Post-implementation Data Research Articles

Implementation of a Depression Screening Tool at the Department of Radiation Oncology

<h3>Purpose/Objective(s)</h3> Depression is a common comorbidity in cancer that has detrimental effects on patient health outcomes and quality of life. Unrecognized depression can impede treatment adherence resulting in disease progression and mortality in cancer patients. Inadequate depression screening and referral practices were observed and verbalized as a concern by internal stakeholders at an academic Radiation Oncology Department (ROD) in Baltimore, Maryland. Thus, the purpose of this Quality Improvement (QI) project was to implement and evaluate the Patient Health Questionnaire (PHQ-9) depression screening tool with subsequent psychosocial referrals for all positive screens. <h3>Materials/Methods</h3> The QI project used the Mobilize-Assess-Plan-Implement-Track (MAP-IT) framework. The QI team implemented four core interventions during the fifteen-week project: Staff education, PHQ-9 screening, provision of mental health resources, and psychosocial referrals for patients with moderate to severe depressive symptoms (PHQ-9 scores of ≥10). A convenience sample of adult cancer patients (≥18 years old) with a confirmed cancer diagnosis and a radiation treatment plan were eligible to participate. Rates of PHQ-9 screening, positive screens, referrals, and social worker follow-up were collected weekly, analyzed, and plotted on run charts. A combination of descriptive statistics, <b>t</b>-tests, and a chi-squared (X²) test examined differences between pre-and post-implementation data for statistical significance. <h3>Results</h3> All targeted staff attended the education session (n = 10), and there was a 100% completion rate for the pre- and post-surveys. Post education, the average score for staff competency significantly increased from 62% to 96% (<i>P</i> = < 0.001; 95% CI [17.5, 57.0]. Post-implementation, PHQ-9 screening compliance increased from 2% baseline to 67% (<i>P</i> = < 0.001, <b>df</b> = 1, n = 145). Of the patients screened, 19% scored above the threshold indicative of a positive screen (n = 27). Subsequently, all positive screens were referred to an Oncology Social Worker (<i>P</i> = < 0.001), and 93% received follow-up care (n = 25). <h3>Conclusion</h3> Routine depression screening and psychosocial referrals among cancer patients receiving radiotherapy in an outpatient setting are feasible when streamlined into the clinical workflow. An integrated care approach with PHQ-9 screening improves the early identification of depression and increases patient access to psycho-oncology care. Registered nurses are in critical positions to perform primary and secondary prevention interventions to reduce the burden of depression. Considerations for future development include a collaborative and stepped care approach to address the unmet psychosocial needs that exist in the oncology population.

1280 A Retrospective Audit of The Management of Facial Lacerations in The Emergency Department in A Busy South Wales Tertiary Centre

Abstract Aim To assess the management of facial lacerations in the Emergency department at Morriston Hospital using NICE laceration guidance. Method We performed a retrospective audit on the management of facial lacerations that presented to Morriston A&amp;E between 5/7/20 - 23/7/20. Two reviewers independently assessed ED documentation from all patients with a coded diagnosis of facial laceration. The criteria assessed included the examination of neurovascular status, consideration of analgesia, risk assessment for tetanus or infection and antibiotic choice. Following this we have implemented a Facial laceration checklist sticker to serve as a clinical tool to examine, risk stratify and to aid documentation. Results In this timeframe we assessed 50 patients in total. Prior to any intervention: 37% had documented Neurovascular examination, 58% had no tetanus risk assessed or prescribed, Analgesia was considered in 43% of cases and antibiotics were prescribed in 20% of cases (10% vs 90% for Flucloxacillin vs Chloramphenicol.) We are currently still collecting post implementation data. Conclusions With SHO staff rotations in Plastic Surgery, Maxillofacial Surgery and A&amp;E as frequently as on a 4 monthly basis there can be variation in experience when managing facial lacerations. It is therefore important to have quick, clear and accessible clinical tools to support the recognition of complications in facial lacerations. Chloramphenicol was the most commonly prescribed antibiotic which was not within nice guidelines and only prescribed by Maxillofacial and Plastic surgery. This prompts the next step in reviewing literature in order to delineate the grounds for its usage.

Coronavirus Disease 2019 Vaccine Impact on Rates of Severe Acute Respiratory Syndrome Coronavirus 2 Cases and Postvaccination Strain Sequences Among Health Care Workers at an Urban Academic Medical Center: A Prospective Cohort Study.

Background Coronavirus disease 2019 (COVID-19) vaccine trials and post-implementation data suggest that vaccination decreases infections. We examine vaccination’s impact on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) case rates and viral diversity among health care workers (HCWs) during a high community prevalence period.MethodsIn this prospective cohort study, HCW received 2 doses of BNT162b2 or mRNA-1273. We included confirmed cases among HCWs from 9 December 2020 to 23 February 2021. Weekly SARS-CoV-2 rates per 100,000 person-days and by time from first injection (1–14 and ≥15 days) were compared with surrounding community rates. Viral genomes were sequenced.ResultsSARS-CoV-2 cases occurred in 1.4% (96/7109) of HCWs given at least a first dose and 0.3% (17/5913) of HCWs given both vaccine doses. Adjusted rate ratios (95% confidence intervals) were 0.73 (.53–1.00) 1–14 days and 0.18 (.10–.32) ≥15 days from first dose. HCW ≥15 days from initial dose compared to 1-14 days were more often older (46 vs 38 years, P = .007), Latinx (10% vs 8%, P = .03), and asymptomatic (48% vs 11%, P = .0002). SARS-CoV-2 rates among HCWs fell below the surrounding community, an 18% vs 11% weekly decrease, respectively (P = .14). Comparison of 50 genomes from post–first dose cases did not indicate selection pressure toward known spike antibody escape mutations.ConclusionsOur results indicate an early positive impact of vaccines on SARS-CoV-2 case rates. Post-vaccination isolates did not show unusual genetic diversity or selection for mutations of concern.

Development and Evaluation of a Research-Driven Health Communication Campaign to Increase Fruit and Vegetable Consumption Among SNAP-Eligible Ohio Adults

Background: Despite evidence of the protective effects of a diet high in fruits and vegetables, intake among Ohio adults remains low. A health communication campaign is an attractive behavior change intervention due to its potential to reach a large audience. Focus of the Article: This study aims to examine the development of a state-level health communication campaign and to assess outcome measures relative to fruit and vegetable intake. Research Question: Two research questions were evaluated: (1) How did Ohio State University Extension use formative research to inform the campaign’s development? and (2) Was campaign exposure associated with increased fruit and vegetable consumption or readiness to increase fruit and vegetable consumption among the target audience comprising Ohio adults eligible for the Supplemental Nutrition Assistance Program (SNAP)? Program Design/Approach: Ohio State University Extension conducted extensive formative evaluation prior to developing the Celebrate Your Plate health communication campaign. The campaign was designed to increase the target audiences’ fruit and vegetable consumption, reinforce messages taught in nutrition education classes, and reach a larger segment of the population with messages promoting healthy behaviors. The campaign was implemented statewide through a multi-year phased rollout and comprised a mix of printed and digital communication channels and an accompanying website. Supportive individual- and community-level programming was also implemented by Ohio State University Extension as part of a multilevel approach to increasing fruit and vegetable intake. Importance to the Social Marketing Field: The limited existing research on the effectiveness of health communication campaigns to increase consumption of healthy foods largely focuses on national campaigns and this study examines effectiveness of a locally tailored campaign. Methods: This study comprised a mixed-methods multi-stage evaluation: qualitative data were collected in four pilot counties to assess the target audience’s awareness and reception of the campaign and recommendations for future efforts. Cross-sectional post-implementation outcome evaluation data were collected and analyzed to assess campaign exposure and behaviors of the target audience. Results: During the pilot evaluation, the target audience responded positively to campaign materials and identified the perceived cost of healthy recipes as a main barrier to changing eating patterns. After the campaign was rolled out statewide, approximately 18% of the target audience indicated exposure to Celebrate Your Plate in aided recall. Campaign exposure was significantly associated with higher fruit ( p &lt; .001) and vegetable ( p &lt; .001) consumption. The Stages of Change model was used to conceptualize readiness to increase fruit and vegetable consumption; campaign exposure was significantly associated with readiness to increase fruit ( p = .001) and vegetable ( p = .027) consumption. Recommendations for Research or Practice: Results of this study show that campaign exposure is significantly associated with higher fruit and vegetable consumption and readiness to consume more fruits and vegetables among the target audience, though more rigorous evaluation is needed to determine causality. Limitations: This study included cross-sectional data and lacked a control group and consequently cannot be used to determine if behavioral observations resulted from campaign exposure. Additionally, this study relied on self-reported data and is susceptible to response biases.

Antibiotic prescribing practices in general surgery: a mixed methods quality improvement project

SummaryBackgroundA single pre-operative antibiotic dose provides optimal prophylaxis against surgical site infection (SSI), but significant variability persists in adherence to prophylaxis guidelines. We describe a quality improvement project aiming to improve guideline-driven antibiotic prescribing within surgical teams at a tertiary hospital.MethodsFace-to-face interviews with surgical teams and anonymous surveys of senior surgeons and anaesthetists were used to collect qualitative data on the perceptions and attitudes of prescribers. This informed intervention development, including a daily ward-round checklist using the acronymous ‘ABBDDOMM’, from A (antibiotics) to M (microbiology), combined with education and heightened guideline accessibility. A first audit cycle was performed for patients undergoing intra-abdominal surgery during a two-month period (cycle one). Post-implementation data were collected 12 months later (cycle two).FindingsInterviews provided insight into common themes and barriers surrounding antibiotic prescribing, whilst surveys explored future solutions to these barriers. In cycle one, 100/205 (48.8%) patients received extended antibiotics beyond the single-dose prophylaxis. Following intervention, only 41/138 (29.7%) patients received extended antibiotic courses, demonstrating a 21.5% reduction in prolonged antibiotics (P<0.0005). In cycle one, 107/205 patients (52.2%) received antibiotics compliant with Trust Guidelines, compared to 80/138 (58.0%) in cycle two.ConclusionOur proposed checklist, alongside antimicrobial stewardship education, prompts daily review of important patient parameters and results to significantly reduce inappropriate post-operative antibiotic prescribing. Promoting the sustained use of similar checklists by junior doctors and focusing on measures to improve uptake of pre-operative induction antibiotic guidelines is required to achieve further benefits.

#KnockTheNausea: Use of Aromatherapy in the Pediatric Perianesthesia Care Unit

<h3>Introduction</h3> Post-operative nausea and vomiting (PONV) is a major cause of distress in the PACU (Post-anesthesia Care Unit). It is associated with an increased risk of potential complications, patient dissatisfaction, and delayed discharge. The prolonged stay in PACU directly affects the efficiency of our patient throughput. Nonpharmaceutical therapies offer an alternative to antiemetic therapies with benefits in being noninvasive and inexpensive. <h3>Identification of the problem</h3> PONV in the PACU setting is an important cause of morbidity in children. This puts patients at risk for complications including but not limited to dehydration, aspiration, wound dehiscence, and bleeding post operatively. <h3>EBP Question/Purpose: PICO question. Databases utilized</h3> In pediatric postoperative patients ages 5-18, does aromatherapy reduce the incidence of postoperative nausea and vomiting (PONV) and therefore improve patient/family satisfaction when used adjunctively with current practice? P - Pediatric postoperative patients I - Aromatherapy C - Current state/practice O - Reduced PONV and improved patient/family satisfaction Databases utilized were PubMed, Google Scholar, and CINAHL <h3>Methods/Evidence</h3> • The IOWA model was followed • Education for staff and families was created • Utilized validated pediatric nausea/vomiting tools for patients/families in PACU • Choice of ginger or peppermint offered to patient/family with PONV • A survey was developed for nurses and patients/parents to document effectiveness of aromatherapy • Inclusion criteria: ○ Patients undergoing the following surgical procedures: ■ Orchidopexy, testicular/ovarian torsion, inguinal hernia, hydrocelectomy, tympanoplasty/mastoidectomy, and eye muscle correction ○ Patients age 5-18 •Exclusion Criteria: ○ All other surgical procedures <h3>Significance of Findings/Outcomes</h3> Pre-implementation: 3-month period of pharmacological and non-pharmaceutical interventions. Post-implementation data: 3-month period pharmacological, non-pharmaceutical interventions, Pre/post implementation PONV scores, and patient satisfaction scores post implementation. Post-implementation findings: • 150 patients met inclusion criteria ○ 100 patients eliminated due to not completing survey ○ 50 surveys completed ■ 20 completed correctly ■ 12 surveys eliminated due to denying nausea pre intervention ■ Total sample size of 8 • 6 reported reduction in PONV • 2 reported no change or reduction in PONV Regarding patient satisfaction data: • 20 completed surveys ○ 7 completed satisfaction survey, therefore sample size of 7 ○ 3 rated their experience "neutral" ○ 4 rated their experience "satisfied/extremely satisfied" <h3>Implications for perianesthesia nurses and future research</h3> The use of aromatherapy is an integrative and holistic approach to help minimize PONV in post-operative patients. Patients achieved relief which aids in decreasing the chance of potential complications. Patients also had an increase in satisfaction post-operatively in the PACU. Future goals: Integrate BARF tool/Likert scale into current electronic medical charting as an objective way to assess and document PONV within the institution.

Innovative Utilization of Wright's Model for Competency Validation.

Wright's competency assessment model is well known, yet implementation has been largely challenging. Some organizations have attempted enterprise-wide implementation. This article summarizes how Wright's model was used from a specific topic perspective. Centralized nursing professional development practitioners created flexible competency validation guidelines and supplemental tools (literature review, exemplar, and peer review) for use by sedation nurses regardless of experience or practice setting. Post-implementation data show 62% adoption of new validation methods after 1 year.

Incorporating physical manipulatives into an integrated pharmacotherapy course to reinforce antimicrobial spectrum of activity

Background and purposeTeaching and learning the spectrum of activity (SOA) of antimicrobial agents can be a challenge in pharmacy education. This study describes the implementation and assessment of a novel tool to aid in the instruction of SOA. Physical manipulatives were used as an active-learning technique to model bacterial pathogens for antimicrobial SOA in an infectious diseases (ID) integrated medication therapy management course. Educational activity and settingPharmacy students enrolled in two consecutive years of the ID course were provided the opportunity to utilize a set of manipulatives for in-class activities and out-of-class practice. The manipulatives were small, colored building blocks that could be used to model bacterial pathogens for antimicrobial SOA. A key was included with each set of blocks, color-coding each block to represent a different bacterial pathogen or pathogen group. Blocks were used during classroom instruction to model the SOA of antimicrobial agents, compare/contrast SOA between medications, and model bacterial pathogens requiring empiric coverage for various infections, allowing students to produce “bug-drug” matches. Course data from the previous year was utilized to compare pre-implementation aggregate performance with post-implementation data. Performance on SOA-related questions was assessed during the course, using an independent samples t-test. FindingsThe intervention group exhibited a statistically significant increased mean score on test questions relating to SOA as compared to the control group. SummaryThe use of manipulatives was associated with improved performance on SOA-related questions in an integrated ID course of pharmacy students.

Implementation of a Universal Decolonization Protocol to Reduce Surgical Site Infections in Orthopedic Surgery Patients

Background : Orthopedic surgical site infections (SSISs) are costly complications, increasing morbidity and mortality. between CY2018 and July 2019, our facility experienced an increase in complex (deep and organ space) SSIs, most due to common skin organisms. During this period, our preoperative process included the use of 2% chlorhexidine (CHG) impregnated cloths for patient self-application the night before and the morning of surgery. Day of surgery (DOS), the preoperative nurse repeated the CHG cloth application on the surgical site and applied an iodophor product to the patient's nose. Methods : A multidisciplinary team was engaged to develop a preoperative five-day universal decolonization (UD) protocol: daily use of a 4% CHG antiseptic foam skin cleanser and twice a day use of an alcohol-based nasal sanitizer. Kits with UC products and instruction were distributed by the surgeons’ offices during the preoperative appointment. Kit receipt was confirmed during the preadmission phone call. Alcohol-based nasal sanitizer repeated DOS. Compliance with UC kit use was confirmed DOS. The 12-month pre- and post-implementation periods were compared. Results : In the pre- and post-intervention periods 4,610 and 4,361 procedures were performed, respectively. Random sampling of procedure documentation showed greater than 99% patient-reported compliance. No reports of adverse effects were received. Analysis of the pre- and post-implementation data revealed a decrease in all NHSN procedure complex SSI standardized infection ratio (SIR) from 1.287 to 0.762. The SSI SIR for individual procedure types (spinal fusion, hip/knee replacement) were also decreased with the exception of laminectomies. The complex SSI rate per 100 procedure was decreased overall and for each individual procedure category. Conclusions : The implementation of a preoperative five-day UC protocol decreased the complex SSI SIR and complex SSI rate per 100 procedures for all NHSN procedures.

The Best of Both Worlds: Eliminating Creatine Kinase-Muscle/Brain (CK-MB) Testing in the Emergency Department Leads to Lower Costs Without Missed Clinical Diagnoses.

The 2014 American Heart Association/American College of Cardiology (AHA/ACC) clinical guidelines recommend cardiac troponin as a superior biomarker to creatine kinase (CK) and creatine kinase-muscle/brain (CK-MB) for the detection of acute coronary syndrome (ACS), namely myocardial infarction and unstable angina. In April 2018, our Emergency Department (ED) transitioned from using standard troponin to using high-sensitivity troponin T, and adopted a clinical guideline consistent with the AHA/ACC. The guideline recommended high-sensitivity troponin T without CK/CK-MB testing in the majority of clinical situations, limiting CK/CK-MB testing to two specific clinical cases: 1) estimated glomerular filtration rate (eGFR) value <15 mL/min, or 2) recent acute coronary syndrome (ACS) event. Per our ED’s policy, a “negative” troponin T was defined as being below the limit of detection (LOD) (i.e., <6 ng/L); such a value obtained at least 3 hours after symptom onset “ruled out” an ACS event and did not require a repeat troponin.The goal of this retrospective study was to determine whether the guideline limiting CK-MB testing missed clinically-significant cardiac outcomes (ACS or new diagnosis of coronary artery disease [CAD]) or was associated with mortality. Pre-implementation data (July 1, 2017 - December 31, 2017) was compared with post-implementation data (July 1, 2018 - December 31, 2018). After guideline introduction, CK/CK-MB ordering decreased by nearly 90%, while troponin ordering increased by nearly 20%, likely due to the introduction in June 2018 of high-sensitivity troponin T, which yielded numerous intermediate/indeterminate-range results that prompted repeat testing. Fewer than 1.5% of patients with a “negative” troponin (below the LOD) and a “positive” CK-MB (above the upper limit of normal [ULN]) had ACS or new-diagnosis CAD; patients with either diagnosis did not expire during their hospital stay or within 30 days of their index visit. CK-MB Index, which has a higher specificity than CK, only found ACS or new CAD among 0.8% of positive results. Considering both decreased CK/CK-MB and increased troponin ordering, the net annual direct cost savings in cardiac biomarker testing was extrapolated to $12,700. Had our institution not transitioned to higher cost high-sensitivity troponin ($2.054/unit) from standard troponin ($1.65/unit), and had the rate of troponin ordering increased solely proportionate to the rate of ED visit increase (2% year-over-year) rather than increase nearly 20% (likely due to the transition to high-sensitivity troponin), then the total six-month direct costs on troponin testing would have been $14,632 instead of $21,267.12, and annual direct cost savings would have been $18,945.80 instead of $12,700. The new ED clinical guideline did not result in a significant number of missed ACS or new-diagnosis CAD, and was associated with direct cost savings. These savings probably underestimate total savings, as the reduced number of “false-positive” CK-MB results likely prevented additional costs, such as hospitalization, specialty consultation, coronary calcium CT, echocardiogram, cardiac stress test, and coronary artery catheterization.

An Analysis of the Safety of Medication Ordering Using Typo Correction within an Academic Medical System.

Spelling during medication ordering is prone to error, which can contribute to frustration, confusion, and, ultimately, errors. Typo correction can be utilized in an effort to mitigate the effects of misspellings by providing results even when no exact matches can be found. Although, typo correction can be beneficial in some scenarios, safety concerns have been raised when utilizing the functionality for medication ordering. Our primary objective was to analyze the effects of typo correction technology on medication errors within an academic medical system after implementation of the technology. Our secondary objective was to identify and provide additional recommendations to further improve the safety of the functionality. We analyzed 8 months of post-implementation data obtained from staff-reported medication errors and search query information obtained from the electronic health record. The reports were analyzed by two pharmacists in two phases: retrospective identification of errors occurring as a result of typo correction and prospective identification of potential errors with continued use of the functionality. In retrospective review of 2,603 reported medication-related errors, 26 were identified as potentially involving typo correction as a contributing factor. Six of these orders invoked typo correction, but none of the errors could be attributed to typo correction. In prospective review, a list of 40 error-prone words and terms were identified to be added as stop words and 407 medication synonyms were identified for removal from their associated medication records. Our results indicate, when properly implemented, typo correction does not cause additional medication errors. However, there may be benefit in implementing further precautions for preventing future errors.

Formative process evaluation of a guideline-driven process for improving the cultural responsiveness of alcohol and drug treatment services

BackgroundTo improve Australian Aboriginal and Torres Strait Islander people’s access to, and experience of, healthcare services, including Alcohol and other Drug (AoD) treatment services, principles and frameworks have been developed to optimise cultural responsiveness. Implementing those principles in practice, however, can be difficult to achieve. This study has five aims: i) to describe a five-step process developed to operationalise improvements in culturally responsive practice in AoD services; ii) to evaluate the fidelity of implementation for this five-step process; iii) to identify barriers and enablers to implementation; iv) to assess the feasibility and acceptability of this approach; and v) to describe iterative adaptation of implementation processes based on participant feedback.MethodsParticipating services were 15 non-Aboriginal AoD services in New South Wales, Australia. Implementation records were used to assess the implementation fidelity of the project. Structured interviews with chief executive officers or senior management were conducted, and interview data were thematically analysed to identify project acceptability, and the key enablers of, and barriers to, project implementation. Quantitative descriptive analyses were performed on the post-implementation workshop survey data, and responses to the free text questions were thematically analysed.ResultsA high level of implementation fidelity was achieved. Key enablers to improving culturally responsive practice were the timing of the introduction of the five-step process, the active interest of staff across a range of seniority and the availability of resources and staff time to identify and implement activities. Key barriers included addressing the unique needs of a range of treatment sub-groups, difficulty adapting activities to different service delivery models, limited time to implement change in this evaluation (three months) and the varied skill level across staff. The project was rated as being highly acceptable and relevant to service CEOs/managers and direct service staff, with planned changes perceived to be achievable and important. Based on CEO/management feedback after the project was implemented at the initial services, several improvements to processes were made.ConclusionThe operationalisation of the five-step process developed to improve cultural responsiveness was feasible and acceptable and may be readily applicable to improving the cultural responsiveness of a wide variety of health and human services.

Implementing a pharmacist-led transition of care model for posttransplant hyperglycemia.

DisclaimerIn an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.PurposeThe implementation of a pharmacist-managed transition of care program for kidney transplant recipients with posttransplant hyperglycemia (PTHG) is described.MethodsIn September 2015, a collaborative practice agreement between pharmacists and transplant providers at an academic medical center for management of PTHG was developed. The goal of the pharmacist-run service was to reduce hospitalizations by providing care to patients in the acute phase of hyperglycemia while they transitioned back to their primary care provider or endocrinologist. For continuous quality improvement, preimplementation data were collected from August 2014 to August 2015 and compared to postimplementation data collected from August 2017 to August 2018. The primary endpoint was hospitalizations due to hyperglycemia within 90 days post transplantation. Secondary endpoints included emergency department (ED) visits due to hypoglycemia and the number of interventions performed, number of encounters completed, and number of ED visits or admissions for hypoglycemia. A Fisher’s exact test was used to compare categorical data, and a Student t test was used to compare continuous data. A P value of <0.05 was considered to be statistically significant.ResultsForty-three patients in the preimplementation group were compared to 35 patients in the postimplementation group. There was a significant reduction in hospitalizations due to hyperglycemia in the postimplementation versus the preimplementation group (9 vs 1, P < 0.05); there was a reduction in ED visits due to hyperglycemia (5 vs 0, P = 0.06). There were no ED visits or hospitalizations due to hypoglycemia in either group. Clinical transplant pharmacists performed an average of 8.3 (SD, 4.4) encounters per patient per 90 days.ConclusionA collaborative practice agreement was created and successfully implemented. A pharmacist-managed PTHG program could be incorporated into the standard care of kidney transplant recipients to help minimize rehospitalizations due to hyperglycemia.

Duplicate Testing: Enhancing Transitions in Care Communication in the Infusion Center and Emergency Department Settings.

Two objectives of the American Board of Internal Medicine's Choosing Wisely® initiative include avoiding duplicate testing and choosing care that is free from harm. Oncology nurses in an academic comprehensive cancer center observed a pattern of testing duplication and related dissatisfaction among providers and patients. A quality improvement project was initiated to quantify the problem and reduce duplication by implementing collaborative solutions to improve interdepartmental communication during handoffs. Postimplementation data revealed a 35% decrease of testing duplication in the patient population.

A Quality Improvement Project on Agitation Management in the Emergency Department

IntroductionAgitation is common in the emergency department. When agitation is not detected early, patients can become aggressive and violent, potentially leading to restraint use and subsequent injury. The goals of the project were early detection and management of patient agitation, reduction of restraint use in the emergency department, and determination of the usability of the Behavioral Activity Rating Scale. MethodsThis quality improvement project was assessed using a pre- and posttest single unit design, comparing 4 months of postimplementation data to historic controls at the same time of year in the previous year. The intervention was implementing the Behavioral Activity Rating Scale in the ED electronic medical record. Data were collected through retrospective chart review and nurse survey. From September through December of both 2017 and 2018, data were collected on restraint use. The 4-month 2018 data collection period included measures of Behavioral Activity Rating Scale documentation and the System Usability Scale survey for nurses to measure ease of usability of the Behavioral Activity Rating Scale. ResultsThe Behavioral Activity Rating Scale was documented frequently (n = 4 867 documentations) by emergency nurses to assess patients with behavioral health and medical complaints (n = 780). Nurses identified 18 episodes of violent behavior in behavioral health patients on the Behavioral Activity Rating Scale (2.31%) and applied restraints 18 times. The most common chief complaints for patients who were identified as violent was suicidal ideation (n = 6; 33.33%).In 2017, there were 20 episodes of restraint use during the same time period, a nonsignificant difference (χ2 = 0.72; P = 0.40). However, only 2 patients were kept in restraints longer than 1 day in 2018 compared with 8 in 2017. Emergency nurses found the Behavioral Activity Rating Scale to be usable in the structured usability assessment (μ = 83.46; SD = 11.73). DiscussionThe Behavioral Activity Rating Scale is a usable tool for emergency nurses to assess for patient agitation. With the incorporation of agitation management interventions, the ED team can potentially manage agitation before violence occurs. Further studies are needed on the use of agitation or aggression assessment tools for managing patient behavioral activity such as aggression in the emergency department.

Improving Assessment, Diagnosis, and Management of Urinary Incontinence and Lower Urinary Tract Symptoms on Acute and Rehabilitation Wards That Admit Adult Patients: Protocol for a Before-and-After Implementation Study.

BackgroundUrinary incontinence (UI) and lower urinary tract symptoms (LUTS) are commonly experienced by adult patients in hospitals (inpatients). Although peak bodies recommend that health services have systems for optimal UI and LUTS care, they are often not delivered. For example, results from the 2017 Australian National Stroke Audit Acute Services indicated that of the one-third of acute stroke inpatients with UI, only 18% received a management plan. In the 2018 Australian National Stroke Audit Rehabilitation Services, half of the 41% of patients with UI received a management plan. There is little reporting of effective inpatient interventions to systematically deliver optimal UI/LUTS care.ObjectiveThis study aims to determine whether our UI/LUTS practice-change package is feasible and effective for delivering optimal UI/LUTS care in an inpatient setting. The package includes our intervention that has been synthesized from the best-available evidence on UI/LUTS care and a theoretically informed implementation strategy targeting identified barriers and enablers. The package is targeted at clinicians working in the participating wards.MethodsThis is a pragmatic, real-world, before- and after-implementation study conducted at 12 hospitals (15 wards: 7/15, 47% metropolitan, 8/15, 53% regional) in Australia. Data will be collected at 3 time points: before implementation (T0), immediately after the 6-month implementation period (T1), and again after a 6-month maintenance period (T2). We will undertake medical record audits to determine any change in the proportion of inpatients receiving optimal UI/LUTS care, including assessment, diagnosis, and management plans. Potential economic implications (cost and consequences) for hospitals implementing our intervention will be determined.ResultsThis study was approved by the Hunter New England Human Research Ethics Committee (HNEHREC Reference No. 18/10/17/4.02). Preimplementation data collection (T0) was completed in March 2020. As of November 2020, 87% (13/15) wards have completed implementation and are undertaking postimplementation data collection (T1).ConclusionsOur practice-change package is designed to reduce the current inpatient UI/LUTS evidence-based practice gap, such as those identified through national stroke audits. This study has been designed to provide clinicians, managers, and policy makers with the evidence needed to assess the potential benefit of further wide-scale implementation of our practice-change package.International Registered Report Identifier (IRRID)DERR1-10.2196/22902

Standardizing Sign-out With I-PASS Handoff in Family Medicine Residency.

Handoff miscommunications are a leading cause of medical errors. A structured handoff is an effective communication tool. We introduced the I-PASS Handoff Bundle for resident sign-out in the inpatient setting. We aimed to reduce preventable adverse events and unexpected floor calls while also improving residents' confidence and preparedness to care for patients overnight. We conducted an observational study at a single-site family medicine residency between April 2019 and March 2020. Residents received trainings in the I-PASS standardized handoff through didactic lectures and on-the-job sessions in September and November 2019. We evaluated the effectiveness of the I-PASS Handoff Bundle by comparing pre- and postimplementation data including number of medical errors and unexpected floor calls, along with residents' reported levels of preparedness and confidence to care for patients overnight. Prior to the I-PASS intervention, more than half of resident surveys included at least one unexpected floor call whereas postintervention about one-third of resident surveys included unexpected floor calls (P<.05). However, the intervention did not significantly affect residents' confidence level in caring for patients overnight and residents' rating of the usefulness of anticipatory guidance for managing night floor calls. We did not identify any medical errors related to communication issues at patient handoff within the family medicine service. I-PASS intervention significantly reduced unexpected floor calls. However, the intervention did not improve residents' reported confidence and preparedness to care for patients overnight.

Implementation of the Moyo fetal heart rate monitor in district hospitals in Bihar, India: a feasibility study

ObjectivesGlobally, half of all stillbirths occur during birth. Detection of fetal distress with fetal heart rate monitoring (FHRM), followed by appropriate and timely management, might reduce fresh stillbirths and neonatal...

Immunogenicity and safety of a novel ten-valent pneumococcal conjugate vaccine in healthy infants in The Gambia: a phase 3, randomised, double-blind, non-inferiority trial

Immunogenicity and safety of a novel ten-valent pneumococcal conjugate vaccine in healthy infants in The Gambia: a phase 3, randomised, double-blind, non-inferiority trial

An affordable pneumococcal conjugate vaccine after 20 years

An affordable pneumococcal conjugate vaccine after 20 years