Pilot Quality Improvement Project Research Articles

Home hospice for older people with advanced dementia: a pilot project

BackgroundDementia is a terminal illness making the palliative and hospice approach to care appropriate for older people with advanced dementia.ObjectiveTo examine clinical and health services outcomes of a quality improvement pilot project to provide home hospice care for older people with advanced dementia.Study designTwenty older people with advanced dementia being treated in the Maccabi Healthcare Services homecare program, received home hospice care as an extension of their usual care for 6–7 months (or until they died) from a multidisciplinary team who were available 24/7. Family members were interviewed using validated questionnaires about symptom management, satisfaction with care, and caregiver burden. Hospitalizations prevented and medications discontinued, were determined by medical record review and team consensus.FindingsThe findings are based on 112 months of care with an average of 5.6 (SD 1.6) months per participant. The participants were on average 83.5 (SD 8.6) years old, 70% women, in homecare for 2.8 (SD 2.0) years, had dementia for 5.6 (SD 3.6) years with multiple comorbidities, and had been hospitalized for an average of 14.0 (SD 18.1) days in the year prior to the project. Four patients were fed via artificial nutrition. During the pilot project, 4 patients died, 2 patients withdrew, 1 patient was transferred to a nursing home and 13 returned to their usual homecare program. The home hospice program lead to significant (p < 0.001)improvement in: symptom management (score of 33.8 on admission on the Volicer symptom management scale increased to 38.3 on discharge), in satisfaction with care (27.5 to 35.3,), and a significant decline in caregiver burden (12.1 to 1.4 on the Zarit Burden index). There were five hospitalizations, and 33 hospitalizations prevented, and an average of 2.1(SD 1.4) medications discontinued per participant. Family members reported that the professionalism and 24/7 availability of the staff provided the added value of the program.ConclusionsThis pilot quality improvement project suggests that home hospice care for older people with advanced dementia can improve symptom management and caregiver satisfaction, while decreasing caregiver burden, preventing hospitalizations and discontinuing unnecessary medications. Identifying older people with advanced dementia with a 6 month prognosis remains a major challenge.

State Based Perinatal Quality Collaborative Pilot-Statewide Reduction of Colorado Primary Cesarean Delivery Rate [04OP

INTRODUCTION: The Colorado Perinatal Care Quality Collaborative performed a pilot quality improvement project to increase adherence to guidelines from the Consensus for the Prevention of the Primary Cesarean Delivery in a statewide cohort of hospitals to safely reduce their nulliparous, term, singleton, vertex (NTSV) cesarean delivery (CD) rate. METHODS: This quality improvement initiative was performed at 6 community hospitals across Colorado. Pre (January 2017 to May 2018) and post intervention (June to Oct 2018) NTSV CD and composite maternal and neonatal morbidity rates were determined for each hospital and the overall cohort using Colorado State Vital Statistics data. Interventions included distributing institution and provider specific NTSV CD rates, education for providers and nurses, implementation of a pre-cesarean labor dystocia checklist, and convening two forums for collaboration between hospitals. NTSV CD and composite maternal and neonatal morbidity rates were compared before and after the interventions for each hospital and the cohort. RESULTS: The 6 participating hospitals perform 19% of live births in Colorado. Pre-intervention hospital NTSV CD rates ranged from 19.3% to 33.8%. The cohort pre-intervention NTSV CD rate was 24.6%, and decreased to 21.9% post-intervention (P=0.04, 95% CI 0.77-0.99). There was no significant increase in composite maternal or neonatal morbidity post-intervention (8.6% vs 7.1% and 7.1% vs 6.8% respectively). CONCLUSION: A quality improvement effort led by a state-based Perinatal Quality Collaborative was effective at safely reducing NTSV CD rates across multiple hospitals. Future efforts will aim at expanding the number of participating hospitals and sustainability.

Documentation of Code Status in Hospitalized Patients: A Pilot Quality Improvement Project (P4.9-071)

Documentation of Code Status in Hospitalized Patients: A Pilot Quality Improvement Project (P4.9-071)

Increasing isoniazid preventive therapy in people living with HIV in north central Nigeria: outcomes from a quality improvement strategy

Abstract Background Isoniazid preventive therapy (IPT) significantly reduces the incidence of active tuberculosis in people living with HIV. However, despite high tuberculosis morbidity and mortality in people living with HIV, uptake of IPT remains grossly suboptimal, with implementation impeded by several barriers related to health workers and patients. We evaluated the use of a quality improvement approach to improve IPT in a tertiary hospital in north central Nigeria with a high HIV burden. Methods In July, 2018, a 4-week quality improvement pilot project was undertaken at the Federal Medical Centre in Keffi, Nigeria. The facility-based continuous quality-improvement committee, comprised of different cadres of staff working in the hospital's antiretroviral therapy clinic, reviewed their HIV quality-of-care indicators and noted that only 3% of eligible HIV clients received IPT between September, 2017, and March, 2018. The committee did a root cause analysis and identified poor knowledge of clinicians on the importance of IPT, fear of drug resistance, frequent stock-outs of isoniazid, and poor medication adherence as the key reasons for low rates of IPT. In response to these findings, the following key change ideas were implemented: IPT orientation for clinicians, incorporation of IPT education into routine health education for people living with HIV, display of IPT information education and communication materials in consulting and patient waiting rooms, and auditing of clients' folders prior to consultation to identify and tag eligible folders with IPT sticky notes. Findings Between June 19, 2018, and July 17, 2018, 278 adult clients with a clinic appointment had their folders audited for IPT eligibility and 108 eligible folders (39%) were identified and tagged with an IPT sticker. Of those eligible for IPT, 103 (95%) kept their clinic appointment and all had a 6-month course of isoniazid prescribed. However, of the patients who attended, only 93 (90%) received IPT because stock of the drug had run out. Interpretation A quality improvement strategy for improving IPT in HIV patients was effective, with 86% of eligible patients receiving treatment—an 83% increase from baseline. Quality-improvement principles such as team work and implementation of change ideas targeted at root causes of the problem were pivotal to success. Continued implementation and scale-up of effective change ideas to other hospitals could greatly reduce tuberculosis morbidity and mortality in people living with HIV, while ensuring continued availability of isoniazid. Funding CDC-PEPFAR.

Medical Scribe Impact on Patient and Provider Experience

The electronic health record (EHR) has created additional administrative burdens on providers to perform data entry while trying to engage with the patient during the health care visit. Providers have become frustrated and distracted with the documentation requirements which further hindered connectivity, and communication with the patient. The utilization of medical scribes in the outpatient clinical setting was a strategy shown to enhance patient and provider interaction, decrease clinician's administrative tasks, and promote satisfaction among providers and patients. This was an innovative quality improvement pilot project to improve the patient and provider experience using scribes in an outpatient setting. Two providers, to include one Family Medicine doctor and one Internal Medicine physician, and four hospital corpsmen participated in this pilot project. The four hospital corpsmen received a 2-week training of the fundamentals of the EHR and their role as scribes prior to the start of the project. Two corpsmen were designated for each provider and worked with their provider throughout the 12-week project period. The two primary aspects evaluated during the implementation of the scribes were the patient experience, and provider experience. Navy Medicine and the University of South Carolina Institutional Review Boards (IRB) considered this project exempt from full IRB review. The experience questionnaire results indicated a slight mean decrease, but did not negatively impact patient satisfaction or overall patient experience. The local Medical Treatment Facility patient satisfaction, obtained through the Interactive Customer Evaluation, and the Joint Outpatient Experience Survey, indicated that there was no decrease in patient satisfaction or overall experience during the project period. The providers' experience improved with an average 50% decrease in time spent after hours documenting in the EHR, enhanced engagement with patient, staff, and ancillary team members, and improved work life balance. Additional findings of improved clinic efficiencies, completion of notes for both providers and positive qualitative comments from the scribes were identified. In multiple settings, documentation requirements burden providers. The consideration of scribes could foster work life balance, retention, and wellness. The patient and provider experience was strengthened through the utilization of medical scribes, so future research centered on the provider and patient experience could be beneficial to organizations. Further study of the scribe's experience, especially considering the positive comments from the hospital corpsmen that participated as scribes during the project, could provide beneficial outcomes. Navy Medicine is advancing every opportunity to strengthen clinical and operational readiness, health and partnerships to provide the highest quality care and promote wellness for our patients. This type of quality improvement initiative could positively support readiness, quality and wellness for our organization, providers, and patients.

Feasibility and Clinical Utility of Electronic Geriatric Assessment (eGA) in Older Patients Undergoing Hematopoietic Cell Transplantation

BackgroundThe prevalence of age-related impairments in older patients (pts) undergoing hematopoietic cell transplantation (HCT), and its relationship with transplant outcomes is largely unknown.MethodsIn a pilot quality improvement project, assessment of functional, social, emotional, cognition, sensory, nutritional and polypharmacy domains was performed using an electronic rapid fitness assessment (eRFA) developed at MSKCC (Shahrokni JNCCN 2017). Older adults (age ≥ 60 years) undergoing HCT for hematologic malignancies from 2015 through 2018 in 2 transplant clinics were included. The prevalence of geriatric impairments, transplant-associated toxicities and survival were analyzed under an IRB approved waiver of authorization.ResultsPatient characteristics are shown in Table 1. The median day from eRFA to HCT was 45 days (range 14-162). Median time to complete eRFA was 10 minutes. Table 2 has a summary of geriatric impairments. Majority of pts (n=33) had at least 1 impairment. The most prevalent were social, emotional, polypharmacy and functional. Median number of geriatric impairments per patient was 4 (range 0-9). Median toxicities per patients was 4 (range 0-12). The most common toxicities were: 25 metabolic, 22 infections, 21 oral/gastrointestinal, and 16 cardiopulmonary. The only pt admitted to the ICU was an allo-HCT pt with 5 impairments. Amongst the 8 pts (4 AHCT, 4 allo-HCT) readmitted to the hospital within the first 100 days of HCT, the median number of impairments was 4 (range 0-9). Seven patients died, 5 from disease, and 2 from GvHD. With a median follow up of 9 months (range 1-38) among survivors, the 18-months progression-free and overall survival were 0.71 (0.55-0.91) and 0.7 (0.51-0.95) respectively (Figure 1).ConclusionsPerforming pre-HCT eRFA among older transplant patients is feasible. With the median completion time of 10 minutes, the eRFA can identify geriatric impairments of this vulnerable population. Future larger studies should assess whether these impairments have association with the outcomes, and whether interventions to improve geriatric impairments also improve transplant outcomes. The prevalence of age-related impairments in older patients (pts) undergoing hematopoietic cell transplantation (HCT), and its relationship with transplant outcomes is largely unknown. In a pilot quality improvement project, assessment of functional, social, emotional, cognition, sensory, nutritional and polypharmacy domains was performed using an electronic rapid fitness assessment (eRFA) developed at MSKCC (Shahrokni JNCCN 2017). Older adults (age ≥ 60 years) undergoing HCT for hematologic malignancies from 2015 through 2018 in 2 transplant clinics were included. The prevalence of geriatric impairments, transplant-associated toxicities and survival were analyzed under an IRB approved waiver of authorization. Patient characteristics are shown in Table 1. The median day from eRFA to HCT was 45 days (range 14-162). Median time to complete eRFA was 10 minutes. Table 2 has a summary of geriatric impairments. Majority of pts (n=33) had at least 1 impairment. The most prevalent were social, emotional, polypharmacy and functional. Median number of geriatric impairments per patient was 4 (range 0-9). Median toxicities per patients was 4 (range 0-12). The most common toxicities were: 25 metabolic, 22 infections, 21 oral/gastrointestinal, and 16 cardiopulmonary. The only pt admitted to the ICU was an allo-HCT pt with 5 impairments. Amongst the 8 pts (4 AHCT, 4 allo-HCT) readmitted to the hospital within the first 100 days of HCT, the median number of impairments was 4 (range 0-9). Seven patients died, 5 from disease, and 2 from GvHD. With a median follow up of 9 months (range 1-38) among survivors, the 18-months progression-free and overall survival were 0.71 (0.55-0.91) and 0.7 (0.51-0.95) respectively (Figure 1). Performing pre-HCT eRFA among older transplant patients is feasible. With the median completion time of 10 minutes, the eRFA can identify geriatric impairments of this vulnerable population. Future larger studies should assess whether these impairments have association with the outcomes, and whether interventions to improve geriatric impairments also improve transplant outcomes.

185. Implementation of a Clinical Decision Support System (CDSS) for Ordering Antimicrobials in a Veterans Affairs Medical Center (VAMC): Results From a Pilot Quality Improvement (QI) Project

BackgroundWhen used as antimicrobial stewardship (AS) tool, CDSS built into electronic health record systems (EHRs) have been associated with more appropriate antimicrobial (AM) use. This QI project aimed to determine the perception toward, acceptance and utilization of an AM-CDSS by internal medicine providers at the Houston VAMC.MethodsFrom October 2017 to March 2018 (pilot period), ID pharmacists trained members of two to four general medicine inpatient teams/month in the use of the AM-CDSS and provided surveys to be completed during the first (pre) and last week (post) of a 1-month rotation. Surveys focused on the provider’s prescribing patterns, self-perception of infectious diseases knowledge, as well as provider’s awareness, perception of utility, ease of use of the AM-CDSS, and its impact on prescribing patterns. A retrospective chart review was conducted to compare the appropriateness, route and duration of AMs ordered and not ordered through the AM-CDSS. For this comparison, patients were randomly selected from patients with same discharge ID diagnosis matched 1:1 each month.ResultsThrough the pilot period, the AM-CDSS had a continual rate of increased usage of 4.4 AM orders/month. A total of 113 surveys were collected (63 pre-AM-CDSS and 50 post-AM-CDSS). Eighty percent of respondents reported having used the AM-CDSS, and 76% reported wanting to continue to use the AM-CDSS. The most common reasons cited for using it were to confirm their AM approach and to practice up-to-date evidence-based medicine. Thirty percent stated that it was hard to locate within the EHR. A total of 120 AM orders (AM-CDSS = 60 and non-AM-CDSS = 60) were reviewed for appropriateness. The most common indications for the orders were CAP (34.2%) and UTI (33.3%). AM-CDSS orders were more likely to be appropriate (83.3 vs. 50%, P = 0.0002) and to include oral AMs (58 vs. 13.6%, P < 0.0001) than non-AM-CDSS orders. There was a not significant shorter duration of therapy in the AM-CDSS group (8.7 vs. 9.4d, P = 0.46).ConclusionMost providers perceived the AM-CDSS as useful and easy to use. The use of the AM-CDSS was associated with more appropriate AM use and more frequent selection of appropriate oral AMs. When feasible, AS programs with trainees should consider including easily accessible AM-CDSS in their EHR.Disclosures All authors: No reported disclosures.

569. Pre-retained: Early Intervention for HIV Patients at High Risk of Becoming Un-retained

BackgroundPoor engagement in HIV care is an established barrier to achieving optimal treatment. Improved engagement is a cornerstone of the national HIV/AIDS strategy and a marker of quality care. However, there is no consensus on strategies for proactive engagement. The objective of this prospective quality improvement pilot project is to demonstrate the effectiveness of early intervention for patients at high risk of becoming un-retained to increase clinic re-engagement and decrease time to re-engagement.MethodsThe Jack Martin Fund Clinic (JMFC) is a New York State Designated AIDS Center within the Institute for Advance Medicine at Mount Sinai in Manhattan. Patients at high risk of becoming un-retained were defined as no PCP follow-up in six months. The investigator arranged an appointment and notified patients to confirm. Re-engagement was defined as PCP follow-up within 90 days of intervention. A chart review was completed to collect demographics, co-morbidities and HIV data for the intervention group (n = 84) and a retrospectively identified control group (n = 126).ResultsThe intervention group achieved a statistically significant outcome of increased re-engagement in care and decreased time to re-engagement. Within the intervention group, 67 of 84 patients (80%) followed-up within 90 days compared with only 65 of 126 patients (52%) in the control (P < 0.01). The time to re-engagement after last PCP visit was also significantly decreased in the intervention group. There were no statistically significant differences between the control and intervention groups regarding race/ethnicity, case management involvement, viral load or co-morbidities.ConclusionThis study demonstrates a low-intensity, high-yield, sustainable intervention that significantly increased re-engagement for HIV patients that are at high risk of becoming un-retained. A unique aspect of this project is the focus on patients who are currently retained, but at risk of falling out of care, as opposed to patients already un-retained. Patients that did not re-engage despite intervention may be at risk for poor retention and earlier care coordination involvement may be considered. Future directions include continuing to follow patients to demonstrate long-term effects of early intervention and re-engagement on rates of retention.Disclosures All authors: No reported disclosures.

Reducing Preoperative Waiting-time in a Pediatric Eye Operation Theater by Optimizing Process Flow: A Pilot Quality Improvement Project

To decrease the preoperative area waiting-time for children posted for eye surgery. A pilot quality improvement project was conducted in a single paediatric eye operation theatre in our tertiary-care hospital. Operation theatre process flow was analyzed, baseline data was collected, and two Plan-Do-Study-Act cycles were performed on consecutive days. Average and maximal waiting-time were recorded across six operation theatre days. The average and maximal waiting time at baseline were 221 and 390 minutes, respectively. After two rapid Plan-Do-Study-Act cycles, these were reduced to 29 (87% reduction) and 52 minutes (87% reduction) from baseline, respectively, and could subsequently be sustained. Preoperative waiting time in ophthalmic operation theatre was significantly reduced by simple process flow optimization, thereby improving quality of care.

Implementing a Parent Education Program in the Special Care Nursery

BackgroundParents of preterm hospitalized infants, whose lengths of stay can range from a few days to several months, often experience emotional liability. Because the Neonatal Intensive Care Unit (NICU) or Special Care Nursery (SCN) is a stressful and intimidating environment, prompt attention should be given to reducing parental stress and increasing parental confidence in preparation to care for their child post-discharge. MethodsA quality improvement pilot project was designed to evaluate the parent education and support program, titled HUG Your Baby, in a Level II SCN for its ability to decrease stress and increase confidence for postpartum mothers of preterm infants born at less than 35 weeks gestation during the infant's hospitalization. ResultsThe outcomes demonstrated a statistically significant decrease in maternal stress and a statistically significant increase in maternal confidence. DiscussionThe HUG Your Baby program is an effective parent education and support program that would benefit NICU and SCN families.

Training Child Care Inspectors to Deliver Health Messaging: A Quality Improvement Pilot Project.

Early childhood obesity is at epidemic proportions. Early child care providers have a unique opportunity to instill healthy eating and active living behaviors in children that can foster lifelong health. Academic-community partnerships that involve collaborations between child care centers, local public health departments, and universities provide one avenue to strengthening healthy eating and active living-related knowledge and skills among early child care providers. This quality improvement pilot intervention, titled Healthy Child Care Makes a Healthy Start, is one example of this type of collaboration. This quality improvement pilot project consisted of two complementary intervention components. Inspectors were trained to cofacilitate a strategic planning process with university researchers to help providers implement healthy eating and active living-related policy, system, and environment changes in their child care homes and centers. An average of five changes were implemented in participating child care locations. Inspectors also received training on health-related best practices and delivered 1-minute health messages to child care providers during routine inspection visits. This type of innovative partnership has the potential to leverage a currently existing relationship between child care providers and licensing and regulation inspectors and shift the relationship to include dissemination and implementation of health messaging in child care center and home settings.

Increasing Accessibility to Long-Acting Reversible Contraception in a Public Health Setting

ObjectiveTo increase access to long-acting reversible contraception (LARC) by developing and implementing evidence-based criteria for LARC insertions at a public health clinic. DesignA quality improvement pilot project aimed at improving access to LARC for women of reproductive age and decrease associated costs. Setting/Local ProblemEligibility criteria for LARC at a public health clinic in rural Georgia required two clinic visits and unnecessary screening tests for women interested in these methods. These criteria limited eligibility of candidates who desired LARC, increased time between requests for and insertion of LARC, and increased costs. ParticipantsFifteen women of reproductive age who were uninsured or underinsured had a LARC inserted during project implementation. Intervention/MeasurementsThe average number of days between visits based on the old (2007) criteria was compared with the average number of days between visits after implementation of the new (2017) criteria, with specific focus on the number of same-day LARC insertions. A secondary analysis of cost savings was calculated. ResultsAfter implementation of the 2017 criteria, a statistically significant (p < .01) decrease in the mean number of days between request for and insertion of LARC was noted. Every woman who requested a LARC received it, and more than half of LARC insertions were provided the same day. Furthermore, the clinic noted savings of nearly $1,000 on LARC insertions. ConclusionThe wait time for LARC insertion substantially decreased, and more than half of women had a LARC inserted the same day they requested it. By decreasing the wait time between request for and insertion of a LARC and implementing a policy to advocate for same-day insertion, use of the 2017 criteria decreased women’s risk for unintended pregnancy.

Using the PDQ-39 in routine care for Parkinson's disease

IntroductionUsing the 39-item Parkinson's Disease Questionnaire (PDQ-39) in routine care could efficiently identify symptoms that are most important to patients, but little evidence documents its use for this purpose. MethodsA quality improvement pilot project using interviews with patients, caregivers, and providers. ResultsPDQ administration and scoring were successfully integrated into clinic workflows, and results were available for discussions during outpatient visits. Patients reported that completing the instrument helped them remember what to discuss with their provider, formulate specific questions, and identify factors affecting their quality of life. Caregivers found it useful for gaining insight into patients' daily needs. The neurologist reported it made provider-patient discussions more efficient by focusing on domains that were particularly concerning for patients. Ancillary care providers reported that PDQ-39 domain subscores efficiently provided a holistic view of patients' needs and supported setting short- and long-term goals. ConclusionThe PDQ-39 can be integrated into a busy clinical practice and its routine use is valuable for patients, caregivers, and providers.

Screening for postpartum anxiety: A quality improvement project to promote the screening of women suffering in silence

BackgroundPostpartum anxiety is a mental health problem that has largely been ignored by maternity care providers despite an estimated incidence as high as 28.9%. Though postpartum anxiety may or may not be accompanied by depression, and while screening for postpartum depression has become more common place, postpartum anxiety is often not assessed or addressed. PurposeThe purpose of this pilot quality improvement project was to implement a screening, treatment and referral program for postpartum anxiety in the birth centre environment. ProceduresMidwives from 10 geographically diverse birth centres, and all members of the American Association of Birth Centres, were recruited to participate in the project. An online video was developed which detailed postpartum anxiety, screening through use of the anxiety subscale of the Edinburgh Postnatal Depression Scale and a toolkit for treatment and/or referral for screen positive patients. Participants entered patient scores into the Perinatal Data Registry of the American Association of Birth Centres. Individual interviews of midwives were conducted following the 10-week pilot period. Main FindingsThere were a total of 387 participants across 9 participating sites. Among all screened participants with follow-up data, (n = 382), 9.69% (n = 37) were lost to follow-up. Among all participants screened with the Edinburgh Postpartum Depression Scale -3A and Edinburgh Postpartum Depression Scale (n = 318), 12.58% (n = 40) had a positive Edinburgh Postpartum Depression Scale -3A score of greater than six. Of all screened participants with an Edinburgh Postpartum Depression Scale score, 15 (6.98%) had a Edinburgh Postpartum Depression Scale score of less than 12 and an Edinburgh Postpartum Depression Scale -3A score greater than six, and would have not received follow up care if only screened for postpartum depression. Midwife participants expressed heightened awareness of the need to screen and felt screening was easy to integrate into clinical practice. ConclusionsThe Edinburgh Postpartum Depression Scale -3A is a valid, easy-to-use tool which should be considered for use in clinical practice. Modification of the electronic health record can serve as an important impetus triggering screening and treatment. It is important that clinicians are educated on the prevalence of postpartum anxiety, its risk factors, symptoms and implications.

Pilot Implementation of a Low-Literacy Zone Tool for Heart Failure Self-Management (QI808)

•Name and define the 3 components of HF self-care, according to Riegel et al's revised theory.•Describe the meaning and practical significance of the 3 different colored zones in the Zone Tool for Heart Failure Self-Management used in this QI project.•Identify methods by which this QI project's lead evaluated feasibility of the HF zone tool. Heart failure (HF) affects 6.5 million Americans, with 1 million hospitalizations annually, a 21.9% readmission rate, and $31 billion in healthcare costs. Palliative care (PC) decreases HF patients' symptom burden, readmissions, and costs. Many elderly patients have difficulty recognizing and reporting HF symptoms to their providers in a timely manner. Self-care tools with color-coded zones (green = all clear; yellow = caution; red = take action) help patients recognize and respond to HF symptoms and reduce readmissions and costs. The purposes of this quality improvement (QI) pilot project were to evaluate the feasibility of implementing a low-literacy zone tool for HF self-management with home-based PC patients and to test the zone tool's effect on self-care and quality of life. An interdisciplinary PC team developed a zone tool for HF self-management. Fifteen patients with advanced HF in a home-based PC program were recruited for this QI project. Health literacy was prescreened with the Newest Vital Sign instrument. HF self-care and quality of life were measured respectively with the Self-Care of Heart Failure Index and the Kansas City Cardiomyopathy Questionnaire at baseline, 30 days, and 60 days. In post-implementation surveys, participants and nurses rated the zone tool's readability and helpfulness (feasibility). Analyses of variance (ANOVA's) evaluated the zone tool's effect on self-care and quality of life. Participants evaluated the zone tool as easy to understand and helpful in recognizing and reporting HF symptoms. Due to the small sample size, ANOVA's were inconclusive regarding the effect of the HF zone tool on the two primary outcomes of interest. This QI project demonstrated the feasibility of implementing a zone tool for HF self-management for patients in a home-based PC program. Further research with larger samples is needed to assess HF zone tools' effect on self-care and quality of life.

Advanced Practice Registered Nurses on Therapeutic Hypothermia Response Teams.

Therapeutic hypothermia can improve neurological recovery after cardiac arrest when implemented quickly. To determine whether outcomes are improved among patients undergoing therapeutic hypothermia by adding advanced practice registered nurses to a therapeutic hypothermia response team. A pilot quality improvement project was conducted in a Midwest community teaching hospital using a retrospective chart review of all adult patients undergoing therapeutic hypothermia before and after the addition of advanced practice registered nurses to the therapeutic hypothermia response team. Outcomes evaluated included time to target core body temperature, therapeutic hypothermia protocol initiation, discharge status, and hospital length of stay. A total of 14 adult patients (preintervention n = 8, postintervention n = 6) comprised the sample. Length of stay decreased in the postintervention group (median 2.5 vs 6 days for the preintervention group; P = .05), but other outcomes did not differ. This quality improvement project provides foundational data to evaluate advanced practice registered nurses specific metrics and to compare with future data using a larger longitudinal sample.

Obstetric Informatics: Quality Improvement Using Peer-Based Anonymous Physician Score Card [24G

INTRODUCTION: With the widespread adoption of Computerized Physician Order Entry, auditing physician prescribing practices is technically simplified. We propose leveraging data from aggregate audits to develop a visual tool for quality improvement - the peer-based anonymous physician score card. METHODS: For our pilot quality improvement project, we have selected the prescribing of ondansetron for nausea and vomiting of pregnancy. This is a common condition for which recent evidence based recommendations have been updated by APGO and the American College of Obstetricians and Gynecologists in 2014 and 2015 respectively. Data was collected through a retrospective database query from our EMR for all medical records associated with pregnant patients who received a prescription of ondansetron in the ambulatory setting from January 2012 through August 2016 at our suburban hospital. Aggregate prescribing data was then tabularized onto bar graphs and anonymized. RESULTS: A total of 56 physicians were identified prescribing ondansetron as a first line medication. A total 484 patients were identified as having received ondansetron. 344 (71%) of which were not prescribed a first line medication. Of the 140 (29%) patients that did receive a first line medication only 64 (13%) patients received the prescription prior to or on the same date as ondansetron. CONCLUSION: By presenting peer prescribing habits to our physicians in an anonymous fashion, we propose this will serve as a non-invasive tool to raise awareness and reveal barriers to adoption of recent clinical guidelines. We will track prescribing patterns for an additional 6 months and re-evaluate individual and aggregate prescribing patterns after this intervention.

Antibiotic Stewardship in the Medical Intensive Care Unit of an Academic Medical Center: Impact of a Pneumonia Diagnostic Bundle with Pharmacist Intervention

BackgroundAcute bacterial pneumonia is a common empiric diagnosis in medical intensive care unit (MICU) patients. Clinically, however, it may be difficult to distinguish from nonbacterial causes of inflammation and infection of the lung(s). Incomplete diagnostic workup at the time of empiric antibiotic initiation or misinterpretation of available data may impede antibiotic de-escalation and discontinuation. We aimed to reduce unnecessary antibiotic use in the MICU by (1.) bundling pneumonia diagnostic orders into a single comprehensive order set and (2.) by implementing a daily pharmacist-driven antibiotic time-out.MethodsThis before-and-after quality improvement pilot project was conducted in the MICU of Baystate Medical Center, a closed 16-bed unit, from December 2016 through March 2017. Outcomes were compared with a baseline period from December 2015 through March 2016. At baseline, all diagnostic orders were entered individually via computer physician order entry (CPOE) and daily antibiotic stewardship was not provided. For the pilot, a pneumonia order set was built which includes all diagnostic tests and recommended empiric antibiotics based on the local antibiogram. Of note, serial procalcitonin levels first became available at our institution through this order set. An interpretation algorithm was adapted from the literature to aid in their interpretation. A new MICU clinical pharmacist position was created which allowed antibiotic time-outs to be conducted 7 days per week. Antibiotic discontinuation was assessed by comparing days of antibiotic therapy per 1000 patient-days.ResultsFor all antibiotics used to treat bacterial pneumonia, total days of therapy per 1000 patient-days in the MICU decreased from 905.7 in the baseline period to 688.4 in the pilot period (rate difference -217.3, 95% CI -270.8 to -163.9). The usage of narrow spectrum antibiotics increased during the pilot period.ConclusionBundling pneumonia diagnostic orders together into a single order set inclusive of serial procalcitonin measurement as well as providing daily pharmacist-led antibiotic time-outs were associated with decreased antibiotic usage in the MICU.Disclosures All authors: No reported disclosures.

Trauma health literacy: In need of remediation.

Little is known regarding health literacy among trauma patients. Anecdotal experience at our institution has suggested that a profound lack of understanding of basic health care information exists at some level in our patients after hospital discharge. The purpose of this study was to report the results of a pilot quality improvement project to determine trauma patient injury comprehension and how this affects their overall satisfaction with care received. Trauma patients were surveyed for knowledge of their injuries, operations, and satisfaction with their care at the first outpatient visit following hospital discharge from a Level 1 trauma center. One hundred seventy-five surveys were distributed and 35 were returned complete and eligible for analysis. Average time from discharge to survey completion was 16 days. Seventy-five percent of patients were male, and the mean age was 37. Fifty-six percent of the injuries were from a blunt mechanism. Seventy-one percent reported household income of less than $25,000 per annum, and 61% had an education level of high school diploma or less. Forty percent of patients were unable to correctly recall their injuries, and 54% were unable to correctly recall operations performed. Seventy-two percent were unable to recall the name of any physician that provided care during their hospital stay. Nonetheless, 90% of patients were at least somewhat satisfied with their injury understanding, and only 3% felt that their level of understanding had a negative impact on their overall satisfaction with care received. There was no correlation between education or income level and ability to correctly recall injuries or operations. In addition, there was no correlation between ability to recall injuries or operations and patients' satisfaction. The observed deficiency in postdischarge health literacy among our patients is alarming and demonstrates that current hospital discharge education is lacking. Although this deficit did not affect satisfaction with care, we feel a responsibility to improve the health literacy of our patients. The next step at our institution will be to implement a revised discharge education program followed by surveillance to evaluate for improvement. Therapeutic/care management study, level IV.

EPS02.1 Advanced care planning and thinking ahead in cystic fibrosis: a quality improvement pilot project for adults with cystic fibrosis

ePS02.1 Advanced care planning and thinking ahead in cystic fibrosis: a quality improvement pilot project for adults with cystic fibrosis