Process Control Charts Research Articles

Evaluation of ATP bioluminescence for rapid determination of cleanliness of livestock trailers after a commercial wash.

Pathogens such as porcine epidemic diarrhea virus (PEDV), porcine reproductive and respiratory syndrome (PRRSV), and E. coli are known to spread by contaminated vehicles and equipment. Pork producers have adopted trailer wash policies where each trailer is washed, disinfected, and dried before it can return to a farm. Cleanliness of livestock trailers after washing is determined by visual inspection rather than any objective method. Adenosine triphosphate (ATP) bioluminescence is used in many industries to provide real-time feedback on surface cleanliness through the detection of ATP from organic sources. That same technology may provide trailer wash facilities a way of objectively characterizing a livestock trailer's suitability to return to a farm after washing. Two ATP luminometers (3M Clean-Trace and Neogen AccuPoint) were used to estimate the correlation between ATP bioluminescence readings and aerobic bacterial plate counts (APCs) from sampled surfaces and to determine locations within a livestock trailer that can accurately estimate surface cleanliness. Five locations in livestock trailers were evaluated. Those locations included the nose access door (NAD), back door flush gate, rear side access door (RSAD), belly flush gate (BFG), and belly side access door (BSAD). There was a positive log-log association between the two luminometers (r = 0.59, P < 0.01). Every log unit increase in one unit, resulted in a 0.42 log increase (P < 0.01) in the other unit. ATP can come from bacteria, yeasts, molds, and manure. There was a poor association (r ≥ 0.10, P ≥ 0.02) between APCs and the ATP luminometers. Still, an increase in relative light units (RLUs) resulted in a corresponding increase in colony-forming units. The greatest area of surface contamination measured by APC was the NAD. RLUs were also greater in the NAD compared to the RSAD, the BFG, and the BSAD (P ≤ 0.01). Because APCs and luminometer RLUs provided similar outcomes, statistical process control charts were developed to determine control limits for RLUs. This provides real-time feedback to trailer wash workers in determining cleanliness outcomes for livestock trailers. These data suggest that ATP bioluminescence can be a reliable method to monitor cleaning effectiveness in livestock trailers. Bioluminescence is a monitoring tool that should be used in conjunction with microbial methods to monitor procedures for cleaning and disinfection.

Antimicrobial Stewardship and Improved Antibiotic Utilization in the Pediatric Cardiac Intensive Care Unit.

We developed a multidisciplinary antimicrobial stewardship team to optimize antimicrobial use within the Pediatric Cardiac Intensive Care Unit. A quality improvement initiative was conducted to decrease unnecessary broad-spectrum antibiotic use by 20%, with sustained change over 12 months. We conducted this quality improvement initiative within a quaternary care center. PDSA cycles focused on antibiotic overuse, provider education, and practice standardization. The primary outcome measure was days of therapy (DOT)/1000 patient days. Process measures included electronic medical record order-set use. Balancing measures focused on alternative antibiotic use, overall mortality, and sepsis-related mortality. Data were analyzed using statistical process control charts. A significant and sustained decrease in DOT was observed for vancomycin and meropenem. Vancomycin use decreased from a baseline of 198 DOT to 137 DOT, a 31% reduction. Meropenem use decreased from 103 DOT to 34 DOT, a 67% reduction. These changes were sustained over 24 months. The collective use of gram-negative antibiotics, including meropenem, cefepime, and piperacillin-tazobactam, decreased from a baseline of 323 DOT to 239 DOT, a reduction of 26%. There was no reciprocal increase in cefepime or piperacillin-tazobactam use. Key interventions involved electronic medical record changes, including automatic stop times and empiric antibiotic standardization. All-cause mortality remained unchanged. The initiation of a dedicated antimicrobial stewardship initiative resulted in a sustained reduction in meropenem and vancomycin usage. Interventions did not lead to increased utilization of alternative broad-spectrum antimicrobials or increased mortality. Future interventions will target additional broad-spectrum antimicrobials.

Development and implementation of a clinical decision support system-based quality initiative to reduce central line-associated bloodstream infections.

Central venous lines (CVLs) are frequently utilized in critically ill patients and confer a risk of central line-associated bloodstream infections (CLABSIs). CLABSIs are associated with increased mortality, extended hospitalization, and increased costs. Unnecessary CVL utilization contributes to CLABSIs. This initiative sought to implement a clinical decision support system (CDSS) within an electronic health record (EHR) to quantify the prevalence of potentially unnecessary CVLs and improve their timely removal in six adult intensive care units (ICUs). Intervention components included: (1) evaluating existing CDSS' effectiveness, (2) clinician education, (3) developing/implementing an EHR-based CDSS to identify potentially unnecessary CVLs, (4) audit/feedback, and (5) reviewing EHR/institutional data to compare rates of removal of potentially unnecessary CVLs, device utilization, and CLABSIs pre- and postimplementation. Data was evaluated with statistical process control charts, chi-square analyses, and incidence rate ratios. Preimplementation, 25.2% of CVLs were potentially removable, and the mean weekly proportion of these CVLs that were removed within 24 hours was 20.0%. Postimplementation, a greater proportion of potentially unnecessary CVLs were removed (29%, p < 0.0001), CVL utilization decreased, and days between CLABSIs increased. The intervention was most effective in ICUs staffed by pulmonary/critical care physicians, who received monthly audit/feedback, where timely CVL removal increased from a mean of 18.0% to 30.5% (p < 0.0001) and days between CLABSIs increased from 17.3 to 25.7. A significant proportion of active CVLs were potentially unnecessary. CDSS implementation, in conjunction with audit and feedback, correlated with a sustained increase in timely CVL removal and an increase in days between CLABSIs.

Evaluation of ATP bioluminescence for rapid determination of farrowing room cleanliness after pressure washing at a commercial sow farm.

Rotavirus and other pathogenic microorganisms are known to cause scours, respiratory infection, and increased mortality, spread from pig to pig via contaminated equipment, insuffcient washing, and improperdisinfection processes in farrowing rooms on commercial sow farms. Pig producers have adopted cleaning procedures and biosecurity policies as an attempt to ensure farrowing rooms are free of infectious organisms before the next group of sows is introduced. Adenosine triphosphate (ATP) bioluminescence has been used in other industries to provide real-time feedback on surface cleanliness through the detection of ATP from organic sources. That technology may provide producers a way of objectively characterizing a farrowing room's suitability for a new group of sows to be moved into the farrowing room. Three ATP luminometers (Charm Sciences novaLUM II-X, 3M Clean Trace, and Neogen AccuPoint) were used to estimate relationships between ATP bioluminescence relative light units (RLU) and coliform plate counts (CPC). Five farrowing crate locations and the room entryway floor were swabbed to determine locations within a farrowing crate that can accurately estimate room cleanliness. Coliform plate counts were strongly correlated with Charm novaLUM II-X RLU (r = 0.70, P < 0.01). The Clean-Trace CPCs and RLU (r = 0.48, P < 0.01) were moderately correlated. There was a weak correlation between CPCs and AccuPoint RLU (r = 0.32, P < 0.01). The greatest area of surface contamination was the entryway floor and the sow feeder. Because CPCs and luminometer RLU were correlated, statistical process control charts were developed to provide cleanliness thresholds based on RLU values. Based on an adjusted 3σ from the mean RLU critical limit, 7.7% of crates for the Charm novaLUM II-X, 10.6% of crates for the 3M Clean Trace, and 0% of crates for the Neogen AccuPoint would have failed the critical limit for the sow feeder cleanliness thresholds. Using a similar approach, 11.4% of crates for the Charm novaLUM II-X, 10.5% of crates for the 3M Clean Trace, and 15.2% of crates for the Neogen AccuPoint would have failed the critical limit for the crate sorting bar cleanliness thresholds. These data suggest that ATP bioluminescence may be a reliable method to monitor cleaning effectiveness in farrowing rooms on commercial sow farms. Bioluminescence is a monitoring tool that should be used in conjunction with periodic microbial validation to monitor procedures for cleaning and disinfection.

Improving Telemetry use in the Acute Assessment Unit.

Despite published guidelines, telemetry use is inappropriate in 25-43% of cases. This impacts patient safety and telemetry effectiveness. QI methodology was used to review telemetry in a hospital acute medical unit with the aim of reducing inappropriate use and addressing alarm fatigue. A 'Telemetry Indication Form' was created. Eight weeks of baseline data was collated before introducing the 'Indication Form'. Four plan-do-study-act cycles were conducted. At each cycle, data was analysed using statistical process control charts. Inappropriate telemetry use significantly reduced from 32% to 4%. Total telemetry use also fell. Unfortunately, interventions to address alarm rates did not result in significant reduction in false alarms. A 'Telemetry Indication Form' has significant potential to improve patient safety through reducing inappropriate use.

Development of descriptive analysis module within a cloud-based quality analyser: Case study in a guitar industry

Along with the revolution of the manufacturing world, companies face a new challenge to continuously improving their production processes to meet the escalating demand for high-quality goods in a fiercely competitive market. The previous concept of Cloud-Based Quality Analyzer (CQA) can be used as a real-time monitoring software that provides information of the on-going process. This concept can be implemented as an effort to achieve high quality manufacturing. This study aimed to develop the descriptive analysis module to realise the concept of CQA and evaluate its ability in realising online quality monitoring process. By employing the waterfall methodology, this study developed and implemented the descriptive analysis module in the CQA environment. The module was implemented in a case study in guitar manufacturing. The result showed that this module worked perfectly in displaying the multivariate process control chart and successfully gave the warning when some processes were in out-ofcontrol state. Furthermore, the user acceptance test also showed a positive response from the users. The descriptive analysis module was believed able to enhance the quality of manufacturing process while reducing the dependencies to the human quality engineers. However, more case studies in various industries were required to evaluate the benefit of implementing this module.

Structural health assessment through continuous vibration-based monitoring of a stainless-steel lattened in-operation railway bridge

Damage detection in railway bridges is challenging due to changing environmental and operational conditions. Advanced monitoring techniques, such as operational modal analysis (OMA), use vibration to assess the integrity of structures during their operational life. Cov-SSI, a time-based OMA algorithm, is widely used for the automatic identification of system dynamics. Static modelling is essential to separate variability from benign effects and ensure accurate monitoring. Monitoring the health of the structure through control charts highlights damages that influence the dynamic response. This study focuses on the continuous monitoring of railway bridge networks using advanced methods such as MOVA and MOSS. In particular, this work is part of a research project dedicated to the continuous monitoring of a real bridge in operation: the Quisi Viaduct in Alicante (Spain). The viaduct is a stainless steel single-span bolted railway bridge, built at the beginning of the 20th century. The viaduct is equipped with a set of high-sensitivity accelerometers and a dense network of deformation sensors that store a compendium of data of approximately 3 years. This contribution discusses the quality of the data sets and the monitoring strategy, with a focus on the effectiveness of using statistical process control charts to assess the structural health of railway bridges.

A Practical Guide to QI Data Analysis: Run and Statistical Process Control Charts.

Data analysis utilizing run charts and statistical process control (SPC) charts is a mainstay of quality improvement (QI) work. These types of time series analyses allow QI teams to evaluate patterns in data that may not be apparent with pre- and postintervention analysis. A run chart is most useful at the onset of a project when data points may be limited; points can be added prospectively to monitor for changes. An SPC chart is needed to determine if the system is "out of control," indicating an instance of special cause variation, and is recommended for more robust data analysis. These charts are valuable tools in identifying patterns of change, but cannot indicate what caused the change. QI teams can further investigate significant patterns to identify the impact of interventions and promote continued change or sustainability. In this article, we will provide a practical guide to the basics of run and SPC charts, including how to create and interpret them. The reader can use the supplemental data tables to gain the skills needed to build their own charts with readily available software. Finally, we will review more specialized software options that can assist in creation of run and SPC charts.

Implementation of an ultrasound-guided approach for arterial line placements in neonates-quality improvement project.

Our goal was to improve placement success rates for peripheral arterial line (PAL) placements by introducing an ultrasound-guided (USg) approach. Our aim was to maintain success rates over 70% within 18 months. Interventions included development of a training curriculum, and procedure standardization. Among 302 patients, 115 underwent USg catheter placement; the traditional method was used in 187 patients. Outcome measures were first-attempt and overall success rates. Process measures were proportion of PALs placed under US guidance, trainer availability, and trainee sign-off. Line complications were balancing measures. Statistical process control charts were used to monitor metrics. Sustained improvement was seen with the USg approach. The USg approach had first and overall attempt success by the trainers (i.e., independent users) of 83.7% (77/92) and 96.5% (111/115), compared to 50.3% (82/163) and 73.8% (138/187) with the traditional approach. Introducing the USg approach had a significant impact on PAL placement success in neonatal patients.

A New Index to Detect Process Deviations Using IR Spectroscopy and Chemometrics Process Tools

Process analytical technologies (PATs) have transformed the beverage production management by providing real-time monitoring and control of critical process parameters through non-destructive measurements, such as those obtained with infrared (IR) spectroscopy and enabling process readjustment if necessary. New requirements in the analysis of beverages call for new methods, so in this article, we propose a method based on the construction of multivariate statistical process control (MSPC) charts from a new dissimilarity index (the evolving window dissimilarity index, EWDI) to monitor fermentation processes. The EWDI was applied to monitor wine alcoholic fermentation, the biochemical transformation of sugars into ethanol. Small-scale fermentations were carried out and analyzed using a portable mid-infrared spectrometer. In some of them, process deviations due to nitrogen deficiency or temperature changes were intentionally promoted to evaluate the performance of the EWDI. The MSPC charts build by using the fermentations carried out under normal operating conditions allowed identifying deviations of the fermentation in its early stages. Furthermore, the shape of the EWDI curve over time provides insights about the specific type of deviation occurring. These results show the potential of this new approach to improve the monitoring and control of key process stages in biochemical processes in the food industry, which allows maximizing quality and minimizing losses.Graphical

Reassessment of performance evaluation of EWMA control chart for exponential process

AbstractMemory control charts or charts, such as cumulative sums and exponentially weighted moving average (EWMA), are widely used for tracking minor to moderate changes in process parameters. The literature presented an EWMA chart for monitoring exponential processes, assuming probability limits to determine both in‐ and out‐of‐control average run length (ARL). The use of probability limits for memory charts is an incorrect method. So, we are aiming to correct the EWMA chart by Aslam et al. and the proposed EWMA chart (represented by ) for the exponential process using the run‐length (RL) method based on the simulation method instead of the probability‐based method. The ARL, standard deviation of RL, and median of RL are used to evaluate the proposed chart's performance. For practical consideration of the proposed chart, a real‐world example of a urinary tract infection is also presented.

Improving maternal update rates within the first hour of NICU admission.

Timely communication is essential in attaining maternal satisfaction, developing an excellent physician-patient rapport, and increasing trust. This study reports a significant improvement in maternal communication rates through the quality improvement method. An educational module was developed, and NICU staff was presented with the slides, followed by a performance questionnaire to demonstrate understanding. The first phase was completed by obtaining feedback from mothers through a questionnaire. The first plan-do-study-act (PDSA) cycle, carried out for eight weeks looking at the rates of the maternal update provided within an hour of admission of their neonates to the NICU, was followed by the second PDSA cycle, carried out for ten weeks. The improvement was calculated using conventional statistics and a statistical process control chart. During the first phase of the study, thirty-six percent of the mothers were updated within an hour of admission of their neonates to the NICU. During the first PDSA cycle, we did not notice a special cause variation or process change. A significant shift, eight consecutive points above the mean, was noted on the control chart during PDSA cycle 2. The mean±SD of the weekly update rate increased significantly during PDSA cycle 2 (76.8±11) compared to PDSA cycle 1 (47.5±14), p-value = 0.0002. We improved the maternal update rates through the educational module following the QI improvement model using the PDSA cycles.

Implementing Next-Generation Sequencing Process Changes to Increase Capacity and Improve Timeliness of Molecular Biomarker Profiling for Lung Cancer Patients.

Faced with expansion of molecular tumor biomarker profiling, the molecular genetics laboratory at Kingston Health Science Centre experienced significant pressures to maintain the provincially mandated 2-week turnaround time (TAT) for lung cancer (LC) patients. We used quality improvement methodology to identify opportunities for improved efficiencies and report the impact of the initiative. We set a target of reducing average TAT from accessioning to clinical molecular lab report for LC patients. Process measures included percentage of cases reaching TAT within target and number of cases. We developed a value stream map and used lean methodology to identify baseline inefficiencies. Plan-Do-Study-Act cycles were implemented to streamline, standardize, and automate laboratory workflows. Statistical process control (SPC) charts assessed for significance by special cause variation. A total of 257 LC cases were included (39 baseline January-May 2021; 218 post-expansion of testing June 2021). The average time for baseline TAT was 12.8 days, peaking at 23.4 days after expansion of testing, and improved to 13.9 days following improvement interventions, demonstrating statistical significance by special cause variation (nonrandom variation) on SPC charts. The implementation of standardized manual and automated laboratory processes improved timeliness of biomarker reporting despite the increasing volume of testing at our center.

Increasing Chlamydia and Gonorrhea Testing for Adolescents in the Pediatric Emergency Department.

Adolescents who use the emergency department are more likely to engage in high-risk sexual activity and are at an increased risk of sexually transmitted infections. We aimed to increase testing for Chlamydia and gonorrhea from 12% to 50% among adolescents presenting to our pediatric emergency department with at-risk chief complaints over 12 months. Plan-Do-Study-Act cycles were initiated in July 2020. A multidisciplinary team reviewed preexisting data and developed interventions to increase Chlamydia and gonorrhea testing in teens with at-risk complaints, including genitourinary and behavioral health complaints, and females with abdominal pain. Two categories of interventions were implemented: education and electronic medical record optimization. Process measures were the proportion of patients with a documented sexual history and the proportion of patients tested with a documented confidential phone number. Secondary outcome measures included the weekly number of positive test results and the proportion of patients testing positive who were contacted to arrange treatment. Statistical process control charts were used to examine changes in measures over time. Within 14 months of project initiation, the proportion of at-risk patients tested increased from 12% to 59%. Teen phone number documentation remained unchanged from 23%. Sexual history documentation remained unchanged from 46%. The number of positive test results increased from 1.8 to 3.4 per month, and the proportion of patients testing positive who were contacted to arrange treatment remained unchanged at 83%. We surpassed our goal and increased the proportion of at-risk patients tested for Chlamydia and gonorrhea to 59%, sustained for 4 months from the last intervention.

Optimizing Vaccine Delivery Among Pediatric Allogeneic Hematopoietic Cell Transplant Recipients: A Quality Improvement Initiative

Abstract Background Pediatric allogeneic hematopoietic cell transplantation (HCT) recipients are at risk for vaccine-preventable infections (VPI). Although evidence-based guidelines recommend starting vaccination efforts between 3-6 months post-HCT, most children remain sub-optimally vaccinated and at-risk for VPI. Our prior work demonstrated that early vaccination starting at 4-6 months post HCT was safe and immunogenic. To reduce potential patient harm from vaccine-preventable infections (VPI), we created a quality improvement (QI) initiative to increase vaccination rates among eligible pediatric allo-HCT recipients, beginning early post-HCT by implementing a best practice immunization strategy at our institution. Methods This QI initiative applied a quasi-experimental design and multiple bundled interventions in Plan-Do-Study-Act (PDSA) cycles to implement and sustain an early immunization strategy among allogeneic HCT recipients in our ambulatory HCT clinic from November 2018-May 2022. The study aimed to increase vaccination rates in eligible patients by providing a core vaccine bundle (pneumococcal conjugate [PCV13], Haemophilus influenzae type b [Hib], inactivated polio [IPV], diphtheria, tetanus, acellular pertussis [DTaP], and hepatitis B vaccines [HBV]) beginning at 6 months [Day+168 to 180] post-HCT, allowing a 30-day grace period for clinic scheduling. The number of subjects who completed a full vaccine series (4 PCV13, 3 DTaP/HBV/IPV and Hib) within the expected time post HCT were recorded. Subjects were ineligible for early vaccination if the indication for HCT was a primary immunodeficiency, and if at screening or vaccination, subjects had relapsed primary disease, graft failure, died, received anti-CD20 therapies in the preceding 6 months and had no evidence of B cell recovery, or were receiving augmented immunosuppression (prednisone-equivalent of ≥ 2 mg/kg/day). The process measure was the proportion of patients screened for vaccine eligibility vs all eligible allo-HCT recipients at 4 months post-HCT. The outcome measure included the proportion of eligible allo-HCT recipients who received the first doses of core vaccines at 6 months (+30 days) among the total number of eligible patients dur for early vaccination. PDSA interventions included creating and implementing a standardized vaccine clinical practice guideline, stakeholder engagement and communication, pre-clinic screening at 4 months post-HCT, creation of a vaccine order set per time post-HCT, and patient-individualized vaccine decision support recommendations. Results Among 72 children who underwent allo-HCT, 37 (51%) were deemed eligible for early vaccination. Review of institutional baseline data revealed that only 43% of eligible allo-HCT received the core vaccines beginning at 6 mos post-HCT. After the first two PDSA cycles, the proportion of eligible patients receiving core vaccines beginning early post-HCT increased from a baseline of 43% to 62%. After implementation of a patient-individualized vaccine decision support recommendation, early immunization rates increased to 92% and were sustained for over 2 years. In total, 33 (90%) patients, predominantly males (55%) with a median age of 9 y [range 0.33-19], received core vaccines at a median of 175 days [range 168-210] post-HCT during the study period. Among children who received early vaccination post-HCT, 82% remained eligible to continue their recommended vaccine roadmap and completed the full vaccine series by the expected 14-16 months post-HCT. Conclusions A multidisciplinary approach applying QI methodology and individualized vaccine decision support allowed for improved and sustained early vaccination after pediatric allo-HCT and completion of vaccine series, thereby reducing potential VPI-associated patient harm. Figure 1. Statistical Process Control Chart (p-chart) of Quality Improvement Initiative to Improve Vaccination Delivery Starting at 6 months After Pediatric Allogeneic Hematopoietic Cell Transplantation (HCT)

Implementation of an electroencephalogram-guided propofol anesthesia practice in a large academic pediatric hospital: Aquality improvement project.

Propofol-based total intravenous anesthesia is gaining popularity in pediatric anesthesia. Electroencephalogram can be used to guide propofol dosing to the individual patient to mitigate against overdosing and adverse events. However, electroencephalogram interpretation and propofol pharmacokinetics are not sufficiently taught in training programs to confidently deploy electroencephalogram-guided total intravenous anesthesia. We conducted a quality improvement project with the smart aim of increasing the percentage of electroencephalogram-guided total intravenous anesthesia cases in our main operating room from 0% to 80% over 18 months. Balancing measures were number of total intravenous anesthesia cases, emergence times, and perioperative emergency activations. The project key drivers were education, equipment, and electronic health record modifications. Plan-Do-Study-Act cycles included: (1) providing journal articles, didactic lectures, intraoperative training, and teaching documents; (2) scheduling electroencephalogram-guided total intravenous anesthesia teachers to train faculty, staff, and fellows for specific cases and to assess case-based knowledge; (3) adding age-based propofol dosing tables and electroencephalogram parameters to the electronic health record (EPIC co, Verona, WI); (4) procuring electroencephalogram monitors (Sedline, Masimo Inc). Electroencephalogram-guided total intravenous anesthesia cases and balancing measures were identified from the electronic health record. The smart aim was evaluated by statistical process control chart. After the four Plan-Do-Study-Act cycles, electroencephalogram-guided total intravenous anesthesia increased from 5% to 75% and was sustained at 72% 9 months after project completion. Total intravenous anesthesia cases/mo and number of perioperative emergency activations did not change significantly from start to end of the project, while emergence time for electroencephalogram-guided total intravenous anesthesia was greater statistically but not clinically (total intravenous anesthesia without electroencephalogram [16 ± 10 min], total intravenous anesthesia with electroencephalogram [18 ± 9 min], sevoflurane [17 ± 9 min] p < .001). Quality improvement methods may be deployed to adopt electroencephalogram-guided total intravenous anesthesia in a large academic pediatric anesthesia practice. Keys to success include education, in operating room case training, scheduling teachers with learners, electronic health record modifications, and electroencephalogram devices and supplies.

Abstract 325: Two-Year Outcomes of an Electronic Health Record Integrated Rapid Response Team Model

Background: Literature supports improved patient outcomes with dedicated resources for rapid response to patient deterioration in inpatient settings. However, studies of the association of centralized resource allocation and electronic health record (EHR) integration on patient outcomes are lacking. Aim: To improve early, centralized rapid response to patient deterioration and reduce unanticipated transfers to the ICU. Methods: Using a prospective longitudinal quality improvement design, we implemented a centralized, EHR supported patient response team (PRT) at an academic medical center in the southeastern United States. The model served 1,043 inpatient beds. Pre-intervention the PRT used episodic data capture and included 1 critical care RN, 1 physician, and 1 respiratory therapist; each expected to leave assigned patients to respond to non-ICU events. We implemented a dedicated PRT (4 critical care RNs and 1 hospitalist) to provide 24/7 response to code blue, RRT, and stroke code events. The team provided proactive rounding, preventive consultation, and assessment of patients from ICU or emergency within 24 hours. Standardized workflow and outcome documentation was integrated in the EHR. Improvement in processes and outcomes were analyzed using statistical process control charts with 25 data points over a 2-year period. Results: At baseline (FY 2020), the PRT responded to 1739 rapid response calls and 166 code blue events. Unanticipated transfer to ICU occurred in 935 (53.8%) patients. Post-implementation of the integrated PRT model, the rate of early rapid response calls improved (FY 2021 n=2099; FY 2022 n=2239), code blue events decreased (FY 2021 n=151; FY 2022 n=115), and unanticipated ICU transfers also decreased (25%; Figure 1). Conclusions: A centralized PRT model using technology-supported EHR integration, pre-defined workflows, and a dedicated team can reduce non-ICU cardiac arrests and decrease unanticipated transfers to ICU.

Abstract 18105: Lean Six Sigma Approach to Improve Post Percutaneous Coronary Intervention Cardiac Rehab Referral Rates

Background: Cardiac rehabilitation referral rates remain low despite known benefits including decreased mortality and improved quality of life. Studies have identified factors tied to both positive and negative predictors of referral rates, however, overall, it appears to be due to site-specific variation demonstrating the need for hospital-level intervention. Aims: This quality improvement study aimed to improve cardiac rehabilitation referral rates after PCI at our institution utilizing the Lean Sigma Six (LSS) approach, which has been described as a means to improving the quality of healthcare delivery. Methods: An interdisciplinary team used the Define-Measure-Analyze-Improve-Control (DMAIC) framework to implement this study. A GEMBA walk i.e., personal observation of workflow was performed. We Define d and Measure d process of cardiac rehabilitation and the referral rates. We Analyzed to identify that the orders were being placed by multiple team members including residents, general and interventional cardiology fellows, attendings, and nurse practitioners. Process maps were created, and our Intervention was to involve interventional cardiology fellows as stakeholders best suited to place orders since they are involved in all PCIs at our institution. Education was provided specifically to them beginning in July 2022. Statistical Process Control charts were used to analyze data trends from 2019 - 2022 where a total of 3046 PCIs were performed. Control process involved reinforcing the effect of intervention in quarterly meetings. Results: Baseline referral rates ranged from 10-60%. A significant increase in cardiac rehabilitation referral rate achieving a target referral greater than 90% was observed and maintained through the subsequent quarters. Conclusion: LSS is a powerful methodology to examine causes of delay in care. Intervention using LSS principles and tools, may help improve system processes to achieve desired quality outcomes.

Implementation of a health system intervention to reduce time from presentation to surgical intervention for pediatric testicular torsion

Testicular salvage rates for torsion are time-dependent1. Door to detorsion time has been identified as an independent testicular survival factor2. We describe an initiative to reduce door to incision (DTI) time for pediatric testicular torsion. An institutional multidisciplinary quality improvement initiative with a primary outcome of reducing DTI time for pediatric testicular torsion was developed with multidisciplinary stakeholders. Several process and balancing measures were used as secondary outcomes to help interpret and verify the observed change in DTI time. Interventions were implemented in cycles. Initial interventions standardized assessment of suspected torsion by Emergency Medicine utilizing a validated scoring system. A threshold Testicular Workup for Ischemia and Suspected Torsion (TWIST) score led to parallel notification of essential services for rapid assessment and case prioritization3. Subsequently, bedside ultrasound in the Emergency Department was implemented. Progress was tracked in a live dashboard and analyzed with X-mR process control charts and Nelson rules. These tools are used in quality improvement and process control to demonstrate the significance of changes as they are being implemented, prior to when traditional hypothesis testing would be able to do so. We aimed to increase the proportion of cases with DTI times under 4h from 64% to >90% within one year. We observed 22 torsion cases prior to and 62 following initial implementation. The percentage of cases with DTI times under 4h improved from 64% to 95%. At week 29, a shift identified a significant change on the X chart, with reduction in mean DTI time from 221 to 147min. At the same time, a shift on the mR chart identified reduction in patient-to-patient variation. Mean time from arrival to Urology evaluation decreased from 140 to 56min, mean time from arrival to scrotal ultrasound decreased from 70 to 36min, and mean time from scrotal ultrasound to surgical incision decreased from 128 to 80min. These improvements highlight the two key successes of our project: application of the TWIST score and bedside ultrasound for rapid assessment of suspected testicular torsions, and parallel processing of the evaluation and management. Implementation of a protocol for pediatric testicular torsion increased the proportion of cases with DTI time <4h to 95%, decreased mean DTI time, and decreased variation. Our protocol provides a model to improve timeliness of care in treating pediatric testicular torsion.

Decreasing ICU and Hospital Length of Stay through a Standardized Respiratory Therapist-driven Electronic Clinical Care Pathway for Status Asthmaticus.

Status asthmaticus (SA) is a cause of many pediatric hospitalizations. This study sought to evaluate how a standardized asthma care pathway (ACP) in the electronic medical record impacted the length of stay (LOS). An interdisciplinary team internally validated a standardized respiratory score for patients admitted with SA to a 25-bed pediatric intensive care unit (PICU) at a tertiary children's hospital. The respiratory score determined weaning schedules for albuterol and steroid therapies. In addition, pharmacy and information technology staff developed an electronic ACP within our electronic medical record system using best practice alerts. These best practice alerts informed staff to initiate the pathway, wean/escalate treatment, transition to oral steroids, transfer level of care, and complete discharge education. The PICU, stepdown ICU (SD ICU), and acute care units implemented the clinical pathway. Pre- and postintervention metrics were assessed using process control charts and compared using Welch's t tests with a significance level of 0.05. Nine hundred two consecutive patients were analyzed (598 preintervention, 304 postintervention). Order set utilization significantly increased from 68% to 97% (P < 0.001), PICU LOS decreased from 38.4 to 31.1 hours (P = 0.013), and stepdown ICU LOS decreased from 25.7 to 20.9 hours (P = 0.01). Hospital LOS decreased from 59.5 to 50.7 hours (P = 0.003), with cost savings of $1,215,088 for the patient cohort. Implementing a standardized respiratory therapist-driven ACP for children with SA led to significantly increased order set utilization and decreased ICU and hospital LOS. Leveraging information technology and standardized pathways may improve care quality, outcomes, and costs for other common diagnoses.