in the combat en route care environment. Future studies should evaluate the impact of ongoing CCAT training and quality improvement interventions on LPV compliance.

Educator wellbeing and family engagement in Australian early learning settings: perspectives of early childhood educators and families

AbstractWhile the COVID-19 pandemic brought with it multiple challenges for families and the Early Childhood Education and Care (ECEC) workforce, it also highlighted the essential role of ECEC in the lives of children and families and presented unique opportunities for innovation and learning. The current study sought to explore learnings from this uniquely challenging period, including the factors and strategies that best supported educator wellbeing and family engagement in ECEC settings, from the perspectives of families, centre directors and educators. In 2021, 104 Centre Directors/Educators and 102 families completed online surveys exploring wellbeing and educator–family relationships. Correlations suggest that robust professional wellbeing and resilience are potential enabling factors for strong family engagement, and that supportive organisational structures in ECEC settings are a protective factor for both educator wellbeing and family engagement. In addition, five effective family engagement strategies were derived from the qualitative data: (1) drawing on personal and professional knowledges to enrich children’s learning at home; (2) prioritising regular and reliable communication with families; (3) maintaining familiar relationships and a sense of community; (4) providing person-centred support and a bridge to other services; and (5) nurturing mutually supportive educator–family relationships. Learnings provide important insights that may inform ongoing quality improvements across different ECEC contexts, and to help safeguard against the negative impacts of future global crises.

What are the perceptions of faculty and academic leaders regarding the impact of accreditation on the continuous quality improvement process of undergraduate medical education programs at Caribbean medical schools?

BackgroundAccreditation and regulation are meant for quality assurance in higher education. However, there is no guarantee that accreditation ensures quality improvement. The accreditation for Caribbean medical schools varies from island to island, and it could be mandatory or voluntary, depending on local government requirements. Caribbean medical schools recently attained accreditation status to meet the Educational Commission for Foreign Medical Graduates (ECFMG) requirements by 2024. Literature suggests that accreditation impacts ECFMG certification rates and medical schools’ educational processes. However, no such study has examined accreditation’s impact on continuous quality improvement (CQI) in medical schools. This study aims to gather the perceptions and experiences of faculty members and academic leaders regarding the impact of accreditation on CQI across Caribbean medical schools.MethodsThis qualitative phenomenological study inquiries about the perceptions and experiences of faculty and academic leaders regarding accreditation’s impact on CQI. Purposive and snowball sampling techniques were used. Participants were interviewed using a semi-structured interview method. Fifteen participants were interviewed across ten Caribbean medical schools representing accredited medical schools, accreditation denied medical schools, and schools that never applied for accreditation. Interviews were audio recorded, and thematic data analysis was conducted.ResultsThematic analysis yielded six themes, including accreditation and CQI, CQI irrespective of accreditation, faculty engagement and faculty empowerment in the CQI process, collecting and sharing data, ECFMG 2024 requirements, and organizational structure of CQI.ConclusionsThere is ongoing quality improvement at Caribbean medical schools, as perceived by faculty members and academic leaders. However, most of the change process is happening because of accreditation, and the quality improvement is due to external push such as accreditation rather than internal motivation. It is recommended that Caribbean medical schools promote internal quality improvement irrespective of accreditation and embrace the culture of CQI.

Tap Water Microbial Contamination in Prayagraj: Isolation, Purification and Characterization of Pathogenic Bacteria and Their Antibiotic Susceptibility Patterns

Since water is necessary for life, it is crucial for preserving human health and biological processes. However, serious health dangers are associated with drinking water contamination, especially in areas where access to clean water is scarce. The purpose of this study was to assess the physicochemical and microbiological properties of tap water from 10 distinct locations in Prayagraj, Uttar Pradesh, India. Water samples were collected and analyzed microbiologically to isolate and identify harmful bacteria. The study detected the presence of several gram-negative bacteria, including Leminorella grimontii, Morganella morganii, and Citrobacter braakii, among others. Temperature and pH levels varied throughout the sampling sites, according to physicochemical analysis, and some samples had levels of alkalinity over the WHO-recommended safe limits. Antibiotic susceptibility tests indicated that the isolated bacterial strains displayed varying levels of resistance to different antibiotics, with higher resistance to Gentamicin than to Ampicillin. These findings highlight the significance of ongoing water quality monitoring and improvement to reduce the risk of waterborne illnesses, particularly in areas with poor access to clean water and sanitation. Ensuring the safety and purity of water for human consumption is crucial for protecting public health, especially in areas vulnerable to illnesses caused by contaminated water. This study provides valuable insights into the microbiological ecology of Prayagraj tap water and emphasizes the need for effective water management strategies to protect human health and welfare.

Implementation of an Arts at Home program for people living with dementia: Learnings from key stakeholders.

This study explores experiences of people with dementia and family carers who participated in an Arts on Prescription at Home (AoP@Home) program, artists who delivered the AoP@Home program and the managers who coordinated the AoP@Home programs. Semi structured interviews were conducted with the three stakeholder groups to explore experiences around implementation of AoP@Home. Interview questions were specific to each stakeholder group, and designed to capture the varied experiences around coordinating, delivering and participating in AoP@Home programs when delivered as a standard service offering. Qualitative content analysis was applied to evaluate the transcripts. A total of 13 stakeholders participated in interviews: four people living with dementia and four family carers, three artists and two AoP program managers. Three overarching themes emerged across the stakeholder groups: 'what worked well', 'challenges' and 'moving forward'. AoP@Home has potential as an important offering for community-dwelling people with dementia who may no longer be able to access group-based community programs. As AoP@Home is expanded, ongoing implementation monitoring and quality improvement will be essential to ensure maximal applicability of the program across the community aged care sector. SO WHAT?: The implementation of a new AoP@home service has been examined, and finds consumer satisfaction (person with dementia and their carer), and support from staff (artists and program managers). The novel nature of the service, however, requires considerable work to educate service referrers about the service and its benefits.

Quantifying the effect of driving restrictions on fine particulate matter concentrations with WRF-Chem model: A case study in Kaifeng, China

One of the significant sources of urban air particulate matter (PM2.5 and PM10) has been found to be vehicle exhaust emission. Vehicle restriction measures have been taken to alleviate particulate matter pollution in the world. Here, we quantified the impact of vehicle restriction measures on the PM2.5 concentrations using the Weather Research and Forecasting model with Chemistry (WRF-Chem) in Kaifeng, China. This study set up three different scenarios to simulate the spatiotemporal changes of PM2.5 concentrations in four seasons in 2020. They were no emission reduction (S0), the restriction of two tailing license plate numbers (S1), and the restriction of odd–even tailing numbers of license plates (S2), respectively. In general, the odd–even license plate restriction policy has proven to be more effective than restricting two specific license plate numbers. In scenario S1, the range of PM2.5 concentrations reduction in Kaifeng City was between 0.2% and 1.28%. In scenario S2, the range of PM2.5 concentrations reduction was between 0.98% and 14.42%. The results showed that the effectiveness of vehicle restriction measures varies from season to season, and the effect in summer and winter is better than that in spring and autumn. We suggest that it may be difficult to reduce the PM2.5 concentrations to a great extent if simply reducing the traffic exhaust emissions through motor vehicle restrictions, on the contrary, would lead to the increase of O3 concentration, bringing some other effects. This study can serve as a foundation for the rational development of motor vehicle control strategies and help advance the ongoing improvement of air quality.

A Quality Improvement Approach to Elevate Clinicians’ Use of Evidenced-Based Practice

ABSTRACT Mental and behavioral health needs amongst youth are on the rise, increasing the demand for community clinicians to treat increasingly complex cases. Extensive, complex caseloads contribute to burnout particularly when clinicians do not have the training to deliver effective treatment. Case conceptualization is a crucial component of effective treatment, as this guides intervention selection. Case conceptualization is vital within the evidence-based practice model, but this clinical skill is complex and challenging to implement effectively. A quality improvement (QI) approach was used by psychologists to develop and implement an eight-session training series with three cohorts of master’s prepared clinicians to increase their utilization of evidence-based treatments (EBTs) in clinical practice using the Project ECHO model. This QI project was accomplished via an iterative process where feedback was incorporated throughout the series. Participants’ knowledge, self-efficacy, and clinical practice were assessed pre- and post- completion of the series. Iterations in programming to improve the quality of the course are covered in detail. Participants demonstrated significant improvements in self-efficacy and reported positive changes in their clinical practice. There was no statistical change in knowledge, which was high on the pretest. Participants reported increased utilization and self-efficacy using EBTs in their clinical practice following participation in the course. Ongoing QI efforts and data collection are needed to continue to improve programming and demonstrate effectiveness of the series. Future efforts targeting specific EBT approaches for masters-prepared clinicians would be worthwhile.

Analyzing influential factors in suboptimal cervical cancer screening rates at Kline Health Center and implementing a subsequent initiative for improvement.

e23252 Background: The UPMC-Kline Health Center (KHC) in Harrisburg, PA, shows a lower cervical cancer screening rate compared to the general population in the USA (57.08% vs 78%, respectively, based on the Medical Group Fiscal Year 2023 Internal Quality Measures). To understand this gap, we distributed a comprehensive questionnaire to patients, aiming to pinpoint factors contributing to the lower screening rate and plan targeted interventions for improvement. Methods: We randomly distributed questionnaires to female patients aged 21 to 61 during appointment check-in at the KHC, considering our linguistically diverse patient population with surveys available in Spanish, English, and Nepali. Given the diverse linguistic landscape of our patient population, we prepared questionnaires in Spanish, English, and Nepali. The survey aims to identify and address specific clinic-related problems, with a follow-up assessment after a few months to gauge improvements following interventions targeting the underlying causes of screening gaps. Results: Over a three-month span, 65 questionnaires were completed. Among the participants, 38% (25 patients - 7 white/Caucasian, 11 black/African American, 1 Asian, 7 others; 12 Hispanic, 13 non-Hispanic) revealed that they had not undergone screening within the past three years. The analysis of this subgroup unveiled significant issues: 84% (21/25) did not receive paperwork to schedule the test, 88% (22/25) were not contacted to schedule the test, 76% (19/25) did not receive reminder notifications before appointments, and 72%(18/25) expressed concerns about the lack of insurance coverage for costs. Furthermore, 76% (19/25) indicated the requirement to pay a co-pay, and an equal percentage reported difficulties in obtaining the screening test. Additionally, 72%(18/25) mentioned that their healthcare providers did not discuss the screening's importance, while 76%(19/25) noted their providers did not explain the purpose of the test. Conclusions: These findings underscore critical gaps in communication, accessibility, and cost-related barriers to cervical cancer screening at KHC. This ongoing quality improvement project, scheduled for data recollection in a few months, encompasses proposed interventions such as automated reminders, technology integration for communication, and distributing flyers in clinic and waiting areas to foster open communication and address inadequate discussions about the importance of screening. The aim is to improve patient awareness, engagement, and ultimately prevent delayed cancer diagnoses. KHC is committed to enhancing the cervical cancer screening rate to minimize the likelihood of delayed cancer diagnoses.

THE IMPACT OF A CLOSING PROTOCOL (CP) IMPLEMENTATION ON WOUND MORBIDITY IN ABDOMINAL WALL RECONSTRUCTION (AWR) WITH MESH

Abstract Background Wound complications (WC) are associated with increased cost, recurrence, and mesh infection. Operative CPs have not been evaluated in AWR. Our aim was to evaluate the effect of a CP on wound infection (WI) and WC. Method A prospective, institutional database was used to compare AWR with and without CP. Descriptive statistics and a Bayesian Structured time series analysis (BSTA) were performed to evaluate rates of WI and WC. Data is reported as means unless stated. The CP involves antibiotic wound irrigation, glove and instrument exchange, re-draping the field, surgeon-only handling the mesh prior to mesh implantation. The introduction of on-going quality improvement efforts were accounted for in the model. Results A total of 2541 patients were examined with an age of 57.9 ± 12.6 years, 56.7% female, BMI 32.9 ± 9.8 kg/m2, 24.2% diabetic, and 41.2% former-smokers. Defect size was 203.1 ± 205.8 cm2 and 83.1% were CDC Class 1 or 2 wounds. Follow-up was 31.5 ± 41.4 months. Overall WI and WC rate decreased after CP (14.5% vs. 2.6% and 29.3% vs. 10.3%, P < 0.001). Specifically, the rate of wound cellulitis (9.7% vs. 2.7%, P < 0.001), wound infection (13.8 vs. 1.8%, P < 0.001), and mesh infection (2.1% vs. 0.6%, P < 0.004) were reduced after CP. For WI, BSTA revealed a relative effect of 83% (±2%, 95%CI:-87%,-78%; P = 0.0002) reduction compared to counterfactual. For WC, the BSTA revealed a relative effect reduction compared to counterfactual of 67% (±3%, 95%CI:-60%, -72%; P = 0.0002). Conclusion Introduction of a CP prior to mesh implantation in open AWR led to a significant reduction in overall wound infections and wound complications. The use of a CP should be strongly considered.

Assessing Customer Satisfaction in Mahindra’s Automotive Division: The Role of Service Quality and Technological Integration

This study examines customer satisfaction in Mahindra's automotive division, highlighting the impact of technological integration and service excellence. Using a mixed-methods approach, the study examines qualitative insights from in-depth interviews with consumers and service staff in addition to quantitative data from customer surveys. The results show that excellent customer satisfaction is greatly increased by high service quality, with personnel competency, promptness, and reliability being important contributing variables. To further enhance the client experience, cutting-edge technology integration is essential. Examples of these are linked car features and digital service platforms. The report emphasizes how crucial it is for Mahindra to keep coming up with new ideas and tweaking its service plans in order to stay ahead of the competition and satisfy changing customer demands. The management implications emphasize how crucial it is to allocate resources to both human resources and The findings show that timeliness, dependability, and professionalism—the three qualities that make up service quality—are crucial in influencing consumer satisfaction. Additionally, by offering convenience and customized services, the integration of cutting-edge technologies—like digital service interfaces and linked car features—significantly improves the client experience. The results indicate that in order to exceed customer expectations and maintain competitive advantage, Mahindra should give equal weight to ongoing improvements in service quality and technology advances. In order to promote long-term customer loyalty and happiness, the study offers management practical insights by highlighting the necessity of strategic investments in personnel training and state-of-the-art technologies. Keywords: Customer satisfaction, Technology integration, Strategic investments, Competitive advantage, Personalized services, Management insights, Digital service interfaces, Connected car features.

P.137 Neurosurgical consultations in Nova Scotia: a descriptive analysis

Background: Receiving and managing neurosurgical consultations are central to providing quality patient care but are resource intensive processes. As part of an ongoing quality improvement initiative, we conducted a single-institution descriptive analysis of adult neurosurgical consultations. Methods: A retrospective review of prospectively collected consultation records and call schedules from a 12-month period from February 2019 to 2020 was performed. Consults were graded according to disposition (admission for surgery, non-operative admission, additional investigations recommended, opinion without further investigations, unnecessary consult). Results: There were 1916 consultations reviewed, with 52% of calls (n=991) originating outside of our hospital, and 72% (n=1387) coming from an emergency department. Cranial cases made up 64% (n=1230) of consults, while the remaining 36% (n=688) were spine cases. The mean patient age was 60.1±0.4 years. In multinomial logistic regression analysis, age, geographical distance of consulting site, and consult specific variables (neurosurgical subspecialty, inside vs. outside call, emergency department vs. inpatient ward or private office) were associated with consult disposition (p < 0.001). Conclusions: This study provides a descriptive analysis of neurosurgical consultations in Nova Scotia. Results from this study may be used to address inefficacies in the neurosurgical consultation process, including targeted education for consulting physicians.

EXPERIENCING AGING IN PALLIATIVE CARE: A systematic literature review on the elderly patient's experience

The increase in life expectancy drives the demand for extended care, triggering the phenomenon of aging amid care. Recognizing the relevance of palliative care as an approach that seeks comprehensive provision to foster quality of life in the face of chronic, incurable illnesses, this research aims to investigate the experience of aging in palliative care from the patient's perspective. It is a systematic review encompassing studies targeting elderly individuals in palliative care. The databases used included PubMed, SciELO, Lilacs, and Medline, with descriptors specified by Desh related to aging and palliative care. The final sample consisted of nine articles. The results converged around three recurring themes: the challenges faced by the elderly concerning chronic health demands, the coping strategies they adopt, and their involvement in the palliative care process and decisions related to their health condition. Although providing valuable insights into the experience of aging in palliative care, this study is limited by the scarcity of available research exploring the phenomenon from the patients' perspective. It is crucial to drive more investigations in this field, providing opportunities for patients to express their needs and experiences, aiming to enhance the quality of services and contributing to an ongoing improvement in quality of life and satisfaction with received care.