Plan-Do-Study-Act Cycles Research Articles

Improving Access to Community-Based Services for Sexual Assault Survivors

ABSTRACT Background Emergency department (ED) encounters are often the only healthcare provider encounter for patients seeking care after a reported sexual assault (SA), making the encounter a crucial opportunity to connect patients to support services in the community. An opportunity existed at an urban Level II trauma center to standardize SA discharge planning. Aims This quality improvement project aimed to improve access to SA support services. Methods The Model for Improvement guided two plan–do–study–act (PDSA) cycles. Implementation included (a) creation of a QR-code-accessible SA resource website, (b) ED standardized patient print and electronic medical record after-visit summaries with follow-up guidelines and the QR code, (c) ED staff education, and (d) a community stakeholder survey to assess facilitators and barriers to support services. Results During the first PDSA cycle, 19 reported SA survivors were seen in the ED (18 adult, one pediatric) and 14 SA resource website visits. During the second PDSA cycle, 13 reported SA survivors (10 adult, three pediatric) were seen in the ED and 29 website visits. Stakeholder survey data revealed barriers to support services were transportation, overloaded support services, and survivor knowledge of existing services. Conclusion The QR code intervention model is a discrete method of improving access to resources and is applicable to other vulnerable populations. The multiagency SA response team will utilize partner survey data to improve access to community resources such as housing and transportation.

Introducing a Framework for Surgical Discharge Summaries to Improve Accuracy and Succinctness in a Busy District General Hospital.

Background Discharge summaries (TTOs) are essential documents in the effective communication between primary and secondary care, particularly in conveying critical post-discharge instructions to patients. Inconsistencies and omissions in TTOs can significantly undermine patient outcomes and disrupt continuity of care. This is particularly relevant to surgical patients, who often require specific follow-up care such as the removal of clips or drains shortly after discharge. Following the recent transition from paper-based to electronic records at a busy district general hospital (Royal Blackburn Hospital, Blackburn), the quality of TTOs was noted to be substandard.This quality improvement project aimed to enhance the accuracy and clarity of surgical TTOs. Methods A targeted framework was developed in collaboration with local consultants and the consideration of national guidelines to guide the content of surgical TTOs, focusing on five essential components: Reason for Admission, Intervention, Surgical Details, Discharge Plan, and Follow-up Instructions. Initial retrospective data analysis includedTTOs (n=60) across five surgical wards, evaluating their quality against the framework. The framework was then introduced via educational initiatives and integrated into the hospital's electronic patient record (EPR) system (CERNER). The impact of these interventions was assessed through data collection after two Plan-Do-Study-Act (PDSA) cycles. Results Baseline data highlighted significant deficiencies; 42 (70%) of TTOs were missing at least one key element, with missing follow-up details most often the reason. Many TTOs also included excessive or inappropriate information, and their format varied greatly depending on individual writing styles. Following the first PDSA cycle and the introduction of the framework, the numberof TTOs containing all essential data points increased by 14 (30% increase), while those missing two or more elements decreased by 16 (48% decrease). After the second cycle, further improvements were observed, with the number of TTOs missing one or more data points decreased by 6 (21%). Despite the overall progress, follow-up information continued to be the most frequently omitted element. Feedback from resident doctors was positive and the unanimous opinion was that the framework improved not only the quality of TTOs, but also how efficiently they were written. Conclusions Implementing a standardised framework significantly improved the quality of surgical TTOs, particularly by increasing the inclusion of critical information. These results are encouraging. However, anecdotal evidence suggests there is a lack of training in writing TTOs at both undergraduate and foundation levels. Ongoing efforts are required to address these areas to ensure a sustained improvement in quality.

Quality Improvement Measures in Reducing Hypothermia Among At-risk Preterm Neonates in a Neonatal Intensive Care Unit

Background Hypothermia is a significant concern in most neonatal units in both term and preterm, which increases the risk of mortality and morbidity. We aimed to reduce the incidence of hypothermia among at-risk preterm neonates upon admission to the neonatal intensive care unit (NICU) from a baseline of 75%-30% over 15 months. Methods This quality improvement study in a tertiary NICU implemented multiple plan-do-study-act (PDSA) cycles for all inborn neonates with a gestational age of less than 34 weeks or birth weight under 1500 g. The key outcome measure was the incidence of hypothermia, expressed as a percentage. Potential barriers to normothermia were evaluated using fishbone analysis and a key-driver diagram. Baseline data were collected over 3 months, and two PDSA cycles were performed over 18 weeks using a bundled approach and a sustenance phase over 9 months. Key interventions involved the optimization of environmental temperature at various locations, the use of polyethylene wraps for resuscitation, the proper use of transport incubators, and through raising awareness among healthcare professionals. Results A total of 319 neonates were part of the study. The baseline incidence of hypothermia (outcome measure) decreased from a median of 83% to 20.5% after two PDSA cycles and was sustained for over 9 months with reinforcement measures. Only two neonates had hyperthermia during the study period (balancing measure), and 96% compliance with documentation was achieved. Conclusions Quality improvement measures with simple policy reinforcement and a bundled approach can help reduce the incidence of hypothermia in at-risk preterm neonates.

Implementation of a Nurse-Initiated Antibiotic Time-Out (NATO) in Childhood Cancer Patients in Central America

Abstract Background Children with cancer are at high risk for infection and frequently require antimicrobials. Antimicrobial stewardship (AMS) interventions can mitigate toxicity and development of antibiotic resistance yet the pharmacy and infectious diseases specialists who usually perform AMS are often absent in global settings. We report our experience testing a novel intervention to shift the antibiotic timeout to nurses in six pediatric oncology units in Central America. Methods The Nurse-initiated Antibiotic Timeout (NATO) is a scripted conversation between nurses and physicians to reevaluate antibiotic appropriateness after 48 to 72 hours of empiric use for febrile neutropenia. First, we performed a baseline assessment of AMS capacity using the WHO Practical Toolkit for AMS Programmes checklist. Based on these results, sites tailored a generic implementation plan emphasizing educational and documentation tools and iterative PDSA (Plan-Do, Study-Act) cycles to improve implementation and effectiveness outcomes. Results All sites collected antimicrobial use data for a minimum of two months. Four sites then piloted NATO, producing change ideas, including changes to documentation tools, antimicrobial decision categories, communication processes, and times. From August 2022 – October 2023, NATO was performed in 53.4% of febrile neutropenia episodes in the three sites reporting data. Sites had substantial NATO performance rate variation from month to month. Sites reported changes in antimicrobial therapy in 47% of episodes after a 6-month period (Figure 1). Conclusion The difference in performance rate of NATO underscores the importance of real-time reporting to adjust AMS implementation strategies. The change ideas developed by each site differed, however, core tools emerged, which will support AMS in other global settings. Next steps include comparing antimicrobial use pre- and post-intervention and determining a sustainability and scalability plan. Figure 1. Incidence of change in antibiotic therapy over time.

7902 Improvement In Follow-Up Of Post-Hospital Discharge Patients After Targeted Approach

Abstract Disclosure: S. Ward: None. Q. Aziz: None. A.L. Champion: None. K.E. Izuora: None. Improvement in Follow-up of Post-hospital Discharge Patients after Targeted Approach Introduction: Outpatient follow up after discharge from the hospital is a well-established factor affecting health outcomes in patients with chronic medical conditions. A prior QI project at our institution utilizing a Plan-Do-Study-Act (PDSA) cycle showed that overall follow up rate was 24% in patient expected to follow up in our outpatient clinic. The aim of this QI project was to identify and implement a targeted approach to improve outpatient follow up at our clinic. Methods: This study was a second round of a PDSA cycle with the goal of improving outpatient follow up. Analysis of prior data identified 54 patients referred for outpatient follow up in our endocrinology clinic after hospital discharge (non-targeted approach). Of these 54 only 13 patients had established follow up care (24%). We looked closer at the 39 patients who did not follow up to identify areas we could act on to improve follow up; 38% of these patients did not follow due to one of the following: did not know they needed to follow up, lack of knowledge of how to contact office, unable to reach office by phone. To overcome these obstacles, we developed a targeted approach for all patients seen in the hospital who were expected to follow up in the outpatient setting. This approach included the following: clinic business card with contact information given to patient, follow up instructions included in discharge instructions including how and when to contact office, message sent from physician to outpatient clinic staff requesting staff contact patient and schedule follow up appointment. This targeted approach was implemented for all patients requiring outpatient follow up seen by the UNLV Endocrinology consult service from August 1, 2023 to September 30, 2023. Results: During the two months of recruitment we identified 34 patients who needed outpatient follow up. All 34 of these patients had the targeted approach implemented. Of the 34 patients 12 have successfully followed up and one patient has a future appointment scheduled. This is a follow up rate of 35%, an increase of 11% compared with the prior QI data that did not use a targeted approach. If all future appointments are kept the follow up rate will be 38%. Five patients who had scheduled appointments did not show up to their appointment and are not counted in the successful follow group . Conclusions: Our targeted approach showed an improvement in outpatient follow up from 24% to 35% compared to a non-targeted approach. Five patients that scheduled appointments did not keep those appointments. Future steps would include evaluating reasons for no-show and identifying approaches to improve our no-show rate. . Presentation: 6/2/2024

Implementing a new multidisciplinary, remote, dementia staff training program for Veterans affairs nursing homes

BackgroundPreventing Loss of Independence through Exercise (PLIÉ) is a group program for people living with dementia that combines movements to support daily function with present moment body awareness and social engagement that has been found to have physical, emotional, social, and cognitive benefits. The goal of this study was to develop and refine a PLIÉ remote training program for interdisciplinary Veterans Affairs (VA) nursing home staff members also known as community living center (CLC) staff.MethodsThis pre-implementation study used iterative Plan-Do-Study-Act (PDSA) cycles. The 10-week PDSA cycles occurred from June to September 2021 at 2 VA nursing home sites. Remote training was delivered via Microsoft Teams and included 1-hour live-streamed weekly didactic sessions (nursing staff with PLIÉ instructor) focused on PLIÉ principles and 1-hour weekly live-streamed experiential sessions for staff to apply PLIÉ principles with residents. We administered weekly feedback surveys to iteratively refine the training process.Results14 staff members participated (5 recreation therapists, 3 social workers, 2 registered nurses, 2 chaplains, 1 psychologist, and 1 speech pathologist). The experiential sessions were rated as most helpful overall. Key PDSA refinements included: (1) creating 10-minute video recording summaries to support learning, particularly for those unable to attend live training sessions due to clinical schedules; and (2) incorporating self-reflection and goal setting to support staff incorporation of PLIÉ principles into routine care and personal life. These refinements resulted in increased use of PLIÉ principles with the residents from 67 to 89% of the staff participants. 100% of regular attendees (11/11) rated their overall satisfaction with remote training as “very good” or “excellent.”ConclusionsIt was feasible to train interdisciplinary CLC staff participants to deliver an integrative group movement program for residents with dementia remotely. PDSA cycles supported refinement of the training process and improved uptake. A larger study of PLIÉ remote CLC staff training is needed to assess outcomes on residents and quality of care.

Quality improvement project to reduce inpatient chemotherapy usage on a solid tumor oncology service.

333 Background: Inpatient chemotherapy is not routinely recommended for patients with solid tumors as administration is associated with increased length of stay (LOS), higher healthcare costs, and higher morbidity; and chemotherapy administration within 14 days of death is considered poor quality care. However, inpatient chemotherapy may sometimes be indicated for toxicity monitoring or due to barriers that limit prompt delivery of medications with clinically meaningful benefit. To ensure judicious use of inpatient chemotherapy we are undertaking iterative Plan, Do, Study, Act (PDSA) cycles involving education and policy initiatives on a solid tumor oncology service at an urban, academic medical center. Methods: PDSA cycles followed standard methodology. The initial goal was to reduce inappropriate inpatient chemotherapy use, which was expected to correspond with a 25% overall reduction. The initial intervention consisted of two main components: 1) division-wide education about the indications for inpatient chemotherapy, and 2) formation of a committee to review all chemotherapy requests for adult inpatients with solid tumors. The committee consists of clinicians within division leadership, including the division chief and representatives from operations, quality and safety, and ethics. Requests are sent from inpatient teams to the committee, who review each case for factors supporting inpatient treatment such as patient stability/performance status, clinically meaningful benefit, and practical barriers to outpatient administration. To evaluate the impact of the intervention, data were extracted from the electronic medical record for all patients admitted to the service for the 8.5 months before (12/1/22-8/15/23) and after (8/16/23-4/30/24) the initiation of the first PDSA cycle. Results: At baseline, prior to PDSA cycle 1, there were 930 admissions (n=606 patients), and 111 (11.9%, n=82 patients) received inpatient chemotherapy. During PDSA cycle 1 there were 889 admissions (n=557 patients), and 57 (6.4%, n=35 patients) received inpatient chemotherapy (p<0.001). There was no significant change in the proportion of patients receiving chemotherapy within 14 days or 30 days of death pre-PDSA cycle and post, 7.5% vs. 6.6% within 14 days of death (p>0.9), and 13.1% vs. 11.5% within 30 days of death (p>0.9). Overall, mean LOS for all admissions decreased from 11.1 days to 8.8 days (p<0.001). Conclusions: Preliminary results of this quality improvement initiative using iterative PDSA cycles to optimize inpatient chemotherapy use suggest a benefit. After the first PDSA cycle, there was a 46.3% decrease in the proportion of admissions receiving inpatient chemotherapy, and an overall decrease in LOS. Future PDSA cycles are aimed at limiting end-of-life chemotherapy and streamlining the transition from inpatient to outpatient chemotherapy to reduce delays and improve the patient experience.

Improving influenza vaccination assessment and uptake, one step at a time in a cancer center.

280 Background: Influenza immunization has shown to decrease morbidity and mortality of influenza infections. From September to December 2022, at the infectious diseases (ID) clinic at our institution, 73% of the patients did not undergo influenza immunization assessment during their clinical encounters and only 3% of the patients had the influenza vaccine administered. Furthermore, documentation of vaccine discussion was done in 73% of cases. Our aim was to improve vaccination assessment from 73% noncompliant to 50%. Methods: A multidisciplinary team of nurses, nurse leaders, pharmacists, and quality specialists was assembled to analyze baseline data on influenza vaccination assessment, administration, and documentation at the ID clinic from Sept to Dec 2022 using The Model for Improvement. Quality tools were utilized including Cause and Effect Diagram, Current State Process Flow Chart and Prioritization Matrix, to identify and prioritize opportunities for improvement creating a worklist for improvement focus. Vaccine assessment measured via EPIC immunization tab marked as reviewed, discrete areas to document vaccination and their administration were not a part of nursing or provider’s workflow. Using the Plan, Do, Study, Act (PDSA) method, the following changes were tested: PDSA Cycle 1; A green sticker highlighted those patients needing vaccine assessment. PDSA Cycle 2; A smart phrase was created for documentation in nurses’ notes and PDSA Cycle 3; provider’s notes regarding vaccine recommendations. Results: Interventions were associated with an improvement of influenza assessment via the immunization tab marked as reviewed in the ID outpatient clinic from 73% noncompliance to 3% noncompliance from September 2023 to March 2024. Concurrent with improvement of our assessment process, our on-site vaccination rate increased from 97% error to 89% error (Table) and there was 50% improvement in provider’s documentation. Conclusions: The formation of a multidisciplinary working group and implementation of quality tools interventions resulted in timely significant improvement in vaccination assessment, documentation, and administration. Subsequently, we were granted institutional approval to add an EPIC clinical decision support tool to standardize influenza vaccination documentation. Future strategies include implementation and evaluation of the utilization of Health Maintenance tool in the ID clinic before expansion to other clinics in our institution. Influenza vaccine administration vs outpatient visits in the ID clinic. Month/Year # Outpatient visits # Vaccines administered in clinic % of vaccines administered Influenza Sep-Dec 2022 1827* 54 2.95% Influenza Sept 2023-March 2024 2682 251 9.36% *Includes video and telephone visits.

A multisite initiative to assess the immunization status of medical oncology patients.

289 Background: The Swedish Cancer Institute (SCI) is committed to holistic care and recognizes immunizations are an essential component to quality outcomes. In 2022 the SCI was selected to participate in the Specialty Societies Advancing Adult Immunization (SSAAI) project supported by the Centers for Disease Control and Prevention (CDC) with a goal of incorporating the CDC Standards for Adult Immunization Practice into medical oncology clinical care. The CDC Standards for Adult Immunization Practice are assess, recommend, administer or refer, and document. Recognizing immunization status is not routinely assessed, this quality initiative aimed to increase assessment of immunization status in medical oncology across 7 network clinics on 4 campuses to above 50 % by the end of 2023. Methods: All team members completed the ASCO Quality Training Program. The Plan Do Study Act (PDSA) framework was selected. Assessment was defined as having completed the Immunization Activity Record within the Epic Medical Record system, which includes reconciliation with the Washington state immunization registry. Data was initially abstracted manually to determine the baseline assessment rate until an automated method was developed. A Fishbone diagram determined the top barrier was the lack of awareness about this functionality and lack of training around the task. A workflow diagram and standard operating procedure were implemented. Clinic staff were trained on the new workflow when rooming patients. A small pilot with one clinic of solid tumor medical oncology clinics was completed. Patients included were on active treatment and seen face to face within the clinic. The standardized process and tools were refined, and problem areas addressed. The work was then expanded to all seven of the SCI network medical oncology clinics including hematology as the final PDSA cycle using the same training, process and tools. Results: The Epic Immunization Activity Record completion rate went from less than 1% of solid tumor patients with an active systemic treatment plan to 61% in the pilot project. After two additional PDSA cycles to refine the steps and target problem areas, the rate improved to 67% over a 3-month period. The PDSA cycle was expanded to bring the refined process to all 7 network clinics with a baseline assessment rate of 6% which increased to 45% after interventions within a 3-month period and concluding the 2023 year. Conclusions: Developing tools and implementing a new workflow for immunization assessment yielded a significant improvement in assessment rates thereby setting a foundation of assessment utilizing the CDC Standards for Immunization Practice. The use of concrete written tools improves the sustainability of the changes. Additional tools and refinement of existing tools will be studied to improve the current rate and sustain the gains. Reference: Standards for Adult Immunization Practices | CDC .

Coordinating expensive, difficult-to-obtain prophylactic medications before discharge: A quality improvement project in an academic stem cell transplant unit.

337 Background: Infections are a significant source of morbidity/mortality in allogeneic stem cell transplant (alloSCT) patients and antimicrobial prophylaxis has reduced deaths. Between July 2022 and July 2023, 21% of new alloSCT recipients were discharged from UVA Medical Center without posaconazole or isavuconazonium +/- letermovir in-hand at the time of hospital discharge necessitating daily oral drug administration at the infusion center until medication could be obtained. This led to excess cost for UVA, burden on clinic staff, missed doses, and patient frustration. We sought to decrease the number of new alloSCT recipients discharged without appropriate prophylaxis in-hand from 21% to 10% by November 2024. Methods: Per the 2023 ASCO Quality Training Program associated with this project, a Model for Improvement and Plan Do Study Act (PDSA) methodology was utilized. The population included alloSCT patients with new prescriptions (Rxs) for posaconazole or isavuconazonium +/- letermovir. The outcome measure was percentage of newly discharged alloSCT patients requiring oral prophylaxis at the infusion center. The process measure was Time to Affordable Medication (TAM) defined as days from Rx prior-authorization (PA) request to paid claim with an affordable copay (defined as a copay the patient was able/willing to pay, including free drug approvals or assistance programs). The counter measure consisted of initiating the Rx PA process 10 days prior to planned admission via a discharge test Rx order set instead of waiting until admission. This standardized process allowed for clearer communication and more time for pharmacy technicians to process the Rx for PA, copays, free drug applications, and pharmacy logistics. Upon admission, the official Rx was released to the discharge pharmacy. If Rx shipment was required, this was set up the week prior to discharge. An I-chart (3-sigma) statistical process control (SPC) chart was used to assess the intervention. Results: The baseline TAM was assessed retrospectively in 22 Rxs over 3 months prior to intervention for a mean of 7.5 days. PDSA cycle 1 was implemented Nov. 2023. TAM for the first 35 Rxs was 4.3 days and the SPC upper control limit decreased from 26.3 days to 13.3 days demonstrating overall markedly decreased variation despite data from early 2024 having greater variability due to new insurance deductibles. Rxs requiring 10 or more days were due to free drug application processes. Importantly, no newly discharged alloSCT patients have required drug administration at the infusion center. Conclusions: PDSA #1 resulted in a decrease in TAM of 3.2 days, decreased variation in the process, and no patients discharged without drug in hand. Since we have already surpassed our aim, next steps include demonstrating sustainability of the process and a survey requesting feedback to identify balance measures.

Standardizing the evaluation and management of iron deficiency anemia secondary to heavy menstrual bleeding in the emergency department.

Comprehensive guidelines for the management of iron deficiency anemia (IDA) in adolescents with heavy menstrual bleeding (HMB) presenting to the emergency department (ED) are lacking, leading to variability in care. We aimed to standardize the evaluation and management of these patients through the development and implementation of an evidence-based algorithm using quality improvement methodology. Baseline data of the target population identified variability across four key measures of clinical management: therapy choice and administration, laboratory evaluation, hematology service consultation, and patient disposition. Literature review and consensus from pediatric hematology and gynecology providers informed a draft algorithm that was refined in an iterative multidisciplinary process. From December 2022 to July 2023, we aimed to achieve a 25% relative increase in patients to receive optimal management per the algorithm, while using sequential Plan-Do-Study-Act (PDSA) cycles. Process measures focusing on provider documentation and balancing measures, such as ED length of stay, were assessed concurrently. Forty-nine patients were evaluated during four PDSA cycles. Improvement of ≥40% above baseline regarding recommended therapy administration was achieved across four PDSA cycles. Adherence to recommended therapy choice improved from 57% (baseline) to 100%, minimal laboratory evaluation from 14% to 83%, hematology consultation from 36% to 100%, and appropriate disposition from 71% to 100%. ED length of stay remained stable. Implementation of a standardized algorithm for management of IDA secondary to HMB in adolescents in the ED increased adherence to evidence-based patient care.

Improving flu vaccination rates among adult patients with cancer at Kaiser Permanente.

326 Background: Vaccines protect cancer patients from developing severe illness, hospitalization, and death. At Kaiser Permanente (KP) South Sacramento Medical Center (KPSSC), oncology patients on active chemotherapy had an overall flu vaccination rate of 13% between September 1, 2022, and December 1, 2022. Our aim was to increase this rate to 33% during the 2023 flu season. Methods: In conjunction with the ASCO Quality Training Program, we applied quality improvement initiatives to improve flu vaccination. Our population of interest included adult cancer patients on active chemotherapy at KPSCC. We evaluated the barriers to vaccination assessment by distributing surveys to infusion nurses. We performed three Plan-Do-Study-Act (PDSA) cycles for quality improvement and monitored flu vaccination rates. Cycle 1 (9/11/2023 to 11/5/2023): We distributed the ASCO flu vaccine handout at oncology clinic. We had medical assistants and infusion nurses administer flu vaccines during clinic visits and chemotherapy sessions. Cycle 2 (11/6/2023 to 11/21/2023): We added the vaccine handout in Chinese and Spanish and updated our receptionists’ script to strongly encourage patients to receive flu vaccine. Cycle 3 (11/22/2023 to 12/6/2023): KP flu clinic set up an onsite flu vaccine cart one half day per week in the oncology clinic. Results: Barriers to vaccination assessment in the clinic included lack of time (60%), difficulty remembering to ask (10%), and non-influenza season (10%). Our interventions resulted in an increased flu vaccination rate from 13% in 2022 to 36% in 2023. During cycle 1, 298 out of 615 patients received their vaccine (48.5%). During cycle 2, 16 out of 118 patients received their vaccine (13.6%). PDSA cycle 3 resulted in 14 out of 178 patients receiving their vaccine (7.9%). Conclusions: Promoting vaccine awareness via active engagement with nurses and medical assistants early on and having onsite vaccine availability in the oncology clinic were keys to improve the overall flu vaccination rate. While most vaccines were administered at the beginning of flu season, the addition of language-tailored vaccine handouts and having an onsite vaccine cart towards the end of the season did result in late season vaccinations. Our findings do support the importance of providing timely vaccine information in the oncology clinic. Our future goal is to expand these efforts to other KP Northern California oncology centers to establish stable onsite vaccine availability in clinics and include additional vaccine types.

Improving dihydropyrimidine dehydrogenase genotyping (DPYD) prior to initiation of fluoropyrimidine-based chemotherapy at a community-based hospital: A quality improvement initiative.

347 Background: Dihydropyrimidine dehydrogenase gene (DPYD) testing is crucial in preventing toxicities from fluoropyrimidine chemotherapy. Despite benefits and established guidelines, its adoption within healthcare organizations remains inconsistent and suboptimal. We implemented a quality improvement project to improve DPYD testing prior to fluoropyrimidine chemotherapy at a community-based hospital. We aimed to increase DPYD testing for patients receiving fluoropyrimidine-based chemotherapy from 65% to 95% between July 2023 to July 2024. Balancing measures included DPYD testing turnaround time. Methods: For baseline diagnostics, manual chart review was performed on 126 patients to identify frequency of DPYD testing, and turnaround time (TAT) between May 1, 2023 to August 4, 2023. Patients were excluded if they received fluoropyrimidine-based chemotherapy prior to May 1, 2023. A multidisciplinary team including medical oncology residents and staff, pharmacists, nurses, and clinical informatics specialists worked jointly to identify and address barriers to implementation. Barriers identified included lack of established workflows and awareness of the importance of testing. Diagnostic tools utilized included Ishikawa diagrams and process mapping. The team used Plan-Do-Study-Act (PDSA) cycles to address barriers. A p-chart was used to analyze the results. Results: The baseline DPYD testing rate was 65%. Barriers identified via multidisciplinary sessions included lack of established workflow, awareness and importance of testing. PDSA cycles included education sessions to breast medical oncologists and medical oncology nurses, and development of a best-practice advisory in the electronic medical record. The percentage of eligible patients receiving DPYD testing increased from 65% to 95.8% in the total population. For breast cancer patients, the rate increased from 16.7% to 100%. For gastrointestinal cancer patients, the rate increased from 56.1% to 94.2%. Sustainability was demonstrated two months post-intervention with TAT stable between 7-8 days. Conclusions: Through PDSA cycles, we improved the frequency of DPYD testing for patients receiving fluoropyrimidine chemotherapy from 65% to 95.8%. Future work will assess changes in chemotherapy prescribing behavior in the setting of variant DPYD results, and outcomes of patients with variant DPYD testing.

Optimizing influenza vaccination among oncology patients through quality improvement cycles.

285 Background: Influenza poses significant risks to cancer patients, who are especially vulnerable due to immunosuppression caused by both their disease and treatment. (Cooksley et al., 2005) Sidney Kimmel Cancer Center – Jefferson Health (SKCC)’s Quality Improvement (QI) initiative aimed to increase influenza vaccination rates among adult cancer patients in our Center City clinic from October 2023 to March 2024. At baseline in the 2022-2023 flu season, 49% of our patients had a documented vaccination against influenza, leaving most of our patient population at increased risk for influenza infection. Methods: A series of four Plan-Do-Study-Act (PDSA) cycles were implemented over the course of the vaccination season. Cycle 1 collected baseline data on vaccination status via electronic health records (EHRs) and identified gaps in patient knowledge and vaccine hesitancy. Cycle 2 trained medical assistants (MAs) to engage in effective vaccination conversations, emphasizing the use of presumptive communication techniques and the reconciliation of immunization records in EHRs. Cycle 3 integrated patient education materials on vaccination in the clinical encounter. Cycle 4 scaled assessment protocols across teams. Results: Cumulatively, 68% (2,592/3,824) of unique oncology patients had a documented influenza vaccination by the completion of the season in March 2024. Integration of vaccine reconciliation into the MA workflow was the iteration that led to the biggest increase in vaccination rate among the PDSA cycles tested. We surpassed our initial aim for the season (59%) in this metric. Conclusions: The QI project at SKCC demonstrates that layered strategies involving both patients and care teams can improve vaccination rates among adult cancer patients. Integration of vaccine assessment into clinic workflows was an effective tactic. Future efforts will focus on replicating these successes with other vaccines. Rates of influenza vaccination by PDSA cycle. Cycle # Date Cycle Description Outcome Metric: Cumulative Vaccination Rate (%) 1 Oct 2023 Provider perception survey of vaccination knowledge 65 2 Nov 2023 Integration of vaccine reconciliation in MA workflow 69 3 Dec 2023 Integration of patient education materials to clinical encounter 70 4 Jan 2024 – Mar 2024 Scaling of updated workflows to entire clinic 68

Improving the assessment of cultural, religious and spiritual needs for patients at the end-of-life within an acute hospital trust

BackgroundCultural, religious and spiritual (CRS) needs become increasingly important to individuals as they approach the end of life. CRS needs often remain unmet for patients dying in an acute hospital...

Quality Improvement Initiative: Identifying Barriers to Reducing Time to First Feed With Human Milk in Low Birth Weight Infants.

Early exposure to human milk and time to first trophic feed in low birth weight (LBW) infants (<2 kg) is associated with a decreased risk of mortality, sepsis, and length of hospital stay. This project, focused on infants born at less than 2 kg, aimed to identify the mean time to first feed after birth, identify barriers to initiation of the first feed, and meet the target of having 90% of infants receive their first feed within the first 6 hours of life. This quality improvement (QI) project occurred in a thirty-bed level III NICU over 29 months using two Plan-Do-Study-Act (PDSA) cycles. A first-feed audit tool and a multifaceted educational plan were at the forefront of this initiative. Interventions were multidisciplinary, targeted, and extended to all healthcare team members caring for LBW infants, including staff of Labor and Delivery, the NICU, and the Child Health Transport Team. At the end of the QI project, 91.3% of inborn infants and 27.5% of outborn infants were being fed by 6 hours of age, compared with 78.8% and 12.5%, respectively, prior to the project. The mean time to first feed for inborn infants after the PDSA cycles was reduced to 4.4 hours, having a decrease of 80 minutes. A multidisciplinary approach was a key factor in the success of this QI initiative. Increasing staff education and improving clinical practice guidelines regarding the importance of early exposure to human milk are associated with reducing first feed times after birth.

Implementing Mental Health Screening for Adolescent Hematology and Oncology Patients: A Quality Improvement Initiative.

Purpose: Adolescents and young adults (AYA) with chronic illnesses experience an increase in mental health concerns. A mental health screening (MHS) process for hematology and oncology patients was implemented in a single institution. The quality improvement project was conducted to integrate a MHS process, educate providers about the importance of mental health in this patient population, and evaluate the process. Methods: The COM-B (capability, opportunity, motivation-behavior) model for behavior change was used to inform strategic planning and Plan-Do-Study-Act (PDSA) methodologies for process improvement. Retrospective chart reviews and surveys were conducted to determine missed screening rates and providers' perceptions, knowledge, attitudes, and skills of the MHS process. Results: Of 334 eligible patient encounters, the missed screening rate was 15.0%, the overall error rate of completing the screening was 3.8%, the error rate of completing the suicide or self-harm indicator was 2.6%, and the missed medical social worker touch point was 4.8%. Conclusion: The rising rates of mental health concerns in AYA hematology and oncology patients call for streamlined MHS processes to improve the identification of patients who may need intervention and services. Processes should be tailored to workflows and available resources. Future PDSA cycles will include providing dedicated nursing education and determining the cost needed to meet the rising mental health needs of the AYA hematology and oncology population.

Reducing Unnecessary Transfusions of RBCs in Inpatients Admitted Across Niagara Health Community Hospitals.

Blood products are scarce resources. Audits on the use of red blood cells (RBCs) in tertiary centers have repeatedly highlighted inappropriate use. Earlier retrospective audit at our local community hospitals has demonstrated that only 85% and 54% of all requests met Choosing Wisely Canada guidelines for pre-transfusion hemoglobin (Hb) of 80 g/L or less and single unit, respectively.We sought to improve RBC utilization by 15% over a period of 12 months (meeting Choosing Wisely Canada criteria of pre-transfusion Hb ≤80g/L by >80% and single-unit transfusion by >65%). Following repeated PDSA (Plan-Do-Study-Act) cycles, we implemented educational strategies, prospective transfusion medicine (TM) technologist-led screening of orders, and an RBC order set. The 3-month median percentages of appropriate RBC use for pre-transfusion Hb and single unit (September-November 2021) across all 3 hospitals were 90% and 71%, respectively. Overall, the rate of appropriate RBCs based on pre-transfusion Hb remained above target (>80%), with minimal improvement across all hospitals (median percentage at pre- and post-technologist screening periods of 87% and 90%, respectively). The median percentage of appropriate RBCs based on single-unit transfusion orders has improved across all Niagara Health hospitals with sustained targets (3-month median percentage at pre- and post-technologist screening and most recent time periods of 54%, 56%, and 71%, respectively). We have taken a collaborative, multifaceted approach to optimizing utilization of RBCs across the Niagara Health hospitals. The rates of appropriate RBC use were comparable with the provincial and national accreditation benchmark standards. In particular, the TM technologist-led screening was effective in producing sustained improvement with respect to single-unit transfusion. One of the balancing outcomes was increasing workload on technologists. Local and provincial efforts are needed to facilitate recruitment and retention of laboratory technologists, especially in community hospitals.

Nurse performed bladder ultrasound: a clinical quality improvement initiative

Background: Bladder ultrasound (BUS) provides an accurate measurement of post-void residual (PVR) volume and bladder assessment. Access to BUS is dependent on practitioner availability with delays resulting in poor symptom management, delayed discharge and dissatisfaction. Developing nursing practice to perform BUS can address these patient’s needs. Aims: Through a quality improvement initiative the aims were (1) to develop theoretical knowledge and practical competence of nurses to perform BUS, (2) to evaluate nursing activity in relation to BUS, (3) to evaluate stakeholders perceptions of the initiative. Methods: Based on the Deming Plan-Do-Study-Act (PDSA) cycle, an interprofessional team was created and a theoretical/practical based education program was devised. Activity in relation to the nurse-performed BUS was collected and analysed descriptively. Stakeholder perceptions were evaluated via patient and physician questionnaires subject to descriptive analysis and a focus group with nurses analysed descriptively. Results: The team developed a training program to perform BUS, certifying 11 nurses. Investigation of nursing activity related to BUS (n = 202) showed its use for PVR evaluation, and symptom and catheter assessment. It aided decision-making and nurse-physician communication. Stakeholders were satisfied with the initiative. Patients (n = 30) felt nurses were competent, clearly explaining the procedure, results and inspiring confidence. Physicians (n = 2) saw BUS as enhancing efficiency and care quality, while nurses (n = 7) felt this new skill enhanced nursing care providing a more holistic approach. Team reflection on the results of the evaluation confirmed BUS utility and activity, while nurses requested continuing education and a post-certification refresher course. Conclusion: Through reflection on clinical practice areas for improvement to enhance patient care were identified by the nursing team. Application of the PDSA cycle provided a structured approach to guide the quality improvement initiative. Improvements in nursing care and patient care processes have been observed and this has been a positive experience for stakeholders.

A Clean You Can Trust: Using an Evidence-Based Bundle to Transform Point-of-Use Treatment for Reusable Medical Devices at a Military Treatment Facility

ABSTRACT Introduction Throughout surgical and invasive procedures, reusable instruments and flexible endoscopes become soiled with organic and inorganic materials. When these substances are permitted to dry, a matrix of microbial cells, called biofilm, forms on the surface of devices, irreversibly binding and subsequently impeding the disinfection and sterilization process. To prevent biofilm formation from occurring, devices must be continuously flushed and wiped with water throughout the procedure and at the end of the case. This process, known as point-of-use treatment (POUT), is the critical first step in the decontamination of medical devices. Poor compliance with POUT can increase patient morbidity and mortality and result in failing hospital accreditation. Materials and Methods An interdisciplinary team used the Plan-Do-Study-Act (PDSA) to develop and implement an audit assessing 29 evidence-based criteria for POUT treatment. Each PDSA cycle supported evidence-based opportunities addressing feedback, workflow analysis, policy development, competency assessment creation, training module development, and infection prevention grand rounds. Four audits were performed over ten months to achieve improved organizational POUT compliance. Results Implementing recurrent PDSA cycles that included audits with feedback led to an evidence-based bundle of policies, competencies, and training for 34 different clinical areas. These interventions resulted in a 26% compliance increase (66% to 92%). Program-specific improvements included flexible endoscopes (+4%) and reusable instruments (+20%). Conclusions Multimodal evidence-based initiatives to improve compliance with workflow processes is a translatable POUT evidence-based practice project for similar Defense Health Agengy facilities. Workflow processes can be vetted and distributed using interdisciplinary teams to ensure viability, sustainability, and conformity with organizational requirements, resulting in a more ready force.