Pilot Quality Improvement Project Research Articles

Improving Vaccination Documentation Rates Among Patients With Breast Cancer Through Patient Outreach.

Patients with cancer are at high risk for infection-related morbidity and mortality; vaccinations reduce this burden. In 2021, vaccination documentation rates were low at an academic medical center breast clinic. The purpose of this pilot quality improvement project was to evaluate an education intervention to increase vaccination documentation among patients with breast cancer. During a 16-week period, the 4 Pillars™ Practice Transformation Program was implemented. The oncology nurse navigator assessed and documented vaccination history, discussed recommendations with the provider, and recommended concurrent vaccinations. Within a two-week period, the oncology nurse navigator completed and documented vaccination follow-up via telephone. Vaccination follow-up and documentation for influenza, shingles, and pneumococcal vaccines increased substantially. Findings indicate that an education and outreach program can increase vaccination documentation rates among patients with breast cancer.

Improving pediatric atopic dermatitis care in the emergency department and primary care setting: a collaborative quality improvement pilot project

Improving pediatric atopic dermatitis care in the emergency department and primary care setting: a collaborative quality improvement pilot project

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

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

Piloting an Opioid Risk Screening Tool in Clinical Practice.

Background: Despite much research and many interventions, the opioid epidemic continues to plague the United States. According to the Centers for Disease Control and Prevention (2021), 136 people die daily from both prescription and illicit opioids. Objective: The goal of this pilot quality improvement project is to examine how the implementation of the Opioid Risk Tool (ORT) in clinical practice might impact the beliefs and attitudes of nurse practitioners (NPs) toward prescribing opioid therapy. Methods: A pre-post design was utilized. A convenience sample recruited participants from a private NP Facebook group. The intervention included a prerecorded presentation on the ORT and the use of the ORT for 8 weeks. Results: While 46 NPs completed the presurvey, only 19 NPs completed the postsurvey. Statistical results did not yield significance, but there were several significant clinical trends discovered. Conclusion: Utilizing the ORT to screen for opioid misuse risks has been shown to improve providers' confidence in opioid prescribing. ORT guides providers in discerning patient risk for developing dependence on opioids. Implications for Nursing: Screening for opioid misuse risk is feasible. ORT adds to the clinical context in deciding a course of treatment in pain management.

Implementing a Respectful Maternity Care Guideline During Childbirth Experiences

ObjectiveTo measure the impact of an evidence-based guideline on respectful maternity care on nurses’ attitudes and beliefs about childbirth practices. DesignA quality improvement pilot project with a pretest/posttest design examining the attitudes and beliefs of intrapartum nurses about childbirth practices of respectful care. SettingHigh-risk intrapartum unit at a tertiary care center in the southeastern United States. ParticipantsA convenience sample of 130 registered nurses were invited to participate, and nine completed the pre- and posttests. Intervention/MeasurementsThe intervention included a recorded webinar, access to printed and electronic copies of the guideline, discussions in daily huddles, and a virtual journal club. Data were collected using the 42-item Nurse Attitudes and Beliefs Questionnaire–Revised. Lower scores are reflective of attitudes and beliefs that support a medical model of care, whereas higher scores are reflective of a physiologic model of care. Descriptive statistics and the Wilcoxon signed rank test were used to analyze changes in attitudes and beliefs based on the aggregate scores of the nurse participants. ResultsAlthough there was no change in nurse attitude and beliefs about childbirth practices after 3 months (p = .058), the aggregate scores on a scale of 42 to 168 increased by 5.6 points. Two subscales of the Nurse Attitudes and Beliefs Questionnaire–Revised—Medical Model of Conflict and Women’s Autonomy—had the greatest increase in aggregate scores. ConclusionUnderstanding nurses’ attitudes and beliefs can assist in identifying barriers to the provision of respectful care, particularly during labor and birth, when patients are most vulnerable. Measurement of nurse attitudes and beliefs regarding respectful maternity care may require a longer immersion in a respectful maternity care program to allow for changes over time.

Structured, nurse-led ward rounds to improve interprofessional communication and optimize care of vascular surgery patients: a best practice implementation project.

Ward rounds are crucial inpatient activities during which patients' conditions are discussed. Team-based models such as nurse-led ward rounds (NLWRs) have been conceptualized and trialled, with positive results. An evidence-based quality improvement pilot project to introduce NLWRs was implemented at a cardiovascular medical-surgical unit in a Singapore tertiary hospital. The JBI Evidence Implementation Framework was used to guide the project. The evidence-based NLWR format incorporated stakeholder feedback on NLWR frequency, preparation, coordination, and content. Baseline and 6-month post-implementation audits were carried out. The 4 audit criteria improved from baseline, reaching 100% compliance for criteria 1, 2, and 3 associated with interprofessional communication and collaboration. An improvement from baseline (30% to 46.7%) was also observed for criterion 4 on patient involvement during medical ward rounds. Moreover, there were improvements in clinical outcome data such as patient hospitalization length, "best medical therapy" rates, and inpatient complications. A statistically significant improvement in nurses' confidence to lead discussions during medical rounds was also observed ( p = 0.026). This project promoted greater compliance with NLWR criteria through audit and feedback cycles and the contextualization of implementation strategies. A well-supported program that prepares nurses for interprofessional communication also improves nurses' confidence in team communication, bolstering their ability to provide high-quality patient care.

1416. Walk a Mile in Someone Else’s Shoes: Navigating the Complexity of Daily Environmental Cleaning – A Quality Improvement Pilot Project

Abstract Background A major tenet of environmental cleaning is to focus on high-touch surfaces (HTS). HTS in the patient’s proximity have high rates of contamination, yet cleaning compliance of HTS remains low particularly when the patient is present. This quality improvement (QI) project aimed to use stakeholder input to modify a HTS cleaning checklist. Methods This pilot project used a Plan-Do-Check-Act cycle to modify and evaluate a daily cleaning checklist across acute and long-term care settings at one Midwestern VA Hospital (Figure 1). PDCA Results Two pre-intervention focus groups (patients, N=8 and EMS, N=5) were conducted to understand stakeholder perspectives and barriers to daily cleaning to inform modifications to the cleaning checklist. Participants viewed the graphic and discussed patients’ and EMS’s possible notions upon EMS entering the patient room. The groups were then asked how these insights could be addressed during the cleaning process. Recurrent themes of stakeholder’s perceived barriers to cleaning are depicted in Figure 2. Integrating the stakeholder suggestions to overcome barriers, and the literature suggesting higher touch and contamination of surfaces within proximity to the patient, the QI team and EMS designed a paradigm shift for the checklist including modifying mental models for: a. cleaning patterns from clean-to-dirty to dirty-to-clean (Figure 3) and b. extent of surface cleaning (Figure 4). Pre- and post-intervention observations of daily cleaning compliance of 10 HTS showed a significant improvement of 38% (pre, N=7) to 72% (post, N=10) (p = 0.011). Two EMS interviews were conducted post-intervention to evaluate checklist usability. Emergent themes were discomfort with cleaning any surface near the patient while the patient was in the bed and with the use of the modified cleaning pattern due to discordance with previous training and practices Graphic Exercise Cleaning Pattern Mental Model Modified Checklist Modified Checklist Conclusion Current checklists do not address contextual factors of navigating the environment surrounding patients in bed. HTS cleaning rates may be improved by modifying checklists based on input from local stakeholders. Future research is needed to evaluate modified cleaning processes to facilitate daily cleaning of occupied patient rooms. Disclosures All Authors: No reported disclosures

2669. Improving Trichomoniasis Screening Among Cis- and Transgender Women with HIV

Abstract Background In 2020, the Primary Care Guidance for Persons with HIV added the recommendation for annual trichomoniasis screening. We identified a low trichomoniasis annual screening rate among cis- and transgender female patients living with HIV at the Institute for Advanced Medicine – Morningside Clinic, a New York State Designated AIDS Center with over 1200 patients with HIV in the Mount Sinai Health System in Manhattan. The primary aim of this prospective quality improvement pilot project was to increase the clinic’s annual trichomoniasis screening rate to 25% over the six-month intervention period. Methods A gap analysis identified lack of efficient workflow as the major reason for low trichomoniasis screening. We developed and implemented an intervention as outlined in Figure 1. The intervention began on October 15, 2022. The data was reviewed on April 19, 2023 after the intervention period ended. Results At baseline, there were 423 cis- and transgender women with HIV engaged in care at the Morningside Clinic eligible for annual sexually transmitted infection screening, including trichomoniasis. Pre-intervention screening for trichomoniasis was low at 13.7% (n=58). During the six-month intervention period, there were 280 cis- and transgender women with HIV who required annual trichomoniasis screening and seen at least once for a clinic visit with a primary care provider. Of these 280 eligible patients, 178 were tested for trichomoniasis, a significantly increased screening rate of 63.6%. Conclusion The intervention successfully increased the clinic’s annual trichomoniasis screening rate from 13.7% to 63.6% among women with HIV. The observed increase within six months was above our goal and demonstrates the effectiveness of a low-intensity and highly sustainable intervention to improve annual trichomoniasis screening rates among women with HIV. Despite the intervention, there are still a number of patients who remain unscreened for trichomoniasis as well as other sexually transmitted infections such as gonorrhea, chlamydia and syphilis. We will continue this intervention longitudinally and further identify and address barriers to sexually transmitted infection screening among people living with HIV. Disclosures All Authors: No reported disclosures

Growing Novice Nurses to Perianesthesia Care: Formation of a Post-Anesthesia Care Unit (PACU) Fellowship

PurposeTo provide a proof of concept of a structured, replicable perianesthesia fellowship program for nurses with less than 2 years of experience and new graduate nurses. DesignAn immersive learning experience was implemented as a pilot quality improvement project using the Plan-Do-Study-Act method. MethodsThis 24-week fellowship program used blended learning approaches and the Tiered Skill Acquisition Model (TSAM) to develop foundational Post Anesthesia Care Unit (PACU) skills. Nurse Fellows (4) acquired knowledge in stages, with each week in the program reinforcing and building upon the prior week's learnings. Settings included an initial 10 weeks in the ambulatory PACU, then the acute care PACU (weeks 11-20), and the final 4 weeks were spent in the primary unit where the Fellow would transition into a PACU Staff RN. Through each phase, the Professional Practice Department’s Clinical Mentor Nurse promoted preceptor development, facilitated learning experiences and provided bimonthly evaluations of the Nurse Fellow’s progress via our institution's clinical rounding tool. We used the Nursing Anxiety and Self-Confidence Associated with Clinical Decision Making (NASC-CDM) scale to assess novice nurses’ anxiety and self-confidence associated with making clinical decisions at designated intervals. FindingsAll Nurse Fellows completed the program and remained in PACU positions 2 years post-fellowship. They reported discomfort and increased stress transitioning to different PACUs; however, they later indicated reduced anxiety and greater confidence in clinical decision-making, as noted in subsequent evaluations of the NASC-CDM scale. ConclusionsPerianesthesia fellowship programs incorporating blended learning, skill reinforcement, and formal mentoring on a primary PACU unit build confidence and competence in the novice nurse, making this once-excluded population of nurses a viable option for recruitment directly into the PACU environment.

Intensive Case Management to Reduce Hospital Readmissions: A Pilot Quality Improvement Project.

Hospital readmissions burden the U.S. health care system, and they have negative effects on patients and their families. The primary aim of this study was to pilot an intensive case management (ICM) intervention to reduce 30-day hospital readmissions. A secondary aim was to obtain patient- and caregiver-reported reasons for readmission. The setting was a vertically integrated health care system located in Northern California. This pilot quality improvement project occurred over a 4-month period. The intervention was delivered by master's degree students in nurse case management through an academic-clinical partnership. Patients hospitalized with a 30-day readmission were offered the ICM intervention. A total of 36 patients were identified and 20 accepted. Patient and/or caregiver was interviewed to identify reasons for their readmission. Data were collected about pre-/post-health care utilization including subsequent 30-day readmission. Mixed methods were used to analyze the findings. Thirteen of 20 enrolled patients received the weekly ICM intervention for at least 30 days. Seven declined further contact before 30 days. Patient-reported reasons for readmission included being discharged too soon, poor communication among providers and with patients/families, lack of understanding about disease management and/or treatment options, and inadequate support. Several patients believed that their readmission was unavoidable due to the complexity of their illnesses. We compared 30-day readmissions for those who participated in and those who declined the ICM intervention, finding that those who received the ICM intervention had a lower readmission rate than those who did not receive the intervention (35% vs. 37.5%).

Intensive Case Management to Reduce Hospital Readmissions: A Pilot Quality Improvement Project.

Intensive Case Management to Reduce Hospital Readmissions: A Pilot Quality Improvement Project.

Increasing Nurse-Physician Family-Centered Rounds Communication: A Quality Improvement Pilot Project.

Increasing Nurse-Physician Family-Centered Rounds Communication: A Quality Improvement Pilot Project.

Impact of an Interprofessional HIV Quality Improvement Team on Patient Care and Resident Learning Opportunities.

Although human immunodeficiency virus (HIV) care is a recommended competency for family medicine training, many programs report a lack of HIV expertise among faculty. After the departure of faculty with HIV care experience, an interprofessional HIV quality improvement team (HIV-QIT) of physicians and pharmacists aimed to maintain on-site HIV care and retain learning opportunities for residents, using process improvement and panel reviews with a remote HIV specialist faculty member. This study reports on a multicycle quality improvement pilot project with pre- and postintervention chart reviews between December 2019 and May 2021. All patients received primary care and HIV-QIT chart reviews on-site. We compared patients with integrated HIV care on-site to those receiving external HIV specialty care. Primary outcomes included virologic suppression, CD4 count ≥200 cells/mm3, and adherence to guideline-recommended HIV care. In cycle 1 (January-June 2020), the HIV-QIT reviewed patient charts and sent guideline-based recommendations to physicians. In cycle 2 (July 2020-May 2021), the HIV-QIT implemented several HIV-specific processes, including decision support updates, note templates, order sets, and reference materials. Sustained process improvements included HIV panel chart audits every 3 to 6 months and subsequent provider education. Of 29 patients, more than half (55%, n=16) received integrated HIV care at the primary care site. We found no significant difference in care quality measures between primary and specialty care. Barriers to care completion included missed or canceled follow-up visits, on-site phlebotomy service closures, and declined HIV services. The HIV-QIT maintained on-site HIV treatment and retained experiential learning opportunities through process improvement and specialist-supported care recommendations to primary care physicians.

250 Streamlining rehabilitation for hip fracture patients: a pilot quality improvement project

Abstract Background University Hospital Waterford (UHW) is a busy trauma unit, serving five counties in Ireland’s South East. UHW treats approximately 400 hip fracture patients annually, 27% of whom are referred for off-site rehabilitation either locally or regionally. The national average Length-of-Stay (LoS) for hip fracture patients is 12 days, whereas in UHW the average LoS is 17 days, higher in those awaiting off-site rehabilitation (19 days). Earlier access to rehabilitation results in reduced LoS, better patient outcomes, and enhanced patient flow through the hospital system. Methods We created a pilot six-bedded rehabilitation unit in Kilcreene Regional Orthopaedic Hospital (KROH, an orthopaedic hospital affiliated with UHW) for hip fracture patients. Hip fracture patients for rehabilitation in KROH are identified by the Orthogeriatric team. Weekly multidisciplinary team meetings and wards rounds are conducted by the UHW based Orthogeriatric Consultant and Advanced Nurse Practitioner (ANP). We measured duration of time waiting for rehabilitation in hip fracture patients since this unit’s commencement and compared to data from a previous audit conducted in 2020 in hip fracture patients awaiting rehabilitation. Results Since April 19th 2023, seventeen hip fracture patients have been transferred to KROH for rehabilitation, fifteen of whom were transferred on the same day or the day after they were identified as medically fit and rehabilitation ready. To date, the longest wait time for transfer was three days in two patients. Data from 2020 indicated that the median wait for off-site rehabilitation in centres across the south-east was six days. Conclusion Early results indicate that this pilot six-bedded rehabilitation unit reduces the wait time for rehabilitation in selected hip fracture patients, enhances continuity of care, and improves patient flow through the hospital system. Our future aims include expansion of the unit and collaborating with regional integrated care services to ensure continuity of care post-discharge.

Novel hand hygiene promotion method in a pediatric and maternity hospital: A quality improvement pilot project using auditory feedback.

A pilot quality improvement project was conducted to examine the effect of playing an applause sound effect at a busy hospital concourse for three consecutive days whenever hand hygiene behavior was observed. The immediate effect was documented. The project demonstrated observable interest among people passing by, and hand hygiene events triggered by the sound effect represented 10.1% of all hand hygiene events documented. This supports the possible utility of this intervention in generating public awareness and increasing hand hygiene behavior and demonstrates the feasibility of a longer trial utilizing audio devices.

A Quality Improvement Pilot Project for Noise Reduction in the NICU.

Increased noxious noise leads to adverse short-term and long-term effects on the growing neonate. The American Academy of Pediatrics recommends maintaining a noise level of less than 45 decibels (dBA). The average baseline noise level in an open-pod neonatal intensive care unit (NICU) was 62.6 dBA. The purpose of this pilot project was to reduce the average noise levels by 39% at the end of an 11-week period. The location of the project was in a large, high-acuity level IV open-pod layout NICU that consisted of 4 pods, one of which was cardiac-focused. The average baseline noise level in the cardiac pod was 62.6 dBA in a 24-hour period. Noise levels were not monitored before this pilot project. This project was implemented over an 11-week period. Several modes of education were used for parents and staff. Post-education, Quiet Times were implemented at set times twice daily. Noise levels were monitored for 4 weeks during Quiet Times, with weekly noise level updates for staff. General noise levels were collected a final time to evaluate the overall change in the average noise levels. At the end of the project, noise levels decreased from 62.6 dBA to 54 dBA, a 13.7% reduction. At the end of this pilot project it was noted that: Online modules were the best way to educate staff. Parents should be included in the implementation of quality improvement. Healthcare providers need to know and understand that they can make preventative changes to improve the outcomes of the population.

Using Collaborative Online International Learning to Support Global Midwifery Education.

The COVID-19 pandemic created a gap in global health learning, requiring creative solutions to bridge the divide. Collaborative online international learning (COIL) is a program between universities located in different geographic areas that aims to build cross-cultural learning and collaboration. Faculty members from Uganda and the United States worked collaboratively to plan a 2-session COIL activity for nursing and midwifery students. Twenty-eight students from the United States and Uganda participated in the pilot quality improvement project. Students completed a 13-question REDCap survey measuring satisfaction, time commitment for the activity, and increase in knowledge about differently resourced healthcare systems. Students also were asked to provide qualitative feedback in that survey. Survey results indicate a high level of satisfaction and an increased understanding of a new healthcare system. The majority of students wanted more scheduled activity times, the opportunity to meet face to face, and/or more robust sessions in the future. This COIL activity between students in the United States and Uganda was a no-cost activity that provided global health learning opportunities for students during the global pandemic. The COIL model is replicable, adaptable, and customizable for a variety of courses and time spans.

An Evidence-Based Approach to Protecting Our Biggest Organ: Implementation of a Skin, Surface, Keep Moving, Incontinence/Moisture, and Nutrition/Hydration (SSKIN) Care Bundle

Background: The skin, surface, keep moving, incontinence/moisture, and nutrition/hydration (SSKIN) bundle is a resource to aid in care planning when at risk of pressure injuries. The bundle uses best practices to minimize variations in care. Objectives: The objectives of this quality improvement (QI) pilot project were as follows: (a) increase nurses' knowledge of pressure injury prevention, (b) increase nurses' knowledge of the use of the SSKIN bundle, and (c) to pilot the use of an SSKIN bundle in the clinical setting designed to standardize nursing interventions and documentation. Methods: Nurses completed a module on pressure injury prevention that included a pre- and posttest to determine knowledge. Education on the use of the SSKIN bundle was provided, followed by a posttest to establish understanding and knowledge gained. The bundle was utilized in the acute inpatient rehabilitation unit for 4 weeks, and compliance was assessed using the "all-or-none" approach (100% compliance). At the conclusion of the pilot project, staff nurses completed a post-survey created by the QI leader (Likert scale format). The survey included topics on the ease of learning to use the bundle, improved knowledge, perceived reduction in variation of care, perceived facilitation of discussion on skin, opinions on whether the bundle should be instituted hospital-wide, and incorporation of the bundle into the electronic health record (EHR). Results: There was an increase in pressure injury prevention knowledge from an average score of 88.89% on the pretest to 98.15% on the posttest. The mean score on the SSKIN bundle posttest was 93.75%. The bundle ran for 4 weeks and was initiated for ten patients during 74 shifts. Compliance with all components of the bundle was 77%. Conclusion: A pressure injury prevention initiative, such as the SSKIN bundle, can be a useful tool to help standardize nursing interventions and documentation. Implications for Nursing: Results revealed Nutrition as the component with the highest degree of noncompliance. Practice recommendations include documenting every patients nutrition information, regardless of Braden score.

Increasing Nurse-Physician Family-Centered Rounds Communication: A Quality Improvement Pilot Project.

High-quality nurse-physician communication during family-centered rounds (FCRs) can increase patient safety. In our hospital, interdisciplinary team members perceived that nurse-physician communication during FCRs declined during the COVID-19 pandemic. Using quality improvement methodology, we measured nurses' perceived awareness of components of the shared mental model, nurses' attendance during FCRs, compliance with completing FCR summaries, and average time spent per FCR encounter. A structured resident huddle took place prior to an FCR. Residents used a tool to send individualized alerts to bedside nurses to prepare them for an FCR. Residents developed comprehensive summaries after each FCR encounter and sent a summary text to nurses who were unable to attend the FCR. We assessed 40 FCRs over 16 weeks. Nurses' perceived awareness increased from 70% to 87%. Nurse attendance increased from 53% to 75%. We successfully piloted multiple interventions to improve nurse perceived awareness after an FCR.

P14 Improving adherence to and effectiveness of an adult critical care vancomycin continuous infusion protocol: a pilot quality improvement and administration data accuracy project

Abstract Background Vancomycin treats serious Gram-positive infections. In St George's Hospital (SGH) intensive care unit (ICU) settings, vancomycin is administered intravenously by continuous infusion. Steady-state serum concentrations are monitored daily with a 20–25 mg/L therapeutic target. Non-therapeutic concentrations are associated with patient harm and prolonged stay.1 A service evaluation revealed variable adherence to/effectiveness of the vancomycin prescribing/administration/monitoring protocol. Electronic prescribing and medicine administration (ePMA) system interface issues may have contributed.2 Consequently, multifaceted interventions were devised and piloted on General ICU. Objectives To (i) improve combined protocol prescribing/administration/monitoring adherence; (ii) enhance therapeutic protocol dosing; and (iii) ascertain accuracy of patients’ paper drug administration (PDA) charts compared with the ePMA system. Methods The quality improvement project (QIP) was approved by SGH clinical governance/audit teams. Over a 9 month period (September 2021 to May 2022) system/person-focused interventions were implemented. Protocol dosing2 was revised; introducing a >90 kg patient 2 g loading dose, new renal-function categories and an increased maintenance dose for creatinine clearance (CLCR) >90 mL/min. Protocol accessibility was increased via ePMA and CliniBee/Microguide app integration. Educational protocol presentations were incorporated into medical/nursing induction training. Vancomycin prescribing/administration/monitoring data for non-renal replacement patients during the intervention period, was extracted retrospectively from the ePMA system. This was compared with baseline informing ICU data collected July 2020 to July 2021.2 Patient's drug administration accuracy data (PDA charts/ePMA system) was extracted retrospectively from January to May 2022 and analysed. Results Compared with baseline, the proportion of patients receiving per protocol prescribing/administration of vancomycin loading/maintenance doses with daily monitoring increased [39% (7/18) to 68% (15/22)]. Within 48 h 54% (7/13) of vancomycin serum concentrations in all patients were therapeutic, demonstrating a baseline increase of 21% (3/9 to 7/13). In per protocol treated patients, serum concentrations increased 16% (2/7 to 4/9) therapeutically, decreased 20% (3/7 to 2/9) supra-therapeutically and increased 4% (2/7 to 3/9) sub-therapeutically. Supra-therapeutic concentrations were associated with CLCR <50 mL/min. Sub-therapeutic concentrations were associated with CLCR >90 mL/min and obesity. Compared with the ePMA system, there was 38% (5/13) less PDA charts recording both loading/maintenance doses. Administration time differences >60 min were recorded for 38% (3/8) of loading and 31% (4/13) maintenance doses. Discussion Staff turnover periods were associated with decreased protocol compliance. Further education is required around prescribing/administration of standardized vancomycin infusion bags, with associated rate changes. Integration of pharmacists into daily Microbiology ward rounds may alleviate these issues. Higher 20 mg/kg loading doses for >100 kg patients and maintenance dose revisions may reduce non-therapeutic concentrations.3 Multidirectional variation in vancomycin administration timings recorded between PDA charts/ePMA system, requires further investigation. Infusion-pump data may offer the most accurate administration time for calculating pharmacokinetic variables. Conclusions Multifaceted interventions were successful at improving adherence to/effectiveness of the vancomycin protocol. Findings will inform QIP roll-out across all three SGH ICUs, which will incorporate infusion-pump data collection to facilitate pharmacokinetic modelling. This will inform local dosing strategies and research into patient variability.