Post-intervention Group Research Articles

Decreasing IV magnesium infusion time to improve delivery of patient care.

Hypomagnesemia is a common issue in patients with cancer due to magnesium wasting drugs like calcineurin inhibitors, chemotherapy sides effects such as diarrhea, and poor oral intake. Historically, magnesium has been given over prolonged infusions due to concern for rapid elimination of magnesium when large doses are administered. At UW Health, magnesium was given at a rate of 1g/60 min. A prolonged infusion rate often creates logistical issues including limited IV access, incompatibility concerns and increased chair time. The purpose of this project is to increase the infusion rate of IV magnesium without compromising therapeutic repletion, benefit, and safety. The magnesium infusion rate was increased to the following rates: 4g/60 min, 2g/30 min, 1g/15 min. The primary outcome is the grams of IV magnesium replaced per outpatient visit between the pre-intervention (prolonged) and post-intervention (rapid) groups. Secondary outcomes include assessment of differences in chair time between groups and total incidence of critical magnesium lab values. There was no statistically significant difference in magnesium requirements per outpatient visit between a prolonged and rapid magnesium infusion rate (2.18g vs 2.15g; p = 0.49). Additionally, there was no difference in number of outpatient visits (3 vs 3; p = 1). The average chair time was decreased by 110 min per outpatient encounter between the prolonged and rapid magnesium infusion rate, which was determined to be clinically and statistically significant. This study suggests that there is no difference in magnesium requirements between a rapid or prolonged magnesium infusion in both solid and liquid tumor patients.

Supplementing provider counseling with an educational video prior to scheduled induction of labor

BackgroundInduction of labor (IOL) is common with one in four labors being induced in the United States (US). IOL has been associated with lower birth satisfaction. Video education can address gaps in education and promote anticipatory guidance. Prior studies in obstetrics have focused on randomized designs in English-speaking patients, leaving opportunities to explore how these tools perform in a pragmatic fashion with diverse patient populations. Our objective was to evaluate the effects of a video education tool on patient satisfaction and knowledge of IOL experience in English and Spanish-speaking patients scheduled for IOL at a tertiary care hospital.MethodsThis was a single site pragmatic implementation of a quality improvement measure at an academic hospital. A bilingual survey was developed to evaluate the impact of an educational video on birth satisfaction and knowledge of IOL procedures. The video is freely available in English and Spanish. Baseline postpartum surveys were collected from June to July 2021. The video was subsequently recommended by providers when scheduling IOLs. Post-intervention surveys were collected from September to November 2021 after an implementation period. Groups were compared using t-tests for satisfaction scores and chi-square analyses for categorical variables.ResultsThirty-two participants completed the baseline survey and 72 completed the post-implementation survey with response rates of 88.9% and 91.1%, respectively. There were no statistically significant changes between mean total satisfaction scores (26.9 vs 28.0 out of 40.0, p = 0.290). 61 participants were English speaking (58%) and 43 Spanish (42%). Thirty (42%) patients reported watching the video.Correct identification of amniotomy use improved in the post-intervention group (p = 0.002). No changes were seen in anticipated duration of labor nor in whether patients would choose to be induced again.ConclusionsRecommendation of video education before scheduled IOL was associated with little improvement in knowledge about IOL, but no significant improvement in patient satisfaction. While video education has improved these measures in randomized trials, our study demonstrated that real-world implementation and patient uptake may be initially difficult. This study may help providers emphasize direct education and counseling and promote optimal implementation of innovative educational media.

Assessment of early neonatal practices to prevent hypothermia ; A comparative study

Background Globally, neonatal deaths are significantly attributed to hypothermia. This is mostly because of its co-morbidity with asphyxia, premature birth and severe neonatal infections. Worldwide, neonatal hypothermia case fatality rates (CFRs) range from 8.5% to 52%. This study aimed to assess how well a video-based training intervention on mothers’ knowledge and practices in preventing neonatal hypothermia worked. Methods The knowledge and practices of two groups of primi-para mothers—one control group and one intervention group—were compared in order to achieve this. A total of 124 primipara mothers took part in the research. Using a video based tool, the intervention group was educated about preventing hypothermia in newborns. Both control and intervention group mothers were interviewed to compare the knowledge and practices. Results Sixty-one of the sixty-two mothers in the control group were unsure of which body area to cover in order to preserve the baby’s body heat. Following the intervention, 61 out of 62 mothers in the group recognised which body part to cover to protect the baby’s body heat. In the post-intervention group, 98.4% of moms wore a cap over their baby’s head, compared to just 35.5% in the control group. Conclusion The results of this study demonstrate the significant improvement in mothers’ knowledge and actions about the prevention of neonatal hypothermia resulting from the use of a video-based training tool.

A Pilot and Feasibility Study on a Mindfulness-Based Intervention Adapted for LGBTQ+ Adolescents.

(1) Background: Lesbian, gay, bisexual, transgender, queer and other gender and sexual minority-identified (LGBTQ+) adolescents face mental and physical health disparities compared to their heterosexual and cisgender counterparts. Mindfulness-based interventions (MBIs) may be a potential method to intervene upon health disparities in this population. This pilot study explores the initial acceptability and feasibility, along with the descriptive health changes of an online MBI, Learning to Breathe-Queer (L2B-Q), which was adapted to meet the needs of LGBTQ+ adolescents. (2) Methods: Twenty adolescents completed baseline and post-intervention assessments of mental health, stress-related health behaviors, physical stress, and LGBTQ+ identity indicators. In addition, the adolescents participated in a post-intervention focus group providing qualitative feedback regarding the acceptability of L2B-Q. (3) Results: L2B-Q demonstrated feasible recruitment and assessment retention, acceptability of content with areas for improvement in delivery processes, and safety/tolerability. From baseline to post-intervention, adolescents reported decreased depression and anxiety and improved intuitive eating, physical activity, and LGBTQ+ identity self-awareness with moderate-to-large effects. (4) Conclusions: These findings underscore the need and the benefits of adapted interventions among LGBTQ+ youth. L2B-Q warrants continued optimization and testing within the LGBTQ+ adolescent community.

First step to environmentally sustainable endoscopy practice: Prospective study of minimizing multiple device use during screening colonoscopy at a large tertiary center.

The healthcare sector generates 8% of greenhouse emissions in the United States, of which GI endoscopy is the third largest contributor. Single-use tools are a major contributor to modifiable waste generation during GI (gastrointestinal) endoscopy. Through a quality improvement (QI) initiative, we aimed to reduce endoscopy waste by urging gastroenterologists to be mindful of the tools used during polypectomies and avoid using multiple tools. We discussed green endoscopy initiatives in monthly journal club and business meetings. Over 14 weeks, 210 patients were included in the pre-intervention and 112 in the post-intervention group. At baseline, 34% of colonoscopies required no intervention, 32% required one tool (either biopsy forceps or a snare) and 33% required multiple tools. After the intervention, the use of just one tool increased (17% increase, p<0.01) and the use of multiple tools decreased significantly (16% decrease p<0.01). The odds of using a single tool compared to multiple tools after the intervention was 2.98 (95% CI 1.6-5.53), p=0.005. This single-center QI study noted a significant change in practice patterns favoring using a single tool over multiple tools during colonoscopies after an environmentally conscious practice intervention was applied. This intervention can be readily applied to reduce endoscopy-related waste.

Evaluation of an intervention to decrease length of stay in children with low-risk febrile neutropenia

Abstract Background Febrile neutropenia is one of the most common serious complications of myelosuppressive chemotherapy. For this reason, pediatric oncology patients with FN have traditionally been admitted to the hospital and started on empiric intravenous antibiotics. However, not all FN patients are at high risk of developing subsequent complications, and a low-risk group exists that could safely be discharged early. Methods A retrospective study of 194 FN episodes presenting in pediatric oncology patients at St. Jude Children’s Research Hospital. Outcomes of FN episodes were studied and compared before and after early discharge guidelines for low-risk febrile neutropenic (LRFN) were implemented at St. Jude on May 6, 2020. Results Total length of hospital stay was similar in the pre- and post-intervention groups (median 4 [IQR 3,6] vs. 4 [IQR 3,7] days, P = 0.443). Differences in adverse outcomes were insignificant between the pre- and post-intervention cohorts, with only two ICU admissions after the first 24 hours inpatient in the post-intervention group, one new positive blood culture (&amp;gt; 24 hours – 14 days of admission) in each group, and 36.2% versus 21% new fever after resolution of initial fever in pre- and post-intervention cohorts respectively. Cumulative antibiotic use between the pre- and post-intervention groups was statistically insignificant (median 13.5 [IQR 22.8,8] vs. 14 [IQR 22,9] days, P = 0.537), whereas Levofloxacin use was significantly longer in the post-intervention cohort versus the pre-intervention cohort (median 0 [IQR 0,4] vs. 0 [IQR 0,0] days, P = &amp;lt;0.001). Conclusion The implementation of guidelines for early discharge of LRFN patients showed no reduction in hospital stay. Understanding the optimal strategy for effectiveness of guideline implementation is crucial to improve quality and efficiency of care.

Evaluation of Aedes aegypti control intervention with pyriproxyfen by lcWGS in Manacapuru, Amazonas, Brazil.

Ae. aegypti mosquitoes are considered a global threat to public health due to its ability to transmit arboviruses such as yellow fever, dengue, Zika and Chikungunya to humans. The lack of effective arboviral vaccines and etiological treatments make vector control strategies fundamental in interrupting the transmission cycle of these pathogens. This study evaluated Ae. aegypti mosquito populations pre- and post-intervention period with disseminating stations of the larvicide pyriproxyfen to understand its potential influence on the genetic structure and population diversity of these vectors. This study was conducted in Manacapuru city, Amazonas, Brazil, where 1,000 pyriproxyfen dissemination stations were deployed and monitored from FEB/2014 to FEB/2015 (pre-intervention) and AUG/2015 to JAN/2016 (post-intervention). Low-coverage whole genome sequencing of 36 individuals was performed, revealing significant stratification between pre- and post-intervention groups (pairwise FST estimate of 0.1126; p-value < 0.033). Tajima's D estimates were -3.25 and -3.07 (both p-value < 0.01) for pre- and post-intervention groups, respectively. Molecular diversity estimates (Theta(S) and Theta(Pi)) also showed divergences between pre- and post-intervention groups. PCA and K-means analysis showed clustering for SNP frequency matrix and SNP genotype matrix, respectively, being both mainly represented by the first principal component. PCA and K-means clustering also showed significant results that corroborate the impact of pyriproxyfen intervention on genetic structure populations of Ae. aegypti mosquitoes. The results revealed a bottleneck effect and reduced mosquito populations during intervention, followed by reintroduction from adjacent and unaffected populations by this vector. We highlighted that low-coverage whole genome sequencing can contribute to genetic and structure population data, and also generate important information to aid in genomic and epidemiological surveillance.

Enhancing timeliness of port placement for new treatment patients: A quality improvement initiative.

335 Background: Timely port placement is crucial for patients beginning new treatments, yet delays can impede care and satisfaction. This initiative aimed to address these delays and improve port placement efficiency for new treatment patients. Methods: A single-center prospective cohort study was conducted between July 2022 and December 2023. Data was collected to assess the time from port order to port placement. Interventions included concurrent scheduling of consult and port placement visits in coordination with interventional radiology (IR) and workflow redesign to enhance oncology navigator involvement by directing port orders to an oncology navigation pool for expedited processing and scheduling. The primary endpoint was to compare the mean difference in days between IR consult order and port placement among pre- and post-intervention groups. Results: The study included 144 patients: 102 in the pre-intervention group (July 2022-June 2023) and 42 in the post-intervention group (July 2023-December 2023). The post-intervention group showed a 26.35% improvement in time to port placement from appointment, compared to pre-intervention intervals. The combined quarterly mean indicated a 14.37% reduction in time to port placement from order. The mean interval between IR consult order and port placement was 15.59 days pre-intervention and 13.35 days post-intervention, with a mean difference of 2.24 days (CI -0.92 to 5.4; p = 0.08). Conclusions: This quality improvement initiative demonstrated substantial progress in reducing delays in port placement for new treatment patients. Optimizing workflow processes and increasing navigator involvement significantly improved timeliness and the overall patient experience. Continued monitoring and refinement of these interventions are essential for sustaining these improvements over time. Mean interval between IR consult order and port placement. Timeframe of Pre-intervention Group Mean of Pre-Intervention Group* Mean of Post-Intervention Group* (July 2023-Dec 2023) Mean Difference Between Pre and Post Intervention Group* Standard Error Confidence Interval p-value July 2022-Dec 2022 16.12 13.35 2.76 1.91 -1.04 to 6.57 0.07 Jan 2023-Jun 2023 14.93 13.35 1.58 1.59 -1.59 to 4.74 0.16 July 2022-Jun 2023 (overall) 15.59 13.35 2.24 1.60 -0.92 to 5.40 0.08 *Mean expressed in days.

Ketorolac Dose Ceiling Effect for Pediatric Headache in the Emergency Department

OBJECTIVE This study sought to demonstrate a non-inferiority analgesic ceiling effect previously ­demonstrated within adults for pediatric patients receiving a maximum ketorolac dose of 15 mg. METHODS We conducted a retrospective cohort study of pediatric ED patients weighing at least 60 kg treated with 30 mg (pre-intervention) or 15 mg (post-intervention) intravenous (IV) ketorolac for headache. The primary outcome included patient-reported pain scores. Additional outcomes included demographic variables, adjunct medication use and adverse effects. Categorical data were evaluated using a χ2 test, and numerical data were evaluated using an ANOVA F test and Welch 2-sample t test. RESULTS The pre- and post-intervention groups included 216 and 62 patients, respectively. Overall demographics were similar between the groups (72.3% female, 49.3% White/Caucasian, mean age 15.5 years, mean weight 79.2 kg, and mean baseline 10-point pain score 7.5). Twelve (5.6%) in the pre-intervention group required rescue analgesic compared with 2 patients (3.2%) in the post-intervention group (p = 0.416). In the pre-intervention group, 198 patients (91.7%) received nausea medication compared with 52 patients (83.9%) in the post-intervention group (p = 0.087). Mean 10-point pain scores following ketorolac administration decreased by 3.9 in the pre-intervention group compared with 5.1 in the post-intervention group (p = &amp;lt; 0.001). Common (0.9%) or rare (0.9%) side effects were infrequent and only seen in the pre-intervention group patients. CONCLUSIONS Truncating the maximum intravenous ketorolac dose in pediatric patients at least 60 kg in weight to 15 mg compared with 30 mg results in effective analgesia in pediatric patients with headache. Future research could explore differences in admission rates, treatment of other indications, or treatment with multiple-dose regimens.

Obstetric Anal Sphincter Injury Care Bundle: A Quality Improvement Initiative.

The objective was to implement an evidence-based peri-partum care bundle for women sustaining obstetric anal sphincter injuries and to evaluate compliance with recommendations for antibiotics use, repair in the operating room, and follow-up before and after implementation. This project was reviewed by the Institutional Review Board and determined to be exempt. A clinical care bundle containing education and standardized orders in the electronic medical record was implemented. Characteristics of pre- (October 2017 to September 2019) and post-intervention (October 2019 to August 2021) cohorts were compared and compliance with recommendations for antibiotics use, surgical repair location, and follow-up were evaluated. Chi-squared, Fisher's exact, ANOVA F, and Kruskal-Wallis tests were performed, as indicated. Significance level was p < 0.05. A total of 185 cases were identified. Seventy-five percent of women were nulliparous. Mean gestational age was 39weeks. Pre- and post-intervention groups did not differ in age, BMI, race, parity, gestational age, comorbidities, birthweight, or delivery type. Ninety-eight cases were identified pre-implementation. Eighty-six (88%) had third-degree lacerations. Post-implementation, 87 cases were identified. Seventy (80%) had third-degree lacerations (p = 0.17). Recommended antibiotic-type use improved from 35% pre-implementation to 93% post-implementation (p < 0.001). Repair in the operating room was similar pre-implementation and post-implementation (16.0% vs 12.6%, p = 0.48). Post-partum follow-up within 2weeks improved from 16.3% pre-implementation to 52.8% post-implementation and mean time to follow-up was shorter post-implementation than pre-implementation (18 vs 33days; both p < 0.001). Implementation of an evidence-based peri-partum care bundle resulted in standardization of care in accordance with established recommendations. Compliance with recommendations for surgical repair in the operating room remained unchanged.

The ‘vulnerable nerve’; surgically acquired neuropathy in distal humeral surgery patients and the role of a tourniquet

Background The complication of neuropathy is high in patients undergoing distal humerus surgery. Tourniquets (TQs) are typically used but can lead to nerve injury. Methods We present a comparative study of a pre-intervention group ( n = 38) and a post-intervention group ( n = 38) undergoing distal humerus surgery between November 2020 and July 2023. The intervention included TQ discontinuation and the introduction of intravenous tranexamic acid at induction. Our analysis encompasses patient, anaesthetic, and surgical variables, as well as the rates and severity of neuropathy. Results Post-intervention, the rate of surgically acquired or deterioration in nerve injury improved from 15.8% ( n = 6) to 2.6% ( n = 1). Pre-intervention, the mean TQ duration was significantly longer for patients with post-operative neuropathy versus those without (120 min, SD = 29 vs. 88 min, SD = 38, p = 0.032). Surgery duration was not significantly longer without a TQ but was associated with a greater reduction in haemoglobin (12.7 g/L, SD = 10.9 vs. 25.2 g/L, SD = 15.5, p = 0.03). Discussion Trauma patients have a high risk of acquiring a nerve injury following elbow surgery or deterioration of a pre-surgical nerve injury, which emphasises the concept of vulnerable nerves. The cessation of using a TQ was associated with a lower nerve injury rate, with no cases of major nerve injury and no significant increase in surgical time.

Effectiveness of tramadol-including multimodal analgesia in spinal surgery: a single-center, retrospective cohort study

BackgroundMultimodal analgesia (MMA) is recommended for postoperative pain management; however, studies evaluating the effect of tramadol-including MMA on numerical rating scale (NRS)-based postoperative pain levels and the length of stay (LOS) in the hospital are limited. Therefore, this study aimed to compare the before and after effects of tramadol-including MMA application, and assess its effect on postoperative NRS scores and LOS.MethodsPatients who underwent spinal surgery under general anesthesia at the Rakuwakai Marutamachi Hospital in fiscal years 2020 and 2022 were included in this study. The outcomes between the pre- and post-intervention groups were compared through propensity score matching.ResultsFollowing propensity score matching, 249 patients were included in each group. MMA application significantly decreased the median LOS from 10 to 9 days (p < 0.001). Additionally, the median NRS scores exhibited a significant decrease from 4 to 3 on postoperative day (POD) 3 (p = 0.0109) and from 3 to 2 on POD 5 (p = 0.0087). Following MMA application, the number of patients receiving additional analgesics decreased significantly, from 38 to 6 (p < 0.001).ConclusionsThe introduction of tramadol-including MMA can effectively reduce postoperative pain and decrease the LOS for patients undergoing spinal surgery.

De-implementation of Routine Maternal Oxygen Supplementation for Intrauterine Fetal Resuscitation: A Retrospective Cohort Study.

Current practice guidelines for laboring patients with category II intrapartum tracings recommend maternal oxygen supplementation despite emerging randomized data challenging its benefit and utility. We aim to validate that de-implementing maternal oxygen supplementation for fetal resuscitation did not increase the risk of neonatal acidemia in a real-world setting. This is a retrospective observational study conducted at a single tertiary care center from January 2019 to June 2021. All laboring deliveries during the study period was reviewed and eligible participants included singleton or twin pregnancies between 23-42 weeks gestational age with persistent category II tracings. Known major fetal anomalies, contraindications to labor, and maternal indication for O2 supplementation, including active COVID-19, were excluded. Cohorts were allocated based on time of delivery. Those occurring prior to our hospital policy change identified as historical controls and deliveries after April 1, 2020, as the post-de-implementation cohort. Primary outcome was fetal acidemia, defined as umbilical cord pH < 7.2. Secondary outcomes included severe acidemia (pH < 7.0), 5-minute Apgar score < 4 and neonatal intensive care admission. Regression analyses controlling for known variables associated with neonatal acidemia generated adjusted odds ratios with 95% confidence intervals. Among 9088 deliveries during the study period, 1162 tracings were flagged as persistent category II, including 681 (59%) in the post-intervention group. The two cohorts had comparable baseline and obstetric characteristics. No difference in neonatal acidemia was observed between the post-de-implementation group and historical controls (13.8% vs 15.4%, aOR 0.87, 95% CI 0.62-1.22). Severe acidemia, 5-minute Apgar < 4 and neonatal intensive care admission were not increased in the post-de-implementation group. De-implementation of routine maternal oxygen supplementation for fetal resuscitation did not increase likelihood for neonatal acidemia in a real-world setting, validating guidelines recommending against the intervention.

WP1.18 - A Surgical Post-Take Ward Round Checklist Proforma: A Prompt for Improved Documentation

Abstract Aims Surgical ward rounds are often swift, therefore documentation of diagnostic and management decisions is frequently incomplete. The Royal College of Surgeons of Edinburgh (RCSEd) devised a ward round checklist toolkit to improve documentation of surgical post-take ward rounds. Methods We conducted a baseline audit of our district general hospital general surgery post-take ward round documentation, based on the RCSEd checklist. Documentation in each domain was recorded for each ward round entry for both pre and post intervention groups. Control patients were identified from the surgical take list across 7 different days in a month. The checklist toolkit was then adapted into a proforma for our institution and used on post-take ward rounds for a trial period of 7 days. Results 40 patients were included in the pre-intervention group, 17 in the post intervention group. Following the introduction of the post take ward round proforma, documentation of most recent observations improved from 40% to 82%, admission blood results from 27.5% to 94%, and imaging results from 42% to 90%. Areas of existing good practice improved; history and examination findings were documented in 100% of patients, an improvement from 80% pre-intervention. Nil by mouth status was documented in 80% of cases, up from 50%, and IV fluid requirement in 58%, up from 10%. Conclusions A proforma for post take ward rounds improved documentation of key diagnostic and management information. As a result, we recommend a standardised approach to documentation to encourage consistency of recording key information in the patient record.

Implementation of a Novel Pathway to Integrate Palliative and Oncology Care for Patients With Acute Myeloid Leukemia in a Community Hospital

PURPOSE Historically, patients with hematologic malignancies are referred to palliative care less often and later in the disease trajectory than those with solid tumors. Recent evidence demonstrates the benefit of early, integrated inpatient palliative care (PC) for patients with acute myeloid leukemia (AML) receiving chemotherapy at academic centers. The current study evaluated the feasibility of implementing standardized early palliative care services (PCS) during hospitalization for AML treatment in a community setting. METHODS Starting June 2018, automated consultations for PCS were incorporated into clinical pathways to encourage early, integrated services for patients receiving chemotherapy for AML with an expected hospital stay of 4-6 weeks. Expectations were established that consultations would be performed within 72 hours of request; patients would have two visits per week by a palliative care clinician and at least one visit by a member of the interdisciplinary team. To measure the feasibility of this intervention, data on number of patients who received palliative care consultation and time to palliative care consultation were compared with institutional historical controls. RESULTS On the basis of retrospective chart review, the postintervention group (n = 21) had greater PCS compared with historical controls (n = 28; 95% v 36%). The average number of PC team member visits per patient was significantly greater after the intervention: PC clinicians (1.04-8.05, P &lt; .001), chaplains (1.3-3.3, P = .0085), and social workers (1.0-4.3, P &lt; .001). Of those patients who received PCS, 74% had their initial palliative medicine consultation within 3 days of a clinician's order and 100% within 4 days. CONCLUSION We have demonstrated the feasibility of implementing standardized integration of PCS for patients with AML hospitalized for treatment in a community setting.

SP8.5 - Enhancing the confidence of FY1 Doctors in managing General Surgical Patients through the introduction of an online handbook– A quality improvement project

Abstract Background Emerging as a Foundation Year 1 (FY1) doctor from undergraduate training can be daunting. Furthermore, working in Colorectal Surgery can pose challenges: managing both elective and acute surgical patients with complex needs. We designed a General Surgery and Colorectal Surgery handbook to help FY1 doctors navigate training. This Quality Improvement Project aimed to assess the impact of and alleviate some of the uncertainty experienced by FY1 doctors during this transitional phase. Methods An electronic handbook was compiled with contributions from across the Multidisciplinary Team which was reviewed and approved for distribution within our Trust. An online questionnaire was distributed to assess pre-placement confidence in key domains on a 10-point Likert scale. This was sent to FY1 doctors who had previously completed a rotation within colorectal surgery without the handbook. The handbook was distributed to new cohort of FY1 doctors a week prior to the start of their rotation in Colorectal Surgery. An identical questionnaire was sent to the new cohort of FY1s within a month of their rotation and results were compared with previous cohort. Results In all surveyed areas, there was an improvement in confidence in the post-intervention group compared to that shown in the pre-intervention group. The average improvement in median score across all areas was 3.8 points. Conclusion This project demonstrated an overwhelmingly positive response to a formalised handbook by FY1 doctors in training. This intervention has helped FY1 doctors manage colorectal and general surgery patients with enhanced confidence thus paving way for safer patient care.

Association of support group leader experience with Scleroderma Patient-centered Intervention Network Support group Leader EDucation Program outcomes: Secondary analysis of a two-arm parallel partially nested randomized controlled trial

Introduction/Objective: The Scleroderma Patient-centered Intervention Network Support group Leader EDucation Program was found in a randomized controlled trial to substantially improve leader self-efficacy. Whether the program is effective for leaders with different levels of experience, including candidate leaders with no prior experience and leaders with ⩽3 years experience or ⩾4 years experience, is not known. The objective of the present post hoc secondary analysis was to evaluate outcomes by leader experience, age, and education. Methods: The trial was a pragmatic, two-arm partially nested randomized controlled trial with 1:1 allocation to intervention or waitlist control. Eligible participants were existing or candidate support group leaders. The 13-session leader training was delivered in groups of five to six participants weekly via videoconference in 60- to 90-min sessions. The primary outcome was leader self-efficacy, measured by the Support Group Leader Self-efficacy Scale (SGLSS) immediately post-intervention. Secondary outcomes were Support Group Leader Self-efficacy Scale scores 3 months post-intervention and emotional distress, leader burnout, and volunteer satisfaction post-intervention and 3 months post-intervention. Leaders were classified as having no experience, ⩽3 years experience, or ⩾4 years experience. Results: A total of 148 participants were randomized to intervention (N = 74) or waitlist (N = 74). Compared to leaders with ⩾4 years of experience, Support Group Leader Self-efficacy Scale scores were non-statistically significantly higher post-intervention for leaders with 0–3 years experience and lower for leaders with no experience. The 3 months post-intervention Support Group Leader Self-efficacy Scale scores were significantly lower for leaders without experience and similar for leaders with 0–3 years to those with ⩾4 years experience. There were no differences by experience on other outcomes or by age and education on any outcomes. Conclusion: Support group leader education improved leader self-efficacy but was most effective for leaders with experience prior to initiating the program. Trial Registration: NCT03965780; registered on May 29, 2019.

Buprenorphine Use in the Military Health System (MHS).

The CPG's updated recommendation is supported by buprenorphine's lower risk of overdose and misuse.(1) In comparison to full mu-opioid agonists, buprenorphine possesses a superior safety profile with respect to respiratory depression, even in non-dependent individuals, and fatal overdose, when not combined with other sedating medications.(2-5) Purpose/hypothesis: This project identifies prescribing trends of buprenorphine for chronic pain before and after implementing two pharmacy interventions. Procedures/data/observations: Patient charts were reviewed before and after removal of a drug authorization key in the electronic health record and development of an educational presentation for providers. In the pre-intervention group, 19 patients were included and 13 patients in the post-intervention group. Prescriptions for buprenorphine decreased by 31.5% from the pre-intervention to post-intervention period, but three new prescriptions were started after interventions. Adverse reactions were the cause of the decrease in prescriptions, most commonly nausea and vomiting. This data may be valuable to providers as they expand their knowledge about buprenorphine's analgesic use. This is a longitudinal project and identifying barriers that may limit prescribing of buprenorphine may be beneficial for future educational interventions.

Improving effective coverage of medical-oxygen services for neonates and children in health facilities in Uganda: a before–after intervention study

Medical oxygen services are essential for the care of acutely unwell patients. We aimed to assess the effects of a multilevel, multicomponent health-system intervention on hypoxaemia detection, oxygen therapy, and mortality among neonates and children attending level IV health centres and hospitals in Uganda. For this before-after intervention study, we included children who attended paediatric or neonatal wards of 24 level IV health centres and seven general or regional referral hospitals in the Busoga and North Buganda regions of Uganda between June 1, 2020, and June 30, 2022. All neonates younger than 1 month and children aged 1 month to 14 years were eligible for inclusion. We excluded neonates who were not sick but stayed in the maternity ward for routine postnatal care. The intervention involved clinical training, mentorship, and supportive supervision; provision of pulse oximeters and cylinder-based oxygen sources; biomedical-capacity support; and support to develop and disseminate oxygen supply strategies, oxygen therapy guidelines, and lists of essential oxygen supplies. Trained research assistants extracted individual patient data from case notes using a standardised electronic data collection form. Data were collected on health-facility details, age, sex, clinical signs and symptoms, admission diagnoses, pulse oximetry readings, oxygen therapy details, and final patient outcome. The primary outcome was the proportion of admitted neonates and children with a pulse oximetry oxygen saturation reading documented in their patient case notes on day 1 of health-facility admission (ie, pulse oximetry coverage). We used mixed-effects logistic regression to evaluate the effect of the intervention. We obtained data on 71 997 eligible neonates and children admitted to 31 participating health facilities; the primary analysis included 10 001 patients in the pre-intervention period (ie, June 1 to Oct 30, 2020) and 51 329 patients in the post-intervention period (ie, March 1, 2021, to June 30, 2022). Because 1356 patients had missing data for sex, 4365 (46·7%) of 9347 in the pre-intervention group and 22 831 (46·2%) of 49 410 in the post-intervention group were female; 4982 (53·3%) in the pre-intervention group and 26 579 (53·8%) in the post-intervention group were male. The proportion of neonates and children with pulse oximetry at admission increased from 2365 (23·7%) of 10 001 in the pre-intervention period to 45 029 (87·7%) of 51 328 in the post-intervention period. Adjusted analysis indicated greater likelihood of a patient receiving pulse oximetry during the post-intervention period compared with the pre-intervention period (adjusted odds ratio 40·10, 95% CI 37·38-42·93; p<0·0001). Large-scale improvements in hospital oxygen services are achievable and have the potential to improve clinical outcomes. Governments should be encouraged to develop national oxygen plans and focus investment on interventions that have been shown to be effective, including the introduction of pulse oximetry into routine hospital care and clinical and biomedical mentoring and support. Bill & Melinda Gates Foundation and ELMA Philanthropies. For the Luganda and Lusoga translations of the abstract see Supplementary Materials section.

Reduction of Pediatric Gastrostomy Tube Healthcare Utilization and Socioeconomic Disparities: Longitudinal Benefits of Quality Improvement

BackgroundDisparities in emergency department (ED) utilization after gastrostomy (G-) tube placement were previously demonstrated at our children’s hospital. We aimed to reduce postoperative G-tube dislodgements and ED visits with a particular focus on socially vulnerable children. MethodsOur improvement team implemented a G-tube care bundle (6/2018-9/2019) targeting caregiver preparedness and standardizing care in the pre-, intra-, and post-operative periods. Patients who had G tubes placed between 1/2011-8/2022 were categorized to either pre- or post-intervention groups. Primary outcomes were tracked prospectively. National area deprivation index (ADI) was assigned retrospectively and employed to evaluate social risk. Univariate comparisons were made between pre- and post-intervention groups, and between High ADI (≥80) and Low ADI (<80) subgroups in both pre- and post- intervention periods. We used statistical process control methods to further analyze change over time. Results396 children were included (188 pre-intervention, 208 post-intervention). The post-intervention cohort demonstrated a lower rate of outpatient dislodgement at 90 days following G-tube placement (21.3% vs 10.1%, p=0.002) and fewer G-tube-related ED visits per G-tube placed within one year of placement (mean 0.8 visits vs 0.6 visits, p=0.012). Pre-intervention, children from high ADI neighborhoods had significantly greater healthcare utilization compared to those from lower ADI neighborhoods. Post-intervention, previously statistically significant disparities were no longer present. Outpatient G-tube dislodgements within 90 days were particularly mitigated. ConclusionsA longstanding quality improvement initiative has led to sustained reductions in overall G-tube-related health care utilization. Care standardization and improvement may mitigate outcome disparities related to socioeconomic advantage. Type of studyRetrospective Comparative Study and Prospective Quality Improvement Level of EvidenceLevel III