Post-intervention Audit Research Articles

Improving the adoption of an electronic clinical decision support tool and evaluating its effect on venous thromboembolism prophylaxis prescribing at a Sydney tertiary teaching hospital

AbstractBackgroundAn electronic venous thromboembolism (VTE) prophylaxis clinical decision support (CDS) tool was implemented in an electronic medication management system at an Australian tertiary teaching hospital. The VTE CDS had not been clinically validated nor widely adopted.AimThis study evaluated the effectiveness of the VTE CDS for improving risk‐appropriate prescribing of VTE prophylaxis, a peer‐to‐peer strategy for improving adoption of the VTE CDS and the effects of the strategy on VTE risk assessment documentation, risk‐appropriate prophylaxis prescribing rate and user acceptability of the VTE CDS.MethodsNominated junior medical officers were trained to educate and promote the use of the VTE CDS to target colleagues over 6 weeks. Pre‐ and postintervention audits of VTE risk assessment and prophylaxis prescribing were conducted. A user acceptance survey was distributed.ResultsAnalysis of pre‐ and postintervention audit data (n = 198 for each) revealed no significant differences in rates of VTE CDS adoption or risk‐appropriate VTE prophylaxis prescribed. More patients had risk‐appropriate prophylaxis prescribed when the VTE CDS was used (90%; 63/70) than when it was not used (71.5% (233/326); p = 0.001). Documented evidence of VTE risk assessment increased significantly from 51.5% (102/198) to 68.2% (135/198) following the intervention (p < 0.001). Most survey responses were favourable towards VTE CDS usability despite limitations.ConclusionPeer‐to‐peer promotion was unsuccessful in improving VTE CDS adoption in this study. Findings suggest VTE CDS use is associated with more appropriate VTE prophylaxis prescribing decisions and may improve risk assessment documentation. Future studies should examine strategies to sustainably improve adoption of VTE CDS and patient outcomes.

Impact of a standardized protocol for the Management of Prolonged Neonatal Jaundice in a regional setting: an interventional quasi-experimental study

BackgroundProlonged neonatal jaundice (PNNJ) is often caused by breast milk jaundice, but it could also point to other serious conditions (biliary atresia, congenital hypothyroidism). When babies with PNNJ receive a routine set of laboratory investigations to detect serious but uncommon conditions, there is always a tendency to over-investigate a large number of well, breastfed babies. A local unpublished survey in Perak state of Malaysia revealed that the diagnostic criteria and initial management of PNNJ were not standardized. This study aims to evaluate and improve the current management of PNNJ in the administrative region of Perak.MethodsA 3-phase quasi-experimental community study was conducted from April 2012 to June 2013. Phase l was a cross-sectional study to review the current practice of PNNJ management. Phase ll was an interventional phase involving the implementation of a new protocol. Phase lll was a 6 months post-interventional audit. A registry of PNNJ was implemented to record the incidence rate. A self-reporting surveillance system was put in place to receive any reports of biliary atresia, urinary tract infection, or congenital hypothyroidism cases.ResultsIn Phase I, 12 hospitals responded, and 199 case notes were reviewed. In Phase II, a new protocol was developed and implemented in all government health facilities in Perak. In Phase III, the 6-month post-intervention audit showed that there were significant improvements when comparing mean scores of pre- and post-intervention: history taking scores (p < 0.001), family history details (p < 0.05), physical examination documentation (p < 0.001), and total investigations done per patient (from 9.01 to 5.81, p < 0.001). The total number of patient visits reduced from 2.46 to 2.2 per patient. The incidence of PNNJ was found to be high (incidence rate of 158 per 1000 live births).ConclusionsThe new protocol standardized and improved the quality of care with better clinical assessment and a reduction in unnecessary laboratory investigations.Trial registrationResearch registration number: NMRR-12-105-11288.

A checklist to improve the quality of central venous catheter tip positioning.

Central venous catheter insertion is a routine procedure performed by anaesthetists in the peri-operative setting. Upper body central venous catheters are usually placed such that their tip lies within the superior vena cava or at the cavo-atrial junction. Positioning the tip 'too low' in the right atrium has long been argued against on the basis that it increases the risk of perforation, leading to cardiac tamponade. Positioning the tip 'too high' in the brachiocephalic vein or above can also be problematic in that proximal migration can result in extravascular placement of the proximal lumen. Such an incident occurred at our hospital in 2016, resulting in extravasation of a vesicant medication causing tissue necrosis. We undertook a quality improvement project involving a standardised bundle of care and a peri-operative central venous catheter insertion checklist with the aim of reducing the risk of such an incident re-occurring. We conducted a three-month pre-intervention audit (n=84) in 2016 and a post-intervention audit (n=84) in 2017. Compared with the pre-intervention audit, the post-intervention audit coincided with a lower rate of central venous catheter tip malpositioning (5.6% vs. 9.2%); and a higher rate of 'optimal' central venous catheter tip position in the distal superior vena cava or cavo-atrial junction (45.1% vs. 29.2%). The central venous catheter insertion checklist also substantially improved documentation of sterility measures, insertion depth and post-insertional documentation of tip position on chest radiograph.

Structured Handover in General Surgery: An Audit of Current Practice.

Verbal handover alone compromises patient safety, and supporting written documents significantly increases retention of information, with printed handover sheets being the best at avoiding data loss. The Royal College of Surgeons (RCS) has produced guidelines on safe handover practice, in which a minimum dataset is recommended for inclusion when handing over patients to incoming surgical teams, and studies have indicated better adherence to these guidelines when preprinted handover proformas are used. All surgical handover sessions were attended for a one-week period, and copies of handover sheets were taken. These were analyzed against RCS guidelines on the essential dataset for safe handover practice. A standardized handover sheet, developed in accordance with these guidelines and designed to encourage impartation of this minimum dataset, was then circulated among members of the surgical department and made readily available on wards. After a 6-week period, a postintervention audit was conducted using the same methods. Striking differences were seen in the quality of information handed over preintervention and postintervention. The documentation of patient location increased significantly (56%-87%, P < 0.0001; 95% CI, 0.460-0.151), as did the documentation of important outstanding clinical tasks (45%-89%, P = 0.004; 95% CI, 0.439-0.089). Documentation of blood results increased (P < 0.0001; 95% CI, 0.523-0.226), and the proportion of patients for whom the occurrence of a senior review was documented increased from 28% (18) to 85% (45) (P < 0.0001; 95% CI, 0.717-0.419) CONCLUSIONS: The use of a structured, computer-generated handover proforma significantly improved compliance with RCS guidelines within the surgical department of our hospital, and we recommend its continued use among on-call surgical teams.

Management of Low Density Lipoprotein Cholesterol at a primary care diabetes clinic in Kuwait

AimsTo evaluate the impact of clinical audit and focused interventions on reducing cardiovascular diseases risk by treating Low Density Lipoprotein Cholesterol (LDL-C) in patients with type 2 diabetes attending a primary care clinic in Kuwait. MethodsUsing LDL as a surrogate for cardiovascular risk, the audit team performed a clinical audit with focus on the care process indicator of statin prescription. The basic audit reviewed 100 patients’ medical records retrospectively to assess patients’ lipid profiles and statin prescription. A lipid management protocol and algorithm based on national clinical practice guidelines distributed to all healthcare professionals and was implemented for 3 months followed by re-audit of another 100 records. Descriptive and comparative statistics (pre and post) were performed using SPSS, version 22. ResultsStatin prescription increased significantly from (26%) in the basic audit to (85%) in the post-intervention audit (p<0.001). The mean LDL-C value decreased significantly from 3.37±0.67mmol/L to 2.71±0.79mmol/L, p<0.001. Mean total cholesterol was significantly reduced from 5.15±0.73mmol/L to 4.68±0.88mmol/L, p<0.001. Ten years CHD risk decreased from 18.46±11.1% to 16.8±12.23%, p=0.152. ConclusionsImplementing a clinical audit coupled with focused intervention was successful in improving management of LDL-C among patients with type 2 diabetes mellitus attending the primary healthcare sector in Kuwait.

Successful use of "Choice Architecture" and "Nudge Theory" in a quality improvement initiative of analgesia administration after Caesarean section.

Regular, routine, multimodal analgesia provides better pain relief following Caesarean section than reliance on "as required" opiate dosing. This quality improvement report describes the effective use of an education programme coupled with a highlighted, preprinted medication chart, employing "Nudge Theory" principles to achieve significant improvements in the administration of analgesic medications to patients after Caesarean section operations. An acute pain service audit identified a serious deficiency with delivery of regular postoperative analgesic medications to patients following Caesarean section operations. An audit of pain medication delivery to patients following Caesarean section demonstrated that postoperative analgesia was not being administered in line with local prescribing guidelines. Two interventions were planned: Education sessions for anaesthetic recovery and ward staff. Introduction of a new preprinted and highlighted medication chart. A postintervention audit was then conducted. There were statistically significant improvements in all medications administered to patients following the two interventions. For analgesic medications, the rate of administration of drugs in compliance with guidelines rose from 39.6% to 89.9% (P<0.001 using 2-sample z test). Each subgroup of medications also showed statistically significant improvements in administration compliance. A combined approach, including application of "Nudge Theory" to the administration of analgesic medication after Caesarean section, considerably improved delivery of medications prescribed for postoperative analgesia.

Care Pathway Effect on In-Hospital Care for ST-Elevation Myocardial Infarction

Objectives: To study the care pathway effect on the percentage of patients with ST-elevation myocardial infarction ­(STEMI) receiving timely coronary reperfusion and the percentage of STEMI patients receiving optimal secondary prevention. Methods: A care pathway was implemented by the Collaborative Model for Achieving Breakthrough Improvement. One pre-intervention and 2 post-intervention audits included all adult STEMI patients admitted within 24 h after onset and eligible for reperfusion. Adjusted (hospital random intercepts and controls for transfer and out-of-office admission) differences in composite outcomes were analyzed by a multilevel logistic regression. Results: Significant improvements in intervals between the first medical contact (FMC) to percutaneous coronary intervention (PCI) and between the door to PCI were shown between post-intervention audit II and post-intervention audit I. Secondary prevention significantly deteriorated at post-intervention audit I but improved significantly between both post-intervention audits. Six out of nine outcomes were significantly poorer in the case of transfer. The interval from FMC to PCI was significantly poorer for patients admitted during out-of-office hours. Conclusions: After care pathway implementation, composite outcomes improved for in-hospital STEMI care. Collaborative efforts exploited heterogeneity in performance between hospitals. Iterative and incremental care pathway implementation maximized performance improvement.

Cost minimization analysis on IV to oral conversion of antimicrobial agent by the clinical pharmacist intervention

Antimicrobial agents are used to treat the infectious diseases which and has become a routine milieu. Prescribing intravenous (IV) antimicrobial agents are needed for abruptly subduing the infectious stage and will leads to decrease the infectious severity of the patient. The cost minimization Analysis involved monitoring the IV to oral conversions carried out in General Medicine department as a part of Antimicrobial stewardship Programme (ASP) for initial 3 months followed by feedbacks, guideline preparation and CME programs as intervention. This was followed up by a post-intervention audit to assess the effectiveness of the interventions performed. An aggregate of 102 subjects were enrolled in the study and quantitative use of the parenteral AMA was found to be significantly reduced in the post-interventional phase in comparison to the pre-interventional phase (p=0.028) and the conversion per patient rate is also increased (p=0.0001). Similar reductions were also achieved by the intervention in the duration required for oral conversions, average difference is 2days (p=0.000). 19.5% reduction in the usage of cost of antibiotics is achieved with a 0.010076DDD/100 Bed days difference to the control population. The study was successful in increasing the conversion rate which clearly implicated the acceptance of guideline. The recommendations of the clinical pharmacist were successful in reducing both the length of stay and duration of parenteral therapy, there in reducing the consumption and cost of antimicrobial therapy. The cost minimizations were found by IV to oral conversion of antibiotics without any change in the treatment outcome.

The effectiveness of regional anaesthesia before and after the introduction of a dedicated regional anaesthesia service incorporating a block room.

Dedicated regional anaesthesia services incorporating block rooms and/or block teams may facilitate theatre efficiency and improve training in regional anaesthesia. Currently, it is unknown if a dedicated regional anaesthesia service improves the effectiveness of regional anaesthesia. In November 2013, the Royal Brisbane and Women's Hospital established a dedicated regional anaesthesia service comprising a block team and a block room. Pre-intervention (conventional model of care) registry data was retrospectively compared with post-intervention (dedicated regional anaesthesia service) audit data, with regard to pain and opioid requirement in the post-anaesthesia care unit (PACU). The primary outcome was inadequate analgesia, defined as a numerical rating scale (NRS; 0, no pain; 10, worst pain imaginable) for pain >5 in the PACU. Pre- and post-intervention, 43.7% and 27.7% of patients respectively reported a NRS >5 (<i>P</i> <0.001). A difference in the type of blocks and surgery performed may have accounted for the improved outcome seen post-intervention. After adjustment for American Society of Anesthesiologists physical status, block type and surgery type, the odds ratio of having inadequate analgesia (NRS >5) was 0.54 (95% confidence interval 0.39 to 0.76) for post-intervention compared to pre-intervention. Secondary outcomes examined pre- and post-intervention were the absence of pain (39.3% and 55.1% of patients, respectively, <i>P</i> <0.001), systemic opioid analgesia requirement (48.6% and 30.5% of patients respectively, <i>P</i> <0.001) and median maximum NRS (4 [interquartile range (IQR) 0 to 8] and 0 [IQR 0 to 6] respectively, <i>P</i> <0.001). A dedicated regional anaesthesia service was associated with improved effectiveness of regional anaesthesia.

An Advanced Practice Provider-Led Initiative for Delirium Screening and Management in an Oncologic ICU

SESSION TITLE: ICU Management SESSION TYPE: Original Investigation Slide PRESENTED ON: Tuesday, October 31, 2017 at 08:45 AM - 10:00 AM PURPOSE: Delirium occurs in 30-80% of patients admitted to the Intensive Care Unit (ICU) and is associated with increased morbidity and mortality, mechanical ventilator-days, hospital and ICU length of stay (LOS), costs, and long term cognitive impairment. Most cases of delirium are missed by ICU clinicians. The Confusion Assessment Method for the ICU (CAM-ICU) is one of the few validated tools for the assessment of delirium in the critically-ill population. However, routine use of CAM-ICU by nurses alone does not improve delirium recognition and management. We hypothesize that an Advanced Practice Provider (APP) led initiative can close additional gaps in knowledge and improve accuracy of and compliance to CAM-ICU screening and overall delirium management. METHODS: As part of a larger multidisciplinary delirium quality improvement project, a small group of APPs created a comprehensive training program that targeted nurse practitioners (NPs), physician assistants (PAs) and critical care fellows working in the ICU at Memorial Sloan Kettering Cancer Center. The educational sessions included formal didactic lectures, open discussions, and a multi-item questionnaire to capture participants’ demographics, knowledge, and comfort level with the use of CAM-ICU and with delirium management. CAM-ICU administration and delirium pathophysiology, assessment, management and impact were discussed. All participants were provided electronic tablets and completed the questionnaire before and after each educational session. Delirium rates and both compliance to and accuracy of CAM-ICU were recorded before and after the intervention. Survey responses were compared between pre- and post-training using McNemar’s test for categorical variables and Wilcoxon Signed Rank test for continuous variables. Data are presented as absolute numbers, percentages, and medians with first and third interquartile ranges. A p value of < 0.05 was statistically significant. RESULTS: Thirty one ICU practitioners participated in the training program: 8 critical care fellows, 20 board-certified NPs and 3 board-certified PAs with a median of 6 (2.5-10) years ICU experience. Of the 31 practitioners, 5 (16%) had participated in a delirium screening and treatment program prior to our intervention and 13 (41%) had never used CAM-ICU in practice. Scores on the 15-item questionnaire improved from a baseline of 76% to 86% (p < 0.0001). Comfort level with CAM-ICU administration increased from 16% to 61% (p < 0.0001) while comfort level with delirium management increased from 35% to 68% (p = 0.0001). Finally, post-intervention audits revealed compliance to CAM-ICU screening of 99% from a baseline of 60%, accuracy of CAM-ICU results of 90-95% from a pre-training rate of 50-60%, and an increase in ICU delirium rates from 18.3% in the fourth quarter of 2015 to 30% in the fourth quarter of 2016. CONCLUSIONS: An APP-led initiative successfully improved knowledge of delirium prevention and management by physicians, NPs and PAs working in a medical-surgical ICU. The post-training adherence to CAM-ICU screening increased. CLINICAL IMPLICATIONS: Our intervention supports the need for identification of APP delirium champions to lead educational programs for their colleagues in the ICU. DISCLOSURE: The following authors have nothing to disclose: Sarah Rebal, Caroline Shirzadi, Jennifer Agatep, Konstantina Matsoukas, Kate Tayban, Heidi Yulico, Kay See Tan, Kenneth Seier, Yesne Alici, Beatriz Korc-Grodzicki, Louis Voigt No Product/Research Disclosure Information

Developing Interactive Antimicrobial Stewardship and Infection Prevention Curricula for Diverse Learners: A Tailored Approach.

BackgroundTo impart principles of antimicrobial stewardship (AS) and infection prevention and control (IPC), we developed a curriculum tailored to the diverse aptitudes of learners at our medical center.MethodsWe integrated case-based modules, group learning activities, smartphone applications (apps), decision support tools, and prescription audit and feedback into curricula of the medical school, medicine residency program, infectious diseases (ID) fellowship program, and hospital medicine program operations. Interventions were implemented in 2012–2016 using a quasi-experimental before-and-after study design, and this was assessed using pre- and postintervention surveys or audit of antibiotic prescriptions.ResultsOver 180 medical students participated in the AS and IPC seminars. After smartphone app introduction, 69% reported using the app as their preferred source of antibiotic information. Approximately 70% of students felt comfortable prescribing antibiotics for a known infection compared with 40% at baseline (P = .02), and approximately 83% were able to identify the appropriate personal protective equipment for specific scenarios. Approximately 99% agreed that they have a role in promoting patient safety and preventing healthcare-associated infections as medical students. At 20 months, appropriateness of trainee antibiotic prescriptions increased by 20% (P < .01). Almost all ID fellows indicated that the AS and IPC seminar was a vital training supplement. Uptake of internist antibiotic recommendations using AS decision support tools was approximately 70%.ConclusionsAll 5 interventions addressed learning objectives and knowledge gaps and are applicable across a range of environments. Evaluating long-term impact of our curriculum is the focus of future study.

The MOVIN’ project (Mobilisation Of Ventilated Intensive care patients at Nepean): A quality improvement project based on the principles of knowledge translation to promote nurse-led mobilisation of critically ill ventilated patients

ObjectiveProspective quality improvement project to evaluate the impact of a training programme to promote nurse-led mobilisation of intubated critically ill patients. MethodsThis project involved an educational programme to upskill nurses and overcome the barriers/challenges to nurse-led mobilisation. Initial strategies focused on educating and upskilling nurses to attain competency in active mobilisation. Subsequent strategies focused on positive reinforcement to achieve a culture shift. A pre- and post-intervention audit was used to evaluate its effectiveness. ResultsA baseline audit showed that ∼9% of ventilated patients were mobilised. Several barriers were identified. Twenty-three nurses underwent training in actively mobilising ventilated patients. This increased their confidence levels and there was reduction in reported barriers. However, the rate of active mobilisation remained low (9.7%). Subsequently, a programme of positive reinforcement with rewards and visual reminders was introduced, which saw an increase in the number of nurse-led mobilisations of both ventilated patients (from 9.7% to 34.8%; p=0.0003), and non-ventilated patients (29.5% versus 62.9%; p=<0.0001). ConclusionIt is safe and feasible to train nurses to perform active mobilisation of ventilated patients. However, to promote a culture change, training and competency must be combined with a multi-pronged approach including reminders, positive reinforcement and rewards.

Implementation of quality improvement strategies for better patient care

In the recent decade, Quality has become an important policy issue in the Philippine health care setting. Current data suggests thousands of people suffering from complications following medical errors and hospital inaccuracies each year despite having well-qualified medical professionals tending to their conditions. Its impact has become more apparent in hospitals, and the push for continuous quality improvement has become evident following amendments in hospital accreditation standards as well as other accrediting bodies. Yet, quality improvement is one of the most challenging aspects to delve into particularly in regard to enhancing patient care. Several barriers are often encountered involving different technical, structural and cultural facets. Advancement of knowledge and skills of individuals are important elements, but not enough to achieve sustainable changes. This research focused on the determination of these hindrances as well as on the identification of solutions towards better rendering of hospital services in an attempt to improve health care quality amongst its target citizenry. The first phase involved administering patient/caregiver satisfaction surveys concerning both inpatient and outpatient clinical services and facilities, as well as allied in-hospital and outreach community services. Comments and suggestions were likewise invited on how to better service patients in the future. The participation rate was excellent, with 94% of patients agreeing to accomplish the questionnaire. Results reflected an overall satisfaction rate of 61%, with criticisms suggesting poor integration as a plausible reason preventing continuity and efficiency in the transition between levels of care. Three points stood out: first off, an imbalance of focus between different aspects of patient care was noted, vastly centering on the acute medical rather than holistic approach to health care, and also concentrating more on the clinical with less regard on the psychosocial component. There was likewise mention of little or no engagement of caregivers in the course of patient care, leading to eventual disruption of rehabilitation and delay or retardation of recovery. In addition, lack of solidarity and teamwork was cited across different specialties and services, which resulted in disorganized work processes and protocols as well as inconsistencies in healthcare practices and delivery. The second phase involved designing and executing an interplay of methodologies to target different issues previously identified. It is now recognized that a combination of different strategies must be employed in order to achieve a sustainable, long-term effect that could create a significant impact in both care processes and patient outcome. Educational outreach activities were conducted to facilitate link up and enhance continuity of health services; the most notable of which was the conference held on quality improvement, dwelling on topics that include development of better care processes and healthcare organization workflows (“5S” for Hospitals). Staff focused group discussions and health education meetings were likewise initiated, with memorandums and hospitals orders drafted to include agendas for quality improvement being incorporated during staff meetings. In addition, team-building activities outside of the workplace were instigated to foster cohesiveness and camaraderie among medical and nonmedical staff in an effort to improve communication and promote positive interactions. Furthermore, public health forums were initiated to help empower both patient and caregiver, and assist in facilitating restorative or palliative care. Lectures and discussions on how to better manage their illness and address dilemmas in homecare, as well as information on how avoid or minimize caregiver fatigue were tackled. Distribution and posting of educational materials were likewise done. Social workers extended their services beyond financial aid evaluation towards counseling and patient assistance/coordination with other out-of-hospital healthcare facilities that help in the recuperation process. Neighborhood priests, pastors and imams were likewise engaged to cater to the spiritual needs of dying patients and their families. At the upper management level, the organization has coordinated with the Local Health Care Sector to engage local midwives and Barangay (Town) health care workers in managing sick patients in their respective regions. Parallelization and synchronization of workflows with other tertiary hospitals were likewise attempted to enhance patient access to better facilities or highly specialized care, but were unsuccessful due to diverse practices and various other political factors. Phase three involved conduct of post-intervention audit and feedback to determine success of strategies employed. A 24% increase in overall satisfaction across different sectors of service was noted (85% satisfaction rate), with comments including smoother transition from acute to post-acute services, increased responsiveness to the psychosocial needs of the patients leading to clearer understanding about patient condition as well as more extensive involvement in care planning, and greater awareness and broader access to other avenues of care and health services.

Implementation of a postoperative handoff protocol

Background: Standardised handoff protocols have become necessary patient safety tools in the perioperative venue. In this study, the authors took a validated standardised perioperative handoff protocol and implemented it into their institution to improve the perioperative handoff communications from the cardiac operating theatres to the ICU.Methods: This was a prospective, unblinded cross-sectional study. During a 6-week pre-intervention phase, 30 perioperative handoffs were observed and data were collected. Then a new structured hand-off protocol was implemented for one month, which focused on training all participating healthcare providers. This was followed by a post-intervention audit consisting of 30 operating room theatre-to-ICU handoffs using the same methodology as the pre-intervention period.Results: Overall attendance significantly increased from 20% to 86.7%. The percentage of parallel conversations decreased from 100% pre-intervention to 60% post-intervention (p < 0.0001). The mean number of i...

Facilitating terminal discharge: fulfilling the hospitalised patient's wish for home death in the final hours.

Terminal discharge (TD) is the rapid discharge of a hospitalised patient when death is imminent. Its time-limited nature makes it challenging, particularly for ward nurses. To report the development of a structured TD framework, and determine if the framework can expedite TD processes and improve nurses' experience in conducting TDs. A 3-phase audit was carried out in a Singapore hospital. The baseline and post intervention audits evaluated the time taken for TD, incidence of prescription errors, continuity of care, and timeliness of equipment arrangement. Nurse satisfaction was assessed through a written survey. Interventions encompassed the implementation of workflow changes and a TD guide. The mean time taken to complete TDs was shorter in the post-compared to pre-intervention phase (2.9±1.4 vs. 4.6±2.3 hours respectively, p<0.01). Approximately 89% of nurses who used the TD guide were satisfied that it made TDs easier. A structured TD framework is effective in expediting TDs and improving nurse satisfaction.

Implementing Smarter Lunchrooms Makeovers in New York state middle schools: an initial process evaluation.

BackgroundThis paper presents design and findings from the process evaluation of a randomized controlled trial (RCT) testing the effectiveness of Smarter Lunchrooms Movement (SLM) interventions to encourage consumption of either fruit, vegetables, or unflavored milk in middle school cafeterias (grades 6–8, typically children ages 10–14 years). Using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework adapted for environmental interventions, the process evaluation monitored fidelity to SLM protocol, determined barriers and facilitators influencing fidelity, and identified the training and support needs of implementers.MethodsUnder research team guidance, community partners (interventionists) assisted school food service staff (providers) with a six week implementation of protocol items in 13 public middle school cafeterias (two milk treatment, three vegetable treatment, four fruit treatment, and four control) in New York State during the 2013–2014 academic year. Process evaluation measures included semi-quantitative measures of implementation and maintenance (lunchroom audits) and qualitative data (environmental assessments and semi-structured interviews with school food service staff). Analyses identified challenges and opportunities for improving intervention delivery.ResultsApproximately 75 % of enrolled students participated in school lunch programs and thus were exposed to the SLM intervention. Findings indicated potential contamination by other nutrition-related activities in the lunchroom and larger school environment may have affected the intervention impact. Modest implementation fidelity scores were observed for intervention treatments. Providers reported treatments were acceptable and feasible, however interventionists confirmed motivation and perceived effectiveness varied among schools. Post-intervention audits revealed limited maintenance of intervention protocols. Strategies to enhance buy-in and communication among providers and increased interventionist support are recommended.ConclusionsRE-AIM was a valuable framework for this process evaluation. Results highlighted implementation barriers and facilitators, and findings will enhance interpretation of forthcoming outcome data. Results will inform future iterations of the SLM RCT and provide valuable insights for those designing environmental interventions in school cafeterias.

The Smarter Lunchrooms Randomized Controlled Trial: 2014-2015 Process Evaluation Results

To evaluate the implementation and maintenance of a Smarter Lunchrooms (SL) study protocol designed to improve fruit, vegetable, and unflavored milk selection and consumption in middle school cafeterias via low- or no cost environmental changes. Process evaluation utilizing an adapted RE-AIM framework was conducted to monitor fidelity to intervention protocol in 12 New York State public middle schools using a crossover design (6 treatment, 6 control in Fall 2014; 6 maintenance, 6 treatment in Spring 2015). The evaluation also served to determine the extent to which protocol was maintained post-intervention and identify barriers and facilitators to successful implementation. Using cafeteria audits, fidelity scores were calculated at baseline, intervention, and two weeks post-intervention for all schools. Fall 2014 treatment schools were monitored for maintenance during the Spring 2015 intervention period. Additional measures included nutrition environment assessments and post-intervention interviews with food service staff. Qualitative analyses were used to identify barriers and facilitators. Fidelity scores for most protocol items increased during intervention periods. However, post-intervention cafeteria audits revealed poor maintenance across all schools. Limited compliance and maintenance were associated with constrained serving line structures, varied staff motivation, and staff-perceived intervention ineffectiveness. Environmental assessments revealed nutrition programming that could support SL changes but that may have impacted study outcomes. While protocol items were generally feasible to implement, efforts to enhance staff buy-in are necessary to support SL work. Results will enhance analyses of forthcoming study outcomes and will inform future intervention delivery. Findings may also prove valuable for other environmentally-focused interventions in school cafeterias.

An order set and checklist improve physician transfusion ordering practices to mitigate the risk of transfusion-associated circulatory overload.

There are few studies of quality interventions to mitigate the risk of transfusion-associated circulatory overload (TACO). Our aim was to reduce TACO risk in patients admitted to internal medicine at our hospital, by addressing gaps in transfusion practice. A 3-month baseline audit of red blood cell (RBC) transfusion orders was conducted. An intervention consisting of a transfusion order set and physician checklist was developed and implemented based on identified gaps, followed by a 3-month post-intervention audit. Compliance with appropriateness criteria for RBC transfusion was ascertained, along with documentation of transfusion rate, diuretic usage and consent. A total of 97 transfusion orders from 68 inpatients and 95 orders from 62 inpatients were audited in the baseline and post-intervention groups, respectively. Compliance with appropriateness criteria was similar pre- and post-intervention (87 versus 85%, P = 0·81). Specification of transfusion rate improved (84 versus 98%, P < 0·01), and diuretics were appropriately ordered more frequently for patients with TACO risk factors (37 versus 64%, P < 0·01). Timing of diuretics shifted from between or post-transfusion to pre-transfusion (35 versus 86%, P < 0·01), without increases in hypokalemia or acute kidney injury. No case of TACO was observed during the study. Documentation of specific risks discussed during consent discussion improved (4 versus 23%, P < 0·01). A checklist and order set are tools that can improve the quality of transfusion orders by increasing the judicious use of pre-transfusion diuretics and augmenting the specification of transfusion rate. These interventions could be adapted to electronic order formats to improve transfusion safety.

A Quality Improvement Project to Assess Timing of Initial Investigations in Stroke Medicine

There are several investigations that can be completed in the acute phase of admission for patients with suspected stroke.These include receiving a CT Head scan and also blood tests specific...

Medical emergency announcements on cruise ships: an audit of outcome.

Public address announcements are an effective way of alerting staff on cruise ships to life -threatening medical emergencies on-board, but should only be used when truly necessary. An audit to investigate the outcome following this method of activating the medical emergency response team (MERT) suggested system flaws. A new elementary first aid training programme for the crew was then developed, emphasising patient assessment and the correct determination of appropriate levels of response. Following fleet-wide implementation, post-intervention audits were performed on two other company ships to evaluate the impact of the new approach. Data from all MERT activations initiated by public address announcement were prospectively collected during the audit periods, including subsequent means of transfer to the ship's medical centre and duration of medical intervention as indicators of clinical severity. After changing the training programme the overall rate of public announcements for medical emergencies fell by 43%. The proportion of patients requiring transfer by stretcher increased from 5% to 33%, whilst the proportion of patients requiring ≥ 4 h of medical intervention increased from 5% to 44%. The audits suggest that the new training programme may have improved the first aid responders' decision-making as there were fewer inappropriate emergency announcements over the public address system. However, two-thirds of all MERT activations were still for patients either well enough to walk or only needing a wheelchair for subsequent transfer, indicating ongoing opportunity for improvement.