Post-intervention Cohort Research Articles

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 (> 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 = <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.

Volume-based Feeds: A Quality Improvement Project for Better Nutrition.

This quality improvement project at a single institution aimed to increase the proportion of prescribed tube feeds delivered to adult patients in the burn population with greater than 20% affected TBSA. A retrospective chart review was performed on all adult patients with burns from January 2018 to July 2022 with greater than 20% TBSA burns to compare quantitative measures such as length of stay, change in weight, and mean tube feeds delivered over hospitalization. Prospective data collection began in August 2022, when the first intervention was implemented, and continued until July 2023 in the same patient population to serve as a postintervention cohort. Using a multidisciplinary approach, the team implemented 8 interventions, which increased the mean proportion of tube feeds delivered to patients from 43% to 78%, marking a significant increase in nutrition delivered to patients, which is critical for wound healing following burn injuries.

Pediatric cardiac surgical site infections: A single-center quality improvement initiative

ObjectivePediatric cardiac surgery site infections (SSI) represent significant morbidity. Our institution reported elevated SSI rates of 3.48 per 100 cases over a 5-year period above target rates of 2.5 per 100 cases. Therefore, as a quality improvement initiative, we implemented interventions with the goal of decreasing SSI rates by 30%. MethodsPediatric cardiovascular surgery patients (January 2021 to August 2023) who had SSI within 30 days of index operation were included (n = 1514) based on the National Healthcare Safety Network definition. Descriptive statistics were used to compare our preintervention cohort (pre-IV) (January 2021 to April 2022; n = 753) and postintervention cohort (post-IV) (May 2022 to August 2023; n = 761). ResultsIn the post-IV cohort, we found a significant decrease in total SSI (1.97 SSIs per 100 cases [15 out of 761]) versus pre-IV (3.85 SSIs per 100 cases [29 out of 753]), demonstrating a 48% reduction (P = .029). In our post-IV cohort, there was a significant reduction in superficial SSIs (pre-IV, 3.19 SSIs per 100 cases [24 out of 753] vs post-IV, 1.58 SSIs out of 100 cases [12 out of 761]; P = .04). Wounds presenting at 1 to 3 weeks were also reduced in our post-IV cohort (pre-IV, 2.66 SSIs per100 cases [20 out of 753] vs post-IV, 0.66 SSIs per 100 cases [5 out of 761]; P = .002). A significant reduction in SSIs in nonneonates was also noted (pre-IV, 2.79 SSIs per 100 cases [21 out of 753] vs post-IV, 0.92 SSIs per 100 cases [7 out of 761]; P = .007). Additionally, there was a significant reduction in SSIs associated with the Society of Thoracic Surgeons–European Association for Cardio-Thoracic Surgery Congenital Heart Surgery 1 mortality category (P = .033) and the number of readmissions in the post-IV cohort (P = .042). ConclusionsA new surgical site dressing and multidisciplinary surveillance plan effectively reduced the overall burden of SSI rates at our institution. Future studies will address risk factors in specific subpopulations to further reduce SSIs at our institution.

Improving the medication literacy at the time of discharge from hospital (the LiMeTiD study)

Unintended discrepancy in medications at the time of discharge from the hospital is associated with an increased incidence of adverse drug events, including readmission to hospital. Medication literacy is an essential part of health literacy and can reduce medication discrepancies. This prospective observational cohort study aimed to measure the medication literacy of patients at the time of discharge from the hospital when managed with usual care and after the introduction of a medication literacy improvement instrument. This study involved a baseline cohort receiving usual care and a post-intervention cohort aged 50–80 years with high health literacy. The 7 Things I Should Know About My Medications at the Time of Discharge from Hospital instrument, in short, The 7 Domains MedLit Instrument, was designed by the researchers in addition to three medication literacy measurement questionnaires. Medication literacy was measured at 30 h post-discharge. The impact on readmission to hospital was assessed at 30 days post-discharge. The 7 Domains MedLit Instrument was found to significantly increase the number of patients reporting increased counselling by a clinician at the time of discharge from the hospital (clinician, 59.3 % vs. 100.0 %, X2 (1, n = 49) = 11.10, p < 0.01, physician, 28.6 % vs. 76.2, X2 (1, n = 49) = 10.9, p < 0.01, pharmacist 25.0 % vs. 71.4 %, X2 (1, n = 49) = 10.4, p < 0.01)). Significantly, more patients had increased knowledge on drug interactions or adverse drug reactions after using the instrument (26.1 % vs. 61.9 %, P = 0.032 and 30.4 % vs. 66.7 %, P = 0.033, respectively). The 7 Domains MedLit Instrument and the schooling years significantly correlated with the knowledge of drug interactions and adverse drug reactions. Less post-intervention participants visited an emergency department within 30 days post-discharge. The 7 Domains MedLit Instrument significantly improved the patients’ medication literacy at the time of discharge from hospital.

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

Implementation of a structured oral hygiene program through nursing assistant education to address non-ventilator hospital-acquired pneumonia: A quasi-experimental study.

Non-ventilator hospital-acquired pneumonia (NV HAP) is a common complication for hospitalized patients. NV HAP develops when patients aspirate oral secretions containing pathogenic bacteria. Appropriate oral hygiene can help mitigate NV HAP development. Hospital staff, including nursing assistants, play an important role in ensuring that these cares are completed. A quasi-experimental pre-post design was used to evaluate outcomes before and after implementation of a structured oral hygiene education program. A structured oral hygiene program was developed and implemented in a large quaternary hospital. Change in NA knowledge, attitudes, and behaviors before and after implementation of the oral hygiene program was evaluated. Retrospective patient outcomes before and after the intervention were analyzed to detect changes in NV HAP rates. Following the education, nursing assistant knowledge of recommended frequency of oral care for patients who are NPO increased (67.2% vs. 82.1%, p = 0.003). NAs were more likely to report oral hygiene tools including oral suctioning (80.8% vs. 90.2%, p = 0.005) and toothbrushes (89.3% vs. 95.3%, p = 0.031). The unadjusted incidence of NV HAP was significantly lower in the post-intervention cohort (0.25%) compared to the pre-intervention cohort (0.74%), p < 0.001. In the adjusted model, non-invasive positive pressure ventilation increased the odds of NV HAP by nearly sevenfold (AOR = 6.88, 95% CI: 3.99, 11.39). Focused education for NAs is an effective strategy to increase knowledge related to oral hygiene. Implementing a structured oral hygiene program for NAs appears to be a promising practice to decrease NV HAP.

Effect of standardized EHR-integrated handoff report on intraoperative communication outcomes.

We evaluated the effectiveness and implementability of a standardized EHR-integrated handoff report to support intraoperative handoffs. A pre-post intervention study was used to compare the quality of intraoperative handoffs supported by unstructured notes (pre) to structured, standardized EHR-integrated handoff reports (post). Participants included anesthesia clinicians involved in intraoperative handoffs. A mixed-method approach was followed, supported by general observations, shadowing, surveys, and interviews. One hundred and fifty-one intraoperative permanent handoffs (78 pre, 73 post) were included. One hundred percent of participants in the post-intervention cohort utilized the report. Compared to unstructured, structured handoffs using the EHR-integrated handoff report led to: (1) significant increase in the transfer of information about airway management (55%-78%, P < .001), intraoperative course (63%-86%, P < .001), and potential concerns (64%-88%, P < .001); (2) significant improvement in clinician satisfaction scores, with regards to information clarity and succinctness (4.5-4.7, P = .002), information transfer (3.8-4.2, P = .011), and opportunities for fewer errors reported by senders (3.3-2.5, P < .001) and receivers (3.2-2.4, P < .001); and (3) significant decrease in handoff duration (326.2-262.3 s, P = .016). Clinicians found the report implementation highly acceptable, appropriate, and feasible but noted a few areas for improvement to enhance its usability and integration within the intraoperative workflow. A standardized EHR-integrated handoff report ensures the effectiveness and efficiency of intraoperative handoffs with its structured, consistent format that-promotes up-to-date and pertinent intraoperative information transfer; reduces opportunities for errors; and streamlines verbal communication. Handoff standardization can promote safe and high-quality intraoperative care.

High-Volume Surgeons and Reducing Racial Disparities in Route of Hysterectomy

Study ObjectiveTo examine racial disparities in route of hysterectomy and perioperative outcomes before and after expansion of high-volume minimally invasive surgeons (>10 minimally invasive hysterectomies (MIH)/year) DesignRetrospective cohort study SettingMulti-center academic teaching institution PatientsAll patients who underwent a scheduled hysterectomy for benign indications during 2018 (pre-intervention) and 2022 (post-intervention) InterventionsRecruitment of Fellowship in Minimally Invasive Gynecologic Surgery (FMIGS)- trained faculty and increased surgical training for academic specialists in obstetrics and gynecology occurred in 2020. Measurements and Main ResultsPatients in the pre-intervention cohort (n=171) were older (median age 45 years vs. 43 years, p=0.003) while patients in the post-intervention cohort (n=234) had a higher burden of comorbidities (26% ASA class III vs. 19%, p=0.03). Uterine weight was not significantly different between cohorts (p=0.328). Between the pre-intervention and post-intervention cohorts, high-volume minimally invasive surgeons increased from 27% (n=4) to 44% (n=7) of those performing hysterectomies within the division and percentage of hysterectomies performed via minimally invasive route increased (63% vs. 82%, p<0.001). In the pre-intervention cohort, Black patients had a lower percentage of hysterectomies performed via minimally invasive route compared to White patients (Black = 56% MIH vs. White = 76% MIH, p=0.014). In the post-intervention cohort, differences by race were no longer significant (Black = 78% MIH vs. White = 87% MIH, p= 0.127). There was a significant increase (22%) in MIH for Black patients between cohorts (p<0.001). After adjusting for age, BMI, ASA class, prior surgery, and uterine weight, disparities by race were no longer present in the post-intervention cohort. Perioperative outcomes including length of stay (p<0.001), infection rates (p=0.002) and blood loss (p=0.01) improved post-intervention. ConclusionIncreasing FMIGs-trained gynecologic surgeons and providing more opportunities in robotic/laparoscopic training for academic specialists may improve access to MIH for Black patients and reduce disparities.

Electronic Medical Record-Based Nudge Intervention to Increase Comprehensive Molecular Genotyping in Patients With Metastatic Non-Small Cell Lung Cancer: Results From a Prospective Clinical Trial.

Less than half of the patients with newly diagnosed metastatic non-small cell lung cancer (NSCLC) undergo comprehensive molecular testing. We designed an electronic medical record (EMR)-based "nudge intervention" to prompt plasma-based molecular testing at the time of initial medical oncology consultation. A nonrandomized prospective trial was conducted at the University of Pennsylvania's academic practice and two affiliated community practices. Molecular genotyping was performed by tissue- and/or plasma-based next generation sequencing methods. Comprehensive testing was defined as testing for EGFR, ALK, BRAF, ROS1, MET, RET, KRAS, and NTRK. Guideline-concordant treatment was defined as the use of the appropriate first-line (1L) therapy as per the National Comprehensive Cancer Network (NCCN) guidelines. Proportion of patients with comprehensive molecular genotyping results available at any time, molecular results available before 1L therapy, and guideline-concordant 1L treatment were compared between the preintervention and postintervention cohorts using Fisher's exact test or Pearson's chi-squared test. Five hundred and thirty-three patients were included, 376 in the preintervention cohort and 157 in the postintervention cohort. After implementation of the EMR-based nudge, a higher proportion of patients underwent comprehensive molecular testing in the postintervention versus the preintervention cohort (100% v 88%, P = <.001), had results of comprehensive molecular testing available before initiating 1L treatment (97.3% v 91.6%, P = .026), and received NCCN guideline-concordant care (89.8% v 78.2%, P = .035). Across three practice sites in a large health system, implementation of a provider team-focused EMR-based nudge intervention was feasible, and led to a higher number of patients with NSCLC undergoing comprehensive molecular genotyping. These findings demonstrate that behavioral nudges can promote molecular testing and should be studied further as a tool to improve guideline-concordant care in both community and academic sites.

Well-Child Visits for Early Detection and Management of Maternal Postpartum Hypertensive Disorders

Innovative approaches are needed to address the increasing rate of postpartum morbidity and mortality associated with hypertensive disorders. To determine whether assessing maternal blood pressure (BP) and associated symptoms at time of well-child visits is associated with increased detection of postpartum preeclampsia and need for hospitalization for medical management. This is a pre-post quality improvement (QI) study. Individuals who attended the well-child visits between preimplementation (December 2017 to December 2018) were compared with individuals who enrolled after the implementation of the QI program (March 2019 to December 2019). Individuals were enrolled at an academic pediatric clinic. Eligible participants included birth mothers who delivered at the hospital and brought their newborn for well-child check at 2 days, 2 weeks, and 2 months. A total of 620 individuals were screened in the preintervention cohort and 680 individuals were screened in the QI program. Data was analyzed from March to July 2022. BP evaluation and preeclampsia symptoms screening were performed at the time of the well-child visit. A management algorithm-with criteria for routine or early postpartum visits, or prompt referral to the obstetric emergency department-was followed. Readmission due to postpartum preeclampsia. Comparisons across groups were performed using a Fisher exact test for categorical variables, and t tests or Mann-Whitney tests for continuous variables. A total of 595 individuals (mean [SD] age, 27.2 [6.1] years) were eligible for analysis in the preintervention cohort and 565 individuals (mean [SD] age, 27.0 [5.8] years) were eligible in the postintervention cohort. Baseline demographic information including age, race and ethnicity, body mass index, nulliparity, and factors associated with increased risk for preeclampsia were not significantly different in the preintervention cohort and postintervention QI program. The rate of readmission for postpartum preeclampsia differed significantly in the preintervention cohort (13 individuals [2.1%]) and the postintervention cohort (29 individuals [5.6%]) (P = .007). In the postintervention QI cohort, there was a significantly earlier time frame of readmission (median [IQR] 10.0 [10.0-11.0] days post partum for preintervention vs 7.0 [6.0-10.5] days post partum for postintervention; P = .001). In both time periods, a total of 42 patients were readmitted due to postpartum preeclampsia, of which 21 (50%) had de novo postpartum preeclampsia. This QI program allowed for increased and earlier readmission due to postpartum preeclampsia. Further studies confirming generalizability and mitigating associated adverse outcomes are needed.

Using machine learning for targeted advance care planning (ACP) conversations in patients with cancer: A quality improvement initiative.

1552 Background: Despite improvements, patients with advanced cancer often do not receive goal-concordant care at the end of life (EOL). Challenges with prognostication contribute to delays ACP conversations and result in more aggressive care, gaps in symptom management, and hospice underuse. Early identification of patients at high risk for mortality provides an avenue to implement targeted ACP conversations. Methods: We used a validated machine learning model that integrates demographics, lab values, vital signs, and medications to predict in-hospital, 30-day, and 6-month mortality risk for patients with a solid malignancy admitted from the emergency department (ED) to a dedicated solid malignancy oncology unit at Duke University Hospital. This unit includes one oncology and one palliative care attending physician, advance practice providers, and nurse coordinators. Providers received an email when a patient was identified as high risk for mortality. A pre-post study design compared ACP documentation and other EOL healthcare utilization before and after the notification intervention. The pre-intervention cohort included patients hospitalized from 1/7/2019 to 10/25/2019 and the post-intervention cohort from 9/19/2020 to 8/31/2021. We excluded patients admitted to the intensive care unit in the first 24 hours. We used chi-square or Fisher’s exact tests for categorical variables and Kruskal-Wallis tests for continuous variables; we stratified comparisons of categorical variables by physician division using Cochran-Mantel-Haenszel tests. Results: The pre-intervention cohort comprised 105 hospitalizations and 88 unique patients. Mean (SD) age was 64.9 (11.4); 60.0% (n=63) were White, 3.8% (4) Hispanic/Latino, and 65.7% (69) married. The post-intervention cohort comprised 84 hospitalizations and 77 patients. Mean (SD) age was 66.0 (12.2); 52.4% (44) were White, 2.4% (2) Hispanic/Latino, and 60.7% (51) married. Considering index hospitalizations, an ACP note was written for 2.3% (2) of hospitalizations pre-intervention vs. 80.5% (62) post-intervention (p &lt;0.0001). This relationship held even if the physician was in palliative care (4.1% [2] vs. 84.6% [33]) or oncology (0% [0] vs. 76.3% [29]) (p &lt;0.0001). Inpatient length of stay (LOS), hospice referral, code status change, ICU admission rate or LOS, 30-day readmissions, 30-day ED visits, and inpatient and 30-day deaths did not differ significantly between groups. Conclusions: Identification of hospitalized cancer patients with high mortality risk via machine learning led to a substantial increase in documented ACP conversations but did not impact EOL healthcare utilization. Further integration of the model in clinical practice is ongoing. Our intervention showed promise in changing clinician behavior, and additional work is needed to evaluate downstream impacts.

Faculty Onboarding for Workforce Readiness and Belonging.

An academic anesthesiology department benefits from recruiting faculty from various centers, from new graduates to experienced clinicians. Two critical objectives for a department are getting the faculty members up-to-speed thoroughly and efficiently and retaining the faculty members to benefit from their contributions over time. Onboarding plays a pivotal role in meeting both objectives. A successful onboarding process is critical to the enculturation of new employees into an existing work environment. Organizations focusing on improving onboarding practices increase overall success, decrease attrition, and enhance member performance and satisfaction. In this study, we examine our onboarding practices and then create structured tools to improve our processes. A survey gauging the effectiveness and satisfaction of our existing onboarding practices was administered to 11 faculty members hired between 2016 and 2018. Using feedback from the survey, our team identified critical components for improvement and quality measures for onboarding from before faculty arrival until after starting clinical duties. We also measured faculty satisfaction with the onboarding process at different time points. Updated onboarding practices targeting identified areas were implemented in one hiring cycle. Thirteen new faculty members hired over the course of the course of six months assessed the new system's effectiveness. The experience of the previous cohort was compared to the new cohort, highlighting the impact of their feedback on the onboarding process. Our new best practices model, implemented to address primary gaps in our system, has shown promising results. The post-intervention cohort reported more favorable responses to the process, suggesting a positive shift in the onboarding experience. Further free-text feedback included recommendations for additional updates, offering a proactive approach to continuous improvement. A structured, feedback-responsive onboarding process improved the overall experience for new hires. While the response was overwhelmingly positive, further refinement with subsequent iterations is needed to continually improve this process.

BK polyomavirus DNAemia, allograft rejection, and de novo donor-specific antibodies after lowering target tacrolimus levels in pediatric kidney transplant recipients.

BK polyomavirus (BKV) DNAemia is a challenging infectious complication after kidney transplant (KT). Reduction of immunosuppression is the mainstay of management, and tacrolimus is often the first immunosuppressive medication adjusted upon the diagnosis of BKV DNAemia. This study aimed to evaluate the impact of a new institutional protocol with lower target tacrolimus levels on BKV DNAemia, allograft rejection, and de novo donor-specific antibodies (dnDSA) among pediatric KT recipients. We conducted a retrospective chart review of all KT episodes between January 2013 and December 2018. The new protocol with lower target tacrolimus levels was implemented in March 2015. One hundred twenty-seven patients were included in primary analysis. All patients received induction with basiliximab and methylprednisolone and were maintained on a steroid-based immunosuppressive regimen. In the post-intervention cohort, cumulative incidence of BKV DNAemia at 100 days (13.4% vs. 17.8%, p = .605) and 18 months post-KT (34.1% vs. 26.7%, p = .504) was not significantly different from the pre-intervention cohort. Biopsy-proven rejection rate did not change. However, we observed a trend toward earlier development of dnDSA in the post-intervention cohort using the Kaplan-Meier survival analysis (log-rank p = .06). Younger recipient age at the time of transplant was found to slightly increase the risk of BKV DNAemia (OR: 1.09, 95% CI [1.01, 1.16], p = .024). There was an association between BKV DNAemia and biopsy-proven rejection of any type (adjustedOR: 2.77, 95% CI [1.26, 6.23], p = .012), especially acute T-cell-mediated rejection grade 1A and above (adjustedOR: 2.95, 95% CI [1.06, 8.30], p = .037), after adjusted for recipient age at the time of transplant. Targeting lower tacrolimus levels did not decrease the incidence of BKV DNAemia within 100 days or 18 months post-KT, nor did it increase the risk of biopsy-proven rejection among pediatric KT recipients in our center. However, there was a trend toward earlier development of dnDSA, which may portend worse long-term graft outcome post-KT. Our findings highlight the need for individualized immunosuppressive regimens based on immunologic and infectious risk factors and the importance of implementing innovative biomarkers to guide therapy and improve outcomes.

A bundle of opioid-sparing strategies to eliminate routine opioid prescribing in a urogynecology practice

BackgroundCurrent evidence supports that many patients do not use prescribed opioids following reconstructive pelvic surgery, yet it remains unclear if it is feasible to eliminate routine opioid prescriptions without a negative impact on patients or providers. ObjectiveTo determine if there is a difference in the proportion of patients discharged without opioids after implementing a bundle of opioid-sparing strategies and tiered prescribing protocol (BOSS) compared to usual care after minimally invasive pelvic reconstructive surgery (transvaginal, laparoscopic or robotic). Secondary objectives include measures of patient-perceived pain control and provider workload. Study DesignThe BOSS intervention was implemented as a division-wide evidence-based practice change on August 1, 2022. This retrospective cohort compares a 6-month post-intervention (BOSS) cohort to 6- month pre-intervention (usual care) of patients undergoing minimally invasive pelvic reconstructive surgery. A 3-month wash out period was observed after BOSS initiation. We excluded patients <18 years, failure to consent to research, combined surgery with other specialties, urge urinary incontinence or urinary retention procedures alone, and minor procedures not typically requiring opioids. Primary outcome was measured by proportion discharged without opioids and total oral morphine equivalents (OME) prescribed. Pain control was measured by pain scores, post-discharge prescriptions and refills, phone calls and visits related to pain, and satisfaction with pain control. Provider workload was demonstrated by phone calls and post-discharge prescription refills. Data were obtained through chart review on all patients who met inclusion criteria. Primary analysis only included patients prescribed opioids according to the BOSS protocol. Two sample t tests compared continuous variables and chi-square tests compared categorical variables. Results416 patients were included in the primary analysis (207 BOSS, 209 Usual Care). Baseline demographics were similar between groups, except a lower proportion of IBS (13% vs 23%; p<0.01) and pelvic pain (15% vs 24.9%; p=0.01), and higher history of prior gynecologic surgery (69.1% vs 58.4%; p=0.02) in the BOSS cohort. The BOSS cohort was more likely to be discharged without opioids (68.1% vs 10.0%; p<.01). In those prescribed opioids, total OME on discharge was significantly lower in the BOSS cohort (48.1 vs 81.8; p<.01). The BOSS cohort had a 20.6 greater odds (CI 11.4, 37.1) of being discharged without opioids after adjusting for surgery type, arthritis/joint pain, IBS, pelvic pain, and contraindication to NSAIDs. The BOSS cohort was also less likely to receive a rescue opioid prescription after discharge (1.4% vs 9.5%; p=0.03). There were no differences in opioid prescription refills (19.7% vs 18.1%; p=0.77), emergency room visits for pain (3.4% vs 2.9%; p=0.76), postoperative pain scores (mean 4.7 vs 4.0; p=0.07), or patient satisfaction with pain control (81.5% vs 85.6%; p=0.21). After BOSS implementation, the proportion of postoperative phone calls for pain also decreased (12.6% vs 21.5%; p=0.02). Similar results were identified when non-adherent prescribing was included in the analysis. ConclusionsA bundle of evidence-based opioid sparing strategies and tiered prescribing based on inpatient use increases the proportion of patients discharged without opioids after minimally invasive pelvic reconstructive surgery without evidence of uncontrolled pain or increased provider workload.

Sustainability of an enhanced recovery pathway after minimally invasive gynecologic oncology surgery

ObjectiveSame day discharge is safe after minimally invasive gynecology oncology surgery. Our quality improvement peri-operative program based on enhanced recovery after surgery principles led to an increase in same day...

Small bite fascial closure technique reduces incisional hernia rates in gynecologic oncology patients

BackgroundThe potential for the technique of small bite fascial closure in mitigating incisional hernias in gynecologic oncology patients still needs to be investigated.ObjectiveTo evaluate the impact of closure of small...

Improving Adherence to Clinical Practice Guidelines for Managing Gastric Intestinal Metaplasia Among Gastroenterologists at a US Academic Institution.

Clinical guidelines reserve endoscopic surveillance after a gastric intestinal metaplasia (GIM) diagnosis for high-risk patients. However, it is unclear how closely guidelines are followed in clinical practice. We examined the effectiveness of a standardized protocol for the management of GIM among gastroenterologists at a US hospital. This was a preintervention and postintervention study, which included developing a protocol and education of gastroenterologists on GIM management. For the preintervention study, 50 patients with GIM were randomly selected from a histopathology database at the Houston VA Hospital between January 2016 and December 2019. For the postintervention study, we assessed change in GIM management in a cohort of 50 patients with GIM between April 2020 and January 2021 and surveyed 10 gastroenterologists. The durability of the intervention was assessed in a cohort of 50 GIM patients diagnosed between April 2021 and July 2021. In the preintervention cohort, GIM location was specified (antrum and corpus separated) in 11 patients (22%), and Helicobacter pylori testing was recommended in 11 of 26 patients (42%) without previous testing. Gastric mapping biopsies were recommended in 14% and surveillance endoscopy in 2%. In the postintervention cohort, gastric biopsy location was specified in 45 patients (90%, P <0.001) and H. pylori testing was recommended in 26 of 27 patients without prior testing (96%, P <0.001). Because gastric biopsy location was known in 90% of patients ( P <0.001), gastric mapping was not necessary, and surveillance endoscopy was recommended in 42% ( P <0.001). One year after the intervention, all metrics remained elevated compared with the preintervention cohort. GIM management guidelines are not consistently followed. A protocol for GIM management and education of gastroenterologists increased adherence to H. pylori testing and GIM surveillance recommendations.

Evidence-based prescribing of opioids after laparotomy: A quality-improvement initiative in gynecologic oncology

IntroductionAcross specialties, surgeons over-prescribe opioids to patients after surgery. We aimed to develop and implement an evidence-based calculator to inform post-discharge opioid prescription size for gynecologic oncology patients after laparotomy. MethodsIn 2021, open surgical gynecologic oncology patients were called 2–4 weeks after surgery to ask about their home opioid use. This data was used to develop a calculator for post-discharge opioid prescription size using two factors: 1) age of the patient, 2) oral morphine equivalents (OME) used by patients the day before hospital discharge. The calculator was implemented on the inpatient service from 8/21/22 and patients were contacted 2–4 weeks after surgery to again assess their opioid use at home. ResultsData from 95 surveys were used to develop the opioid prescription size calculator and are compared to 95 post-intervention surveys. There was no difference pre- to post-intervention in demographic data, surgical procedure, or immediate postoperative recovery. The median opioid prescription size decreased from 150 to 37.5 OME (p < 0.01) and self-reported use of opioids at home decreased from 22.5 to 7.5 OME (p = 0.05). The refill rate did not differ (12.6 % pre- and 11.6 % post-intervention, p = 0.82). The surplus of opioids our patients reported having at home decreased from 1264 doses of 5 mg oxycodone tabs in the pre-intervention cohort, to 490 doses in the post-intervention cohort, a 61 % reduction. ConclusionsAn evidence-based approach for prescribing opioids to patients after laparotomy decreased the surplus of opioids we introduced into our patients’ communities without impacting refill rates.

Getting the drop on Staphylococcus aureus: Semiquantitative Staphylococcus aureus nasal colony reduction in orthopedic surgery reduces surgical site infection

Surgical site infection (SSI) is a frequent health care-associated infection. We aimed to reduce SSI risk after joint arthroplasty and spine surgery by reducing Staphylococcus aureus colonization burden with presurgery intranasal povidone-iodine (PVP-I) application in conjunction with skin antisepsis ("the intervention"). Retrospective case-control study; postintervention cohort versus a historical cohort. Adults who underwent joint arthroplasty or spine surgery during February 2018 through October 2021 ("post-intervention cohort") included. In the analysis cases any patient who underwent surgery and developed SSI within 90 days postsurgery, controls had no SSI. Postintervention cohort data were compared with a similar retrospective 2016 to 2017 patient cohort that did not use intranasal PVP-I. The postintervention cohort comprised 688 consecutive patients aged 65y/o, 48.8% male, 28 cases, and 660 controls. Relatively more cases than controls had diabetes mellitus (P=.019). There was a 39.6% eradication rate of S aureus nasal colonization post intranasal PVP-I (P<.0001). SSI rate was higher in patients positive versus those negative for S aureus on a 24-hour postsurgery nasal culture (P<.0001). The deep SSI rate per 100 operations postintervention versus the historical cohort decreased for all surgical procedures. Semiquantitative S aureus nasal colony reduction using intranasal PVP-I is effective for decreasing SSI rate in joint arthroplasty and spine surgery. In patients with presurgery S aureus nasal colonization additional intranasal PVP-I postsurgery application should be considered.

Outcomes and Costs of the Transition From a Paper-Based Immunization System to a Digital Immunization System in Vietnam: Mixed Methods Study.

The electronic National Immunization Information System (NIIS) was introduced nationwide in Vietnam in 2017. Health workers were expected to use the NIIS alongside the legacy paper-based system. Starting in 2018, Hanoi and Son La provinces transitioned to paperless reporting. Interventions to support this transition included data guidelines and training, internet-based data review meetings, and additional supportive supervision visits. This study aims to assess (1) changes in NIIS data quality and use, (2) changes in immunization program outcomes, and (3) the economic costs of using the NIIS versus the traditional paper system. This mixed methods study took place in Hanoi and Son La provinces. It aimed to analyses pre- and postintervention data from various sources including the NIIS; household and health facility surveys; and interviews to measure NIIS data quality, data use, and immunization program outcomes. Financial data were collected at the national, provincial, district, and health facility levels through record review and interviews. An activity-based costing approach was conducted from a health system perspective. NIIS data timeliness significantly improved from pre- to postintervention in both provinces. For example, the mean number of days from birth date to NIIS registration before and after intervention dropped from 18.6 (SD 65.5) to 5.7 (SD 31.4) days in Hanoi (P<.001) and from 36.1 (SD 94.2) to 11.7 (40.1) days in Son La (P<.001). Data from Son La showed that the completeness and accuracy improved, while Hanoi exhibited mixed results, possibly influenced by the COVID-19 pandemic. Data use improved; at postintervention, 100% (667/667) of facilities in both provinces used NIIS data for activities beyond monthly reporting compared with 34.8% (202/580) in Hanoi and 29.4% (55/187) in Son La at preintervention. Across nearly all antigens, the percentage of children who received the vaccine on time was higher in the postintervention cohort compared with the preintervention cohort. Up-front costs associated with developing and deploying the NIIS were estimated at US $0.48 per child in the study provinces. The commune health center level showed cost savings from changing from the paper system to the NIIS, mainly driven by human resource time savings. At the administrative level, incremental costs resulted from changing from the paper system to the NIIS, as some costs increased, such as labor costs for supportive supervision and additional capital costs for equipment associated with the NIIS. The Hanoi and Son La provinces successfully transitioned to paperless reporting while maintaining or improving NIIS data quality and data use. However, improvements in data quality were not associated with improvements in the immunization program outcomes in both provinces. The COVID-19 pandemic likely had a negative influence on immunization program outcomes, particularly in Hanoi. These improvements entail up-front financial costs.