Pre-intervention Period Research Articles

Improving Interdisciplinary Communication on an Academic Hospitalist Service: A Quality Improvement Project.

Effective communication is essential for quality patient care, and paging remains among the most common forms of communication despite the introduction of secure texting platforms. The goal of this project was to use quantitative and qualitative analyses of paging to guide improvements in paging best practices. A retrospective analysis of pages sent over a 7-day period was completed, characterizing the volume, content, and effectiveness of pages both preintervention and 3-month postintervention. The content of each page was categorized into laboratories, medications, vital signs, diet, patient assessment/clinical change, pain, or miscellaneous/other. Effectiveness was based on the following five critical elements: (1) two patient identifiers, (2) the sender's name, (3) the sender's callback number, (4) priority or acuity of the page, and (5) patient-care concern. Pages were considered successful if they contained all the five essential elements. The preintervention results guided interventions. Of 3,483 included pages, 1,806 and 1,677 were sent during the preintervention and postintervention periods, respectively. Adherence to all essential paging elements increased from 15.2% to 40% ( p < .001). The largest deficiency was labeling the urgency of a page, which increased from 31.6% to 51.9% ( p < .001). Quantitative and qualitative analyses of pages effectively guided this project to increase the standardization of paging.

Effects of online-offline integrated death education on patients with advanced cancer: A before-and-after study

PurposeTo evaluate the effectiveness of the constructed OOIDE intervention in patients with advanced cancer. MethodIn this study, patients were invited to participate in a 4-week OOIDE intervention. The assessment of patients' ability to cope with death was conducted using a scale in conjunction with interviews. Additionally, patients' 'readiness to die' was assessed. ResultsThirty-two patients with advanced cancer participated in this study. Our intervention significantly enhanced their perspective on life and spirituality, while also reducing their fear of death (P < 0.01). Furthermore, it facilitated their acceptance of death, encouraged a more rational approach to their illness, and fostered an understanding of hospice care, thereby reinforcing their sense of self-worth. Additionally, the intervention improved the relationship between the patient and their families, fostering greater mutual understanding and respect for the patient's perspectives. Comparing the results to the pre-intervention period, there was a significant increase in the number of patients who discussed death with their families and contemplated the place of their passing (P < 0.05). ConclusionOOIDE improves participants' ability to confront death, while also assisting patients' families in the physical and psychological preparations for the loss of their relative.

Estimating the savings of a national project to prevent healthcare-associated infections in intensive care units

Healthcare-associated infections (HAIs) significantly impact patients' morbidity and mortality and have a detrimental financial impact on the health care system. Various strategies exist to prevent HAIs, but economic evaluations are needed to choose which are most appropriate. To present the financial impact of a nationwide project on HAI prevention in intensive care units (ICUs) using a quality improvement (QI) approach. A health economic evaluation assessed the financial results of the QI initiative "Saúde em Nossas Mãos" (SNM), implemented in Brazil between January 2018 and December 2020. Among 116 participating institutions, 13 (11.2%) correctly reported the aggregate cost and stratified patients (with vs. without HAI) in the pre-intervention and post-intervention periods. Average cost (AC) was calculated for each analysed HAI, central line-associated bloodstream infection (CLABSI), ventilator-associated pneumonia (VAP), and catheter-associated urinary tract infection (CAUTI). The absorption model and time-driven activity-based costing were used for cost estimations. Infections the project could have prevented during its implementation were estimated to demonstrate the financial impact of the SNM initiative. The aggregated AC calculated for each HAI from these 13 ICUs - US$8,480 for CLABSI, US$10,039 for VAP, and US$7,464 for CAUTI - were extrapolated to the total number of HAIs prevented by the project (1,727 CLABSI, 3,797 VAP, and 2,150 CAUTI). The overall savings of the SNM as of December 2020 were estimated at US$68.8 million, with an estimated return on investment (ROI) of 765%. Reporting accurate financial data on HAI prevention strategies is still challenging in Brazil. Our results suggest that a national QI initiative to prevent HAI in critical care settings is a feasible and value-based approach, reducing financial waste and yielding a significant ROI for the health care system.

Limited reduction in Clostridioides difficile and Methicillin-Resistant Staphylococcus aureus with the use of an aerosolized hydrogen peroxide disinfection system in tertiary health care facilities in Alberta, Canada

Nonmanual room disinfection systems may reduce the transmission of infections. A variety of systems have emerged; however, a paucity of evidence exists to make an evidence-informed decision for the implementation of a specific system. Alberta Health Services assessed one of these systems. A quasi-experimental prepost design assessed an aerosolized hydrogen peroxide disinfection system on 6 units at 3 acute care facilities in Alberta. To assess clinical effectiveness an interrupted time-series analysis with Poisson distribution compared changes in hospital-acquired Clostridioides difficile infection (HA-CDI) and hospital-acquired Methicillin-resistant Staphylococcus aureus (HA-MRSA) between preintervention, intervention, and postintervention periods. To assess operational feasibility cleaning turnaround time, time to operate, and utilization were considered. A participatory research framework was used to understand the benefits and challenges of operationalization. Incidence rate ratio (IRR) of HA-CDI decreased by 25.7% on FMC-A and 6.9% on RAH-B. Following withdrawal, the IRR of HA-CDI continued to decrease. IRR of HA-MRSA decreased by 25.0% on RAH-B. Following withdrawal, the IRR of HA-MRSA continued to decrease. None of the results were statistically significant. The average time to operate was 3.2hours. Utilization was between 1.7% and 25.6%. Most staff reported benefits and challenges. None of the changes observed in HA-CDI and HA-MRSA after the introduction of the aerosolized hydrogen peroxide system were statistically significant. While most respondents reported multiple benefits and challenges in using the system, the core challenge was delays in inpatient admissions due to the time operate the system. Successful implementation of a nonmanual room disinfection system as an addition to standard cleaning and disinfection requires significant investment and must consider a variety of factors.

Improving hepatitis B screening and vaccination rates in a veterans affairs resident-based primary care clinic

IntroductionIn 2022, the Advisory Committee on Immunization Practices (ACIP) updated its recommendation regarding hepatitis B vaccination and advised vaccination for all adults aged 19–59 regardless of risk factors and those...

Iatrogenic Injury During Intraoperative Transesophageal Echocardiography: Implications for Medical Equipment Storage.

Medical equipment failure is an underappreciated source of iatrogenesis. The authors report a successful root cause analysis and action (RCA2) to improve compliance and decrease risks to patients during cardiac anesthesia care. A quality and safety team of five content experts performed an RCA2 after an iatrogenic injury with transesophageal echocardiogram (TEE) probe insertion. The team used a fishbone diagram to identify causes and performed a Gemba walk to discuss probability of the different causes with key stakeholders. The team reviewed hospital policies and procedures as well as manufacturer manuals regarding best practices for maintenance and storage of TEE probes. The team created a corrective action plan centered on purchasing larger TEE storage cabinets, education of those who handle TEE probes, and implementing standard operating procedures. Effectiveness of the intervention was evaluated by analyzing frequency of TEE probe maintenance. The study period ranged from July 2016 to June 2021. TEE probes required maintenance 51 times, of which 40 (78.4%) occurred prior to the larger storage cabinet purchase, and 11 (21.6%) afterward. The number of TEE probes requiring maintenance per quarter was 4.4 (standard deviation [SD] 2.5) during the preintervention period and 1.0 (SD 1.0) during the postintervention period (mean difference 3.4, 95% confidence interval 1.0-5.9, p = 0.0006). An extensive RCA2 resulting in a corrective action plan centered on compliance with manufacturer recommendations for storage of TEE probes resulted in fewer maintenance requests, which decreased the risk of iatrogenic patient injury from TEE probe failure during cardiac anesthesia care.

Hotline to Helpline: Reducing On-call Demands.

There is a growing societal trend in plastic surgery patients of viewing their medical care as a commodity product rather than as a healthcare service. Our four-provider private plastic surgery practice noticed this phenomenon through our patients' trend of overusing the emergency after-hours service call line. To affect this behavior, we designed a study educating patients on the emergency service call line's purpose and how to handle nonurgent issues independently. After a 6-month preintervention phase to categorize after-hours emergency calls, We improved preoperative patient education and implemented in-office protocols for quicker provider responses. Postintervention data were collected for another 6 months and compared statistically with the preintervention data. In the preinterventional period, we saw a total of 236 after-hours phone calls. The intervention led to a 22% significant reduction in total calls (P = 0.007). Calls were categorized as nonurgent, urgent, and emergent. While emergent calls remained unchanged (P = 0.56), nonurgent calls significantly decreased (P = 0.005). The most common nonurgent calls were regarding pain, routine postoperative concerns, and drain care, with the intervention resulting in a significant reduction of routine postoperative swelling/bruising/discomfort calls (P = 0.04) but not changing pain (P = 0.23) or drain-related calls (P = 0.78). We found that targeted preoperative patient education coupled with a real-time action board in the office, to ensure timely response to patient questions during office hours, can positively impact after-hours call use, and improve overall patient outcomes by catching urgent issues earlier.

Implementation of a standardised accept note to improve communication during inter-hospital transfer: a prospective cohort study

ImportanceThe transfer of patients between hospitals (interhospital transfer, IHT), exposes patients to communication errors and gaps in information exchange.ObjectiveTo design and implement a standardised accept note to improve communication during...

Physical Restraint Knowledge, Attitudes and Practices of Intensive Care Nurses in Turkey: The Effectiveness of an In-Service Training Program

Background: Intensive care nurses use physical restraints (PRs) to prevent critically ill patients from disrupting invasive medical equipment, but they may not recognize the negative or positive consequences. &#x0D; Purpose: The study was conducted with a quasi-experimental, single-group pretest-posttest design to evaluate the impact of PRs training on the knowledge, attitudes, and practices of intensive care nurses. &#x0D; Materials and Methods: The sample of the study consisted of 81 nurses. The data were obtained using a " The Individual Data" and the "Levels of Knowledge, Attitudes and Practices of Staff Regarding Physical Restraints Questionnaire." Descriptive statistics analyzed sample characteristics and Friedman's multiple comparison test performed to compare the effectiveness of training. &#x0D; Results: It was determined that all nurses applied physical restraint, and the rate of application of these on agitated and restless patients was 100%. Sixty-nine-point nine percent of the nurses decided on the physical restraint together with physicians, and 70.4% of them wanted to receive training about physical restraint. The nurses' attitude, and practice scores about the use of physical restraint in the post-intervention period and retest after 1 and 3 months increased significantly compared to the pre-intervention period (p=.000). &#x0D; Conclusion: This study showed that the physical restraint training given to the nurses was effective. The findings recommended to carry out in-service training to increase the knowledge levels of nurses about physical restraint and its application, repeat this training periodically and evaluate its effectiveness.

Hospitalization and evaluation of brief resolved unexplained events (BRUEs) from a statewide sample

ObjectiveThe 2016 clinical practice guideline (CPG) replacing apparent life-threatening event (ALTE) with brief resolved unexplained event (BRUE) was associated with a reduction in hospitalizations and clinical testing among children with this condition in pediatric hospitals. However, as only a minority of acute-care encounters occur in dedicated pediatric centers, the overall effect of this CPG on children with ALTE/BRUE remains unknown. The purpose of this study is to examine changes in the diagnosis and management of BRUE in a statewide sample of non-pediatric hospitals following publication of the CPG. MethodsThis is a retrospective study of encounters of infants (<1 year) presenting to 178 non-pediatric Illinois Emergency Departments (EDs) between 2013 and 2019 with an International Classification of Disease (ICD) 9th and 10th revision billing code of ALTE or BRUE (799.82, ICD-9; R68.13, ICD-10). Our primary outcomes were counts of ALTE/BRUE and the percent of patients with ALTE/BRUE admitted and/or transferred to another facility. Our secondary outcome was clinical testing. We used interrupted time-series analysis for our primary outcome and chi-square testing for secondary outcomes. Results were stratified into academic and community EDs. ResultsThis study included 4639 ED encounters for infants with BRUE that presented to academic EDs (2229; 48.0%) or community EDs (2410; 52.0%). At academic EDs, ALTE/BRUE diagnoses were increasing by 2.3 per quarter prior to the CPG publication and decreased by 0.5 per quarter after the CPG publication, representing a change in slope of −2.8 per quarter (p < 0.01). The percent of ALTE/BRUE patients admitted/transferred was decreasing by 0.1% per quarter in the pre-intervention period and decreased by 0.3% per quarter in the post-intervention period, representing a change in slope of 0.7% (p = 0.03). At community EDs, ALTE/BRUE diagnoses were increasing by 2.9 per quarter prior to the CPG publication and increased by 1.4 per quarter after the CPG publication, a non-significant change in slope. The percent of ALTE/BRUE patients admitted/transferred was decreasing by 1.6% in the pre-intervention period and decreased by 0.9% in the post-intervention period, a non-significant change in slope. At academic EDs, there was no significant change in clinical testing. At community EDs, a lower proportion of patients in the post-intervention period had chest radiographs, blood cultures, metabolic panels, blood counts, and urine testing, while a higher proportion had pertussis testing and respiratory pathogen testing. ConclusionsCounts of BRUE diagnoses and the overall proportion of children admitted or transferred showed a consistent decrease at academic EDs but had a nonsignificant change in trend at community EDs following the CPG publication in 2016. There was no significant change in clinical testing at academic EDs while community EDs had a significant decrease in some testing and an increase in other types of testing. Our findings suggest the need for greater implementation efforts in non-pediatric settings, specifically community EDs, where pediatric patients with BRUE present infrequently in order to optimize care for these children.

A Process Improvement Project to Increase Compliance With Cephalosporin-based Surgical Antimicrobial Prophylaxis in Children With Non-severe Penicillin Allergies

Background/purposeCephalosporins are considered safe and first-line prophylaxis in children with non-severe penicillin allergies. However, use of second-line agents is common and is primarily driven by poor allergic response documentation and misunderstanding of cross-reactivity risk. The goal of this project was to improve compliance with cephalosporin prophylaxis through improved documentation and targeted educational efforts. MethodsA multidisciplinary working group including representatives from allergy, surgery, infectious disease, and pharmacy developed staged interventions to facilitate compliance with cephalosporin prophylaxis. These included: (1) caregiver outreach to clarify incomplete allergy documentation, (2) a decision-support algorithm for prophylaxis use in penicillin-allergic patients, (3) standardized educational resources for surgical faculty and rotating trainees, (4) email reminders with prophylaxis recommendations sent out prior to scheduled cases, and (5) EMR-based decision support during antibiotic ordering. Rates of complete allergy documentation and cephalosporin utilization were compared for general surgery procedures between a 12-month pre-intervention and 14-month post-intervention period. Results578 patients with penicillin allergies recorded in the EMR were included (301 pre-intervention and 277 post-intervention), 54.0% of which received prophylaxis. Compared to the pre-intervention period, complete documentation of allergic reactions increased from 57.1% to 84.2% (p < 0.001) following implementation of all interventions. Appropriate prophylaxis utilization increased from 34.5% to 88.5% following implementation of all interventions (p < 0.001), and evidence of a stepwise increase in appropriate utilization was evident with each intervention stage. Persistent compliance failures during the post-implementation period were most commonly associated with urgent and emergent add-on cases. No adverse events or allergic responses were reported before or after project implementation. ConclusionsCompliance with cephalosporin prophylaxis significantly improved following a multidisciplinary effort targeting education, allergy documentation, and clinical support at the point of care. Ongoing efforts include postoperative audits within 24 h for noncompliant cases in order to identify barriers and improve compliance for urgent and emergent add-on cases. Level of EvidenceIII. Type of StudyProspective.

Short-Course Empiric Antibiotics in Children Undergoing Allogeneic Hematopoietic Cell Transplantation

Fever is common in children undergoing hematopoietic cell transplantation (HCT). Empiric antibiotic (EA) therapy is initiated and often continued until neutrophil engraftment. Prolonged antibiotic exposure reduces microbiome diversity and causes overgrowth of pathogenic organisms, leading to such complications as infections from antibiotic-resistant organisms and Clostridium difficile colitis. Shorter courses of EA therapy have been studied in adults undergoing HCT without significant safety concerns, but data in children are lacking. We instituted a single-center preintervention/ postintervention quality improvement (QI) project to assess the feasibility of short-course EA therapy for first fever in patients undergoing HCT. We aimed to reduce the median duration of broad-spectrum antibiotic use in eligible patients from 20 days in 2020 to 10 days in 2021. Patients were eligible for the intervention, limiting EAs to 7 days for first fever, if they were admitted for their first allogeneic HCT, were afebrile for >24 hours, had no infection requiring systemic treatment, and were hemodynamically stable. Outcome measures included days of EA therapy for first fever and total broad-spectrum antibiotic use during the period of hospitalization, defined as the time from the start of conditioning to 30 days after HCT or hospital discharge, whichever occurred first. Balancing measures included bloodstream infection (BSI), fever, and intensive care (ICU) admission within 3 days of stopping EA therapy. Project criteria were applied retrospectively to patients who underwent HCT in 2020 to construct a preintervention short-course-eligible cohort. During the intervention period, 41 patients underwent allogeneic HCT, of whom 17 (41%) were eligible for short-course EA therapy. Among eligible patients, the median age was 5.3 years, 47% had an underlying malignancy, and 88% received myeloablative conditioning. There were no differences in demographic or HCT characteristics between patients eligible for short-course EA during the intervention and preintervention period (n=24). The short-course EA schedule was adhered to by 14 of the 17 eligible patients (82%). The duration of EA for first fever and total broad-spectrum antibiotic use was significantly decreased in the short-course EA-eligible patients compared to the preintervention cohort, from a median of 17 days to 8 days and from 20 days to 10 days, respectively (P < .01). Of the 14 patients adhering to short-course EA, 2 experienced a balancing measure of recurrent fever requiring resumption of EA, but no infection was identified. There were no BSIs, ICU admissions, or deaths during the hospitalization period in patients who received short-course EA. In this single-center QI project, short-course EA for initial fever was successfully applied to children undergoing allogeneic HCT using strict criteria and led to a significant decrease in broad-spectrum antibiotic use during hospitalization. These results should be validated in a prospective clinical trial to include the impact of short-course EA on antibiotic-resistant organisms, the intestinal microbiome, and HCT outcomes.

Effects of non-technical skill-based surgical education for trainees on herniorrhaphy outcomes.

Non-technical skills are essential for surgical patient safety and are implemented in clinical practice. However, training for non-technical skills has not been thoroughly investigated. This study aimed to evaluate the learning curve for non-technical skill-based education in herniorrhaphy. Quality improvement initiatives, including non-technical skill-based intervention, were performed in the department of surgery. The intervention included declaring the patient safety policy, briefing and debriefing, and criterion for the switching of places of the trainee and instructor as defined by the department. Patients who underwent herniorrhaphy from April 2014 to September 2017 were included. A total of 14 trainees and nine instructors in the pre-intervention period and 14 trainees and seven instructors in the intervention period were included in this study. The median experience of each trainee was 28 and 15 cases in the pre-intervention and intervention groups, respectively. A total of 749 patients were included: 473 in the pre-intervention period and 328 in the intervention period. Demographics and hernia types were mostly similar between groups, and morbidity was not statistically different between the two groups (3.4 vs. 1.2%, p = 0.054). The nonlinear regression model showed an early decline and deep plateau phase of the learning curve in the intervention group. A significant difference was observed in the plateau operation time (61 min in the pre-intervention group and 52 min in the intervention group). This study demonstrated the effectiveness of non-technical skill-based intervention for surgical training. An early decline and deep plateau of the learning curve can be achieved with well-implemented quality improvement initiatives. Nonetheless, further studies are needed to establish a training program for non-technical skill-based learning.

Incidence of infections associated with the use of invasive devices in an ICU after application of the Improvement Science Method

Objective: To reduce the incidence density of ventilator-associated pneumonia (VAP), central line-associated bloodstream infection (CLABSI), and catheter-associated urinary tract infection (CAUTI) in the intensive care unit (ICU) using the Improvement Science method. Methods: This was a single-center retrospective cohort study. A collaborative quality improvement team developed and implemented local changes to HAI-related processes and protocols. Pre-intervention, intervention, and post-intervention periods were compared. The study was conducted at the Adult ICU of a hospital in southern Brazil. Variables were analyzed using interrupted time series analysis with segmented linear regression, simple correlation, and hypothesis testing. Results: There was a reduction in the incidence density of all infections. VAP was reduced from 27.2% to 7.2% (p &lt; 0.001), CLABSI from 3.0% to 0.9% (p = 0.017), and CAUTI from 8.3% to 1.8% (p &lt; 0.001). The ICU stay was also reduced from 6.7 to 6 days (p = 0.018). Conclusion: There was an improvement in all the evaluated parameters. Ongoing monitoring of related indicators and adherence to implemented measures are essential to sustain improvements. Applying the Improvement Science methodology can reduce the incidence of HAIs in the ICU.

Promoting plant-based eating in meat-centric meal contexts: a field study.

Shifting from meat-centric to plant-rich diets may help to enable healthier and more sustainable food systems. Here we present the results of a 1-week intervention to promote plant-based eating in a meat-centric food context (i.e. canteen). The intervention included environmental restructuring strategies (e.g. promotional materials and menu redevelopment) and improvements to the offer of plant-based meals. The evaluation (sales data; pre-registered) spanned 3 weeks prior to the intervention (baseline), 1 week during the intervention (immediate/short-term impact) and 3 weeks after the intervention (follow-up). Opinion surveys were also used to collect data with customers during the intervention. Canteen unit of a university campus in Portugal (Lisbon metropolitan area). In addition to sales data (baseline: 7965 meals; immediate/short-term: 2635 meals; follow-up: 7135 meals), we used opinion surveys to assess customers' meal appraisals during the intervention (n = 370). The odds of a sold meal being vegetarian were 24 % higher in the intervention week compared with the pre-intervention period [OR = 1·24, 95 % CI (1·10, 1·40)] and 9 % higher in the post-intervention period compared with the pre-intervention period [OR = 1·09, (95 % CI (1·00, 1·19)]. Survey data showed that vegetarian meals compared favourably to meat and fish alternatives in liking, sustainability and satiety. A short-term, theory-driven, operationally feasible intervention was effective in promoting increased plant-based meal choices in a collective meal context. Nevertheless, these changes were not entirely sustained over time. Future studies could test whether prolonged or more transformative interventions are necessary to unlock entrenched food practices more effectively in meat-centric collective meal contexts.

Increasing COVID-19 Vaccination Rates for Children With Sickle Cell Disease.

The COVID-19 vaccine is important for children with sickle cell disease (SCD). This quality improvement project'sobjective was to increase the proportion of children with SCD receiving ≥2 COVID-19 vaccine doses to ≥70% by June 2022. We used the Model for Improvement framework. We assessed COVID-19 vaccination rates biweekly. Three plan-do-study-act cycles focusing on patient education, provider awareness, and access were performed. Process measures included the outcome of outreach calls and educational video views. Missed clinic appointments was our balancing measure. Line graphs and statistical process control charts were used to track changes. Interrupted time series was used to model implementation rates while accounting for preexisting trends. A total of 243 patients were included. During the preintervention (September 2021-January 2022) and intervention periods (February 2022-June 2022), overall vaccination rates increased from 33% to 41% and 41% to 64%, respectively. Mean vaccination rate in eligible children in each 2-week period increased from 2.1% to 7.2%. The achieved vaccination rate was 11% greater than predicted for patients with SCD. For the general population the achieved vaccination rate was 23% lower than predicted. The proportion of missed visits did not change (9.0% vs. 9.6%). During outreach calls, 10 patients (13.5%) booked a vaccine. Forty percent of patients watched the promotional video. A significant number of patients with SCD are not vaccinated against COVID-19. Targeting misinformation and improving vaccine access aided in increasing vaccination. Additional interventions are needed as a large number of patients remain unvaccinated.

Impact of nonphysician, technology-guided alert level selection on rates of appropriate trauma triage in the United States: a before and after study.

Overtriage and undertriage rates are critical metrics in trauma, influenced by both trauma team activation (TTA) criteria and compliance with these criteria. Analysis of undertriaged patients at a level I trauma center revealed suboptimal compliance with existing criteria. This study assessed triage patterns after implementing compliance-focused process interventions. A physician-driven, free-text alert system was modified to a nonphysician, hospital dispatcher-guided system. The latter employed dropdown menus to maximize compliance with criteria. The preintervention period included patients who presented between May 12, 2020, and December 31, 2020. The postintervention period incorporated patients who presented from May 12, 2021, through December 31, 2021. We evaluated appropriate triage, overtriage, and undertriage using the Standardized Trauma Assessment Tool. Statistical analyses were conducted with an α level of 0.05. The new system was associated with improved compliance with existing TTA criteria (from 70.3% to 79.3%, P=0.023) and decreased undertriage (from 6.0% to 3.2%, P=0.002) at the expense of increasing overtriage (from 46.6% to 57.4%, P<0.001), ultimately decreasing the appropriate triage rate (from 78.4% to 74.6%, P=0.007). This study assessed a workflow change designed to improve compliance with TTA criteria. Improved compliance decreased undertriage to below the target threshold of 5%, albeit at the expense of increased overtriage. The decrease in appropriate triage despite compliance improvements suggests that the current criteria at this institution are not adequately tailored to optimally balance the minimization of undertriage and overtriage. This finding underscores the importance of improved compliance in evaluating the efficacy of TTA criteria.

Reducing Ophthalmic Antibiotic Use for Non-severe Conjunctivitis in Children.

Antibiotics are often overprescribed for pediatric conjunctivitis. We implemented a system-level quality improvement (QI) intervention to reduce unnecessary ophthalmic antibiotic use. The multi-faceted intervention in Denver, CO comprised a clinical care pathway, nurse protocol modifications, electronic health record (EHR) changes, parent education materials, and clinician education. We evaluated children aged 6 months-17 years with conjunctivitis seen between November 2018 and December 2022. A multi-interrupted time series model evaluated the effectiveness of the intervention over three time periods: Pre-COVID, Pre-Intervention (November 2018-February 2020), COVID, Pre-Intervention (March 2020-March 2021), and Post-Intervention (April 2021-December 2022). Fisher's exact tests compared treatment failure and healthcare utilization rates between time periods and among children receiving or not receiving ophthalmic antibiotics. Among 6960 eligible encounters, ophthalmic antibiotic use was reduced by 18.8% (95% CI: 16.3, 21.3) from Pre-COVID, Pre-Intervention to Post-Intervention. During the Pre-Intervention period following the onset of COVID, a reduction of 16.1% (95% CI: 12.9, 19.3) was observed. Implementation of the intervention resulted in an additional 2.7% (95% CI: -0.4, 5.7) reduction in antibiotic prescribing, primarily in younger children (ages 6 months-5 years). The greatest reduction in prescribing occurred for nurse triage encounters with an 82.1% (95% CI: 76.8, 87.5) reduction in prescribing rates (92.6%-10.5%). Treatment failure occurred in 1301 (18.7%) children and was more common among children that received an ophthalmic antibiotic than those that did not (20.0 vs 17.9%; P = .03). The QI intervention significantly reduced ophthalmic antibiotic prescribing for pediatric conjunctivitis without increasing treatment failure rates or health care utilization.

The impact of a structured assessment and decision tool (I-DECIDED®) on improving care of peripheral intravenous catheters: A multicenter, interrupted time-series study

BackgroundPeripheral intravenous catheters are the most widely used invasive device in hospitals but have serious risks. ObjectiveTo determine if a structured assessment and decision tool (I-DECIDED®) improves daily peripheral intravenous catheter assessment and care decisions. DesignProspective, interrupted time-series study. SettingsSeven adult inpatient wards in three Australian hospitals. Participants825 adults with 867 peripheral intravenous catheters. MethodsBetween August 2017 and December 2018, peripheral intravenous catheter assessments and chart audits were undertaken with informed patient consent. Following a 4-month pre-intervention period (with 2-weekly measures), the I-DECIDED® tool was implemented over 3 months (no data collection) using multiple strategies (stakeholder meetings, vascular access device form, education sessions, ward champions, lanyard cards, and posters), followed by a 4-month post-intervention period (with 2-weekly measures). Primary outcomes were device utilization (number of peripheral intravenous catheters per total number of patients screened); idle/unused catheters; insertion site complications, substandard dressing quality; and primary bloodstream infections. ResultsOf 2055 patients screened, 1175 (57.2%) had a peripheral intravenous catheter, and 825 patients (867 catheters) consented and were included in the final analysis. Device utilization increased from 42.0% of catheters at baseline to 49.6% post-intervention (absolute risk difference [ARD] 7.5%, 95% confidence interval [CI] 4.8, 10.3; relative risk [RR] 1.18, 95% CI 1.11, 1.25; p < 0.001). The proportion of idle catheters reduced from 12.7% to 8.3% (ARD −4.4%, 95% CI −8.5, −0.3; RR 0.66, 95% CI 0.44, 0.97; p = 0.035). Peripheral intravenous catheter complications reduced from 16.1% to 10.9% (ARD −5.2%, 95% CI −9.7, −0.6; RR 0.68, 95% CI 0.48, 0.96; p = 0.026). Substandard dressings reduced from 24.6% to 19.5% (ARD −5.2%, 95% CI −10.7, 0.4; RR 0.79, 95% CI 0.61, 1.02; p = 0.067). Only one primary bloodstream infection occurred (post-intervention). ConclusionsImplementation of a comprehensive device assessment and decision tool (I-DECIDED®) reduced idle catheters and catheter complications, despite higher device utilization. Dressing quality improved but was not statistically significant. Further implementation of the tool could improve hospital safety for patients with an intravenous catheter. ANZCTR trial registrationACTRN12617000067370.Date of registration 13 January 2017. Date of first data collection 3rd August 2017. Tweetable abstract#IDECIDEDassessment reduces prevalence of idle peripheral catheters and device complications.

Clinical impact of the combination of rapid species identification and antifungal stewardship intervention in adults with candidemia

BackgroundCandidemia is associated with a high mortality rate. This study aimed to evaluate the clinical impact of a diagnostic intervention and antifungal stewardship in adults with candidemia, including effectiveness in facilitating appropriate antifungals and improving patient outcomes. MethodsA pre-post quasi-experimental study was conducted to analyze the impact of the integrated workflow of rapid species identification and antifungal stewardship intervention provided by infectious disease specialists for adults with candidemia at a medical center in southern Taiwan from March 1st, 2014 to February 29th, 2016. The primary endpoint was 30-day crude mortality, and secondary outcomes included the time to species identification, time to initial antifungal modification, and length of hospital stay. ResultsTotal 303 patients with candidemia were included, including 152 adults in the pre-intervention period (Mar. 1st, 2014–Feb. 28th, 2015; control group) and 151 in the intervention period (Mar. 1st, 2015–Feb. 29th, 2016; case group). Demographic and clinical characteristics of patients in two groups were similar. The case group had a shorter time to species identification (72 vs. 96 h, P < 0.001) and earlier receipt of antifungals (47 vs. 59 h, P < 0.001) than the control group. Of note, the 30-day mortality rate (27.2% vs. 39.5%, P = 0.028) was lower and the hospital stay (43.5 vs. 46.0 days, P = 0.006) was shorter in the case group. ConclusionRapid diagnostic workflow and antifungal stewardship provided by infectious disease specialists can promote early initiation of antifungal therapy and improve outcome for adults with candidemia.