Prospective Quality Improvement Project Research Articles

Med rec double check: Inpatient psychiatry medication errors identified on admission using Medicaid Web portals and electronic pharmaceutical claims data.

The role of pharmacists during medication reconciliation (MR) is well established, with a number of reports describing this in the context of psychiatric hospitalizations. However, medication errors (MEs) are common during transitions of care, with no exception during psychiatric hospitalizations. Our institution uses pharmacy-performed MR processes using patient interviews and reviewing objective sources, such as electronic pharmaceutical claims data (EPCD), which includes Medicaid Web portals. The inpatient psychiatric pharmacist reviews EPCD sources against previously pharmacy-completed MRs for new admissions, where if discrepancies are found, the patient is reinterviewed to identify and correct MEs. We performed a prospective quality improvement project during 28 days to evaluate the quantity and classification of MEs upon admission to a 22-bed inpatient psychiatry unit. Of 52 included patients, where a cumulative 426 medications were reviewed, a total of 29 MEs in 16 patients were identified. Eight patients had discrepancies on their home medication lists when compared to EPCD, where 7 of these had at least 1 ME due to inaccurate MR. Of all the MEs identified, the greatest quantity was found secondary to the EPCD "double-check" method. The most common MEs in all patients were the omission of home medications (34%), wrong frequency (28%), and ordering medication the patient is not taking (10%). All patients admitted on long-acting injection antipsychotics had errors in last dose received. No MEs resulted in patient harm, and they were identified and corrected by the psychiatric pharmacist 97% of the time.

Implementation of delirium management during the pandemic: lessons learned

Background During the covid-19 pandemic, a non-funded, nurse-led quality improvement project on delirium management was in progress on four Stroke Units (SU). Two sites experienced pandemic-related delays; we set out to learn lessons based on the impact for delivering multicentre trials. Methods Secondary analysis of a prospective quality improvement project. We compared data quality from centres with vs. without delay. Unplanned modifications in study management were classified as a) fatal modifications (ending the study), b) serious modifications (requiring a revision of the registration and/or ethic approval, c) moderate modifications (revising study management), d) minor modifications (improving study performance). Local study coordinators summarised lessons learned. Results The study had an overall delay of 14 months. Centres without delay delivered better data quality and had less loss of patients due to missing primary outcome data in 0.3% vs 28.8% in centres with delay (p<0.001). There were no fatal modifications, two serious (exchange of study centre, adding new outcome parameters), six moderate (e.g. delayed start in two centres, change from in-person to virtual meetings), and one minor modification (four local study coordinators taking parental leave). Lessons learned were frequent communication with study coordinators, attention to data quality, protocolisation of recruitment rates, and adapted education in quality improvement projects. Conclusions Pandemic-related disruption can be substantial, with poorer data quality, but only in a few cases were registration and/or ethic approval modifications required. Facilitators are flexible, including changed time frames, frequent virtual communication, and critical reflection.

A114 IMPROVING THE QUALITY OF PARACENTESIS PRACTICES IN PEOPLE WITH ADVANCED CIRRHOSIS IN AN AMBULATORY CARE SETTING

Abstract Background Spontaneous bacterial peritonitis (SBP) is a lethal complication of decompensated cirrhosis carrying a 90% mortality rate when left untreated. Despite AASLD recommendations, there is a practice gap regarding fluid cell count (FCC) collection during paracentesis. Aims We initiated prospective quality improvement (QI) project to improve FCC collection in an ambulatory care setting from a baseline of 78% to a goal of 100% compliance between September 11, 2022 and April 17, 2023. Methods We examined the effects of a quality improvement initiative in 233 adult patient encounters with cirrhosis undergoing paracentesis in an ambulatory setting located within a quaternary care centre in Toronto, Canada within the study timeframe. Using a multidisciplinary approach, the quality improvement initiatives included focused groups, education regarding AASLD guidelines, development of a paracentesis bundle, and streamlining workflow process. Descriptive statistics were collected. Statistical analysis using run charts and p-charts were conducted using QI Macros. Approval was obtained from the QI Review Committee at the institution where this QI initiative took place. Results Baseline adherence for collecting ascitic FCC per paracentesis procedure was 78%. Inconsistencies during process mapping such as variations in documentation, printing FCC labels and consistency in FCC collection were identified as root causes. Thus, bedside paracentesis bundles were introduced to standardize process and improve workflow. Post-intervention, the FCC rate increased marginally to 79.6% with no special cause variation identified (Figure 1). Subgroup analysis demonstrated FCC collection rates of 100% amongst registered nurse (RN) and nurse practitioners (NP), 97% amongst resident physicians, and 92% amongst attending physicians. Subsequently, another subgroup analysis was completed demonstrating 97% FCC collection rate amongst general hepatology group, while 40% FCC rate amongst specialty hepatology group. Overall rate of SBP was 1.62% (N=3). Conclusions This prospective QI study revealed a gap in guidance pertaining to the role of ascitic fluid cell count collection in patients with cirrhosis undergoing paracentesis in ambulatory settings. Further studies ascertaining rationale for not sending FCC may be helpful in elucidating why there is a gap in clinical practice. Additionally conducting studies in ambulatory settings to assess FCC collection's impact on morbidity and mortality will provide vital evidence and clarity for the role of FCC in this vulnerable patient group. Figure 1: P-chart demonstrating percentage FCC Collection per week from September 11, 2022 to April 17, 2023. UCL indicates upper control limit; CL, center line; LCL, lower Control Limit. Funding Agencies Toronto Centre for Liver Disease funded the MSc QI program for Mary Sedarous (writer) who completed this study as her MSc QI project.

Mental Health Polypharmacy in "Non-Coded" Primary Care Patients: The Effect of Deprescribing.

Background: Mental health (MH) polypharmacy, defined as prescribing multiple mental health medications for the same condition, presents significant challenges in clinical practice. With varying prevalence rates and an increasing trend, particularly in the UK, this deprescribing prospective quality improvement project aimed to address the complexities and risks associated with MH polypharmacy. Patients and Methods: A large primary care centre in London was selected for this project. Electronic records of 667 patients (non-coded in mental health lists) were analysed as a result of the absence of a Systematised Nomenclature of Medicine Clinical Terms (SNOMED CT) for mental health. Seventy-two non-coded patients exhibiting "same-class" as well as "adjunctive" and "augmentation" polypharmacy were identified. Their demographic and health data, including MH diagnoses, physical status, and lifestyle habits, were evaluated. This deprescribing prospective project included 68 patients and employed a model inspired by the Plan-Do-Study-Act (PDSA) cycle, focusing on reducing psychotropic, adjunctive, and augmentative medications while monitoring mental health control through face-to-face consultations using the Patient Health Questionnaire-9 (PHQ-9) and Generalised Anxiety Disorder Assessment-7 (GAD-7) scores, alongside physical health parameters. Results: The project revealed a significant decrease in the average number of psychotropic and adjunct medications from initial consultations to the end of the 18-month period. Additionally, a marked reduction in reported side effects and drug interactions was observed. Improvements in mental health control, as evidenced by PHQ-9 and GAD-7 scores, were noted. Physical health parameters, including BMI, blood pressure, heart rate, HbA1c, and cholesterol levels, also showed significant improvements. Educational initiatives for patients and clinicians were successfully implemented, contributing to these positive outcomes. Discussion: The project faced challenges like balancing medication reduction with mental health stability, patient apprehension, and the absence of standardised protocols. However, the successful reduction in medication numbers and the improvement in health outcomes highlight the effectiveness of the model. This project underscores the necessity of a tailored approach to MH polypharmacy, emphasising continuous education, clinical titration, and adherence to guidelines. Future research is needed to develop clear guidelines for medication combination in mental health care and to understand the long-term effects of polypharmacy in mental health populations. Conclusions: This project demonstrates the potential for significant improvements in the management of MH polypharmacy. By carefully managing medication reductions and employing a comprehensive care approach, including patient education and clinician training, the project achieved improvements in both mental and physical health outcomes. These findings suggest a promising direction for future practices in MH polypharmacy management.

Securing access to a comprehensive diagnostic panel for children with suspected acute lymphoblastic leukemia: Results from the Mexico in Alliance with St. Jude "Bridge Project".

The "Bridge Project" is a Mexico in Alliance with St. Jude (MAS) initiative developed in 2019 to improve access, accuracy, and timeliness of specialized diagnostic studies for patients with suspected acute lymphoblastic leukemia (ALL). The project strategy relies on service centralization to improve service delivery, biological characterization, risk-group classification, and support proper treatment allocation. This is an ongoing prospective multisite intersectoral quality improvement (QI) project available to all patients 0-18 years of age presenting with suspected ALL to the 14 actively participating institutions in 12 Mexican states. Institutions send specimens to one centralized laboratory. From a clinical standpoint, the project secures access to a consensus-derived comprehensive diagnostic panel. From a service delivery standpoint, we assess equity, timeliness, effectiveness, and patient-centeredness. From an implementation science standpoint, we document feasibility, utility, and appropriateness of the diagnostic panel and centralized approach. This analysis spans from July 2019 to June 2023. 612 patients have accessed the project. The median age was 6 years (IQR 3-11), and 53% were males. 94% of the specimens arrived within 48 hours, which documents the feasibility of the centralized model, and 100% of the patients received precise and timely diagnostic results, which documents the effectiveness of the approach. Of 505 (82.5%) patients with confirmed ALL, 463/505 (91.6%) had B-cell ALL, and 42/505 (8.3%) had T-cell ALL. High-hyperdiploidy was detected by DNA index in 36.6% and hypodiploidy in 1.6%. 76.6% of the patients had conclusive karyotype results. FISH studies showed t(12;21) in 15%, iAMP21 in 8.5%, t(1;19) in 7.5%, t(4;11) in 4.2%, t(9;22) in 3.2%, del(9)(p21) in 1.8%, and TRA/D (14)(q11.2) rearrangement in 2.4%. Among B-cell ALL patients, 344/403 (85.1%) had Day 15 MRD<1% and 261/305 (85.6%) Day 84 MRD<0.01. For T-cell ALL patients 20/28 (71.4%) had Day 29 MRD<0.01% and 19/22 (86.4%) Day 84 MRD<0.01%. By securing access to a standardized consensus-derived diagnostic panel, the Bridge Project has allowed better characterization of childhood ALL in Mexico while producing unprecedented service improvements and documenting key implementation outcomes. We are using these results to inform iterative changes to the diagnostic panel and an associated treatment guideline (MAS-ALL18).

Reducing Preventable Bleeding Visits and Institutional Factor Costs for Patients with Bleeding Disorders with a Prospective Quality Improvement Project

Providing optimal care to patients with bleeding disorders requires specialized physician, laboratory, pharmacy, nursing, and institutional resources best achieved at Hemophilia Treatment Centers (HTCs). Current systems for managing the care of a resource intensive patient population may be suboptimal. We observed frequent bleeding related hospitalizations and emergency room (ER) visits in patients with bleeding disorders treated at our HTC that could have been potentially prevented by changes in outpatient care delivery. We initiated a prospective quality improvement (QI) project to improve care delivery and to reduce preventable bleeding related hospitalizations and ER visits for adult patients treated at our HTC. The interventions targeted patient-level and systems-level factors contributing to preventable visits, and barriers to care in our patient population. We compared preventable bleeding related hospitalizations and ER visits, institutional factor cost, use of prophylaxis in severe hemophilia, primary care physician attainment, and patient electronic portal enrollment before and after the QI intervention. In our population of adult patients with bleeding disorders (N=88), the intervention significantly reduced the primary outcome of preventable bleeding hospitalization or ER visit (P=0.0082, Figure), and reduced such visits by 85.4%, meeting the pre-specified criteria for success. Institutional factor acquisition costs to treat preventable bleeding were reduced by 94.5%, from $11,800 to $640 per patient per year; a projected savings of $982,088 yearly. Use of factor prophylaxis in patients with severe hemophilia increased from 58.8% to 100%, attainment of a primary care physician increased from 69.4% to 86.4%, and use of the electronic patient portal increased from 53.2% to 83%; all secondary outcomes met pre-specified criteria of success and were statistically significant. HTC clinic visit attendance was low at 55.2%. The majority of patients (71.6%) had at least one outpatient urgent episode (mean 0.72 episode per year), and 93% had non-urgent management (mean 9.3 episodes per year) occurring outside of a clinic visit. These data demonstrate that concerted outpatient management of patients with bleeding disorders with a quality improvement framework can reduce preventable hospitalization and ER visits. Decreased inpatient utilization resulted in substantial reductions in factor costs at the health system level. The clinical effort required to achieve these results was substantial, and required frequent provider engagement outside of regular clinic visits. The HTC can improve patient outcomes and reduce institutional costs from preventable bleeding episodes by supporting a collaborative quality improvement process led by physician, nursing, and laboratory coagulation experts.

Iatrogenic Hyperhydration in Sickle Cell Disease Patients Admitted for Acute Pain Crisis Management: A Retrospective Analysis from a Single Institution

Background: Parenteral fluids are an important component of acute pain crisis management in sickle cell disease patients. However, lack of uniform guidelines for fluid replacement coupled with underlying host comorbidities result in risk to patients from complications associated with hyperhydration. Contributing factors include inappropriate choice of fluid, rapid fluid infusion rates with prolonged time periods and inadequate monitoring of signs of hyperhydration. Complications of fluid replacement include excessive weight gain, extremity swelling, pulmonary edema and heart failure. In our study we examined the prevalence of hyperhydration in sickle cell anemia patients admitted for acute pain crisis management at our hospital. Methods: We conducted a retrospective chart review on EPIC of sickle cell anemia patients treated for acute pain crisis in the inpatient unit of John Dempsey Hospital, University of Connecticut between January 2022-December 2022, following IRB approval. To capture patients with signs and symptoms of hyperhydration and its clinical consequences, we looked at surrogate markers such as excessive weight gain during admission, signs of fluid retention, charting of patient fluid intake and output, increased oxygen use, diuretic (Lasix) administration, bronchodilator use, abnormal chest x ray findings indicative of fluid overload pattern, activation of rapid response team for patients developing acute symptoms of fluid overload, and urgent patient transfer to a higher level of care including intensive care unit. Results: 256 admitted patient charts were analyzed representing a total of 95 unique sickle cell disease patients. The median length of hospital stay (LOS) was 3 days. 168 patients had LOS from 3 to 10 days. We observed that 10.7% of the patients experienced an increase in oxygen requirements during their hospital stay. Daily weight was collected in only 27 patients (10.5%) for 3 or more days limiting its usefulness to detect subclinical hyperhydration( figure 1). 69 patients (27%) received parenteral Lasix injection for acute symptoms whose chest x rays also showed pulmonary edema or pleural effusions. 13 patients (18%) were transferred to a higher level of care that included 9 patients to step-down unit and 4 to intensive care for endotracheal intubations and ventilatory support. The median hospital stay was 4 days in patients requiring Lasix compared to 3 days in those who did not. Conclusion : Hyperhydration is undesirable complication associated with fluid administration of sickle cell anemia patients admitted with acute vaso-occlusive pain crisis. It occurs in a significant proportion of affected patients that can result in life threatening complications and prolonged hospitalization. Hyperhydration were missed in this retrospective analysis since daily weight measurements were not available in the majority of patients. Strict charting of fluid intake and output, choice of half normal saline for hydration, as well as clinical monitoring of signs and symptoms of subclinical hyperhydration will help reduce this complication and improve patient outcomes. Improving awareness of this complication among health care providers is important towards achieving this goals. Findings from this study are used to design a prospective quality improvement project in our hospital to improve outcomes and reduce hospitalization in sickle cell anemia patients admitted for acute vaso-occlusive pain crisis.

Closing the Gap: A Multidisciplinary Quality Improvement Project Improving Diagnosis and Care for Women with Undiagnosed Bleeding Disorders

Background: Research has shown that irrespective of the hemostatic challenges women face during their lives, they are less likely to be referred to a hematologist than their male counterparts and are managed primarily from a symptomatic standpoint. Women face many barriers to diagnosis including lack of provider awareness of bleeding disorders and the work-up required to make a diagnosis. Unique to menstruating women, there is overlap between many gynecologic diagnoses that can mimic a bleeding disorder; hence, leading to misdiagnosis and treatment targeted towards symptomatology as opposed to establishing a diagnosis. There also remains a major barrier for many women in the United States for diagnosis due to lack of access to care and health literacy. In Eastern North Carolina, compared to United States averages, we have high rates of uninsured, higher rates of poverty, higher patient to primary care physician ratios, and a higher rate of minority patients. Methods: We report on an ongoing, prospective quality improvement project funded by the Foundation for Women and Girls Bleeding disorders that aims to improve the identification of concurrent bleeding disorders in women presenting to the gynecology clinic with excessive vaginal bleeding. During routine gynecology patient encounters, patients are consented and screened utilizing the WHO Bleeding Assessment Tool (BAT). Women who score more than 6 on th e BAT are referred to our Bleeding Disorders Clinic for further diagnostics and evaluation by a hematologist. During the Bleeding disorders evaluation, the BAT score is repeated and specific testing to define a bleeding disorder is obtained. If patients are identified with a bleeding disorder such as Von Willebrand's disease or congenital platelet disorders, additional therapy to correct these are instituted to improve bleeding. In addition, patients who are severely iron deficient from menorrhagia are offered IV iron replacement. Results: In the first three months of this project, we have consented and screened over 70 patients in OB/GYN clinic. Twelve patients (17%) that have screened positive with a score of 6 or more. All twelve patients are being evaluated for congenital bleeding disorders. During our project, the Gynecology physicians have become more aware of patients who might be at risk and have increased their self-referral for hematology evaluation. Demographically, most of our patients came from five counties. Each of these counties has a higher rate of uninsured patients with an average of 16.6%, ranging 15-21% compared with national average of 12%. These counties also have higher rates of patient to primary care ratios than national average, minus Pitt County, a training hospital, with a combined average 1,127:1 ranging from 990:1 to 1,270:1 compared to US average 810:1. Median household Income averaged $46,040 ranging $41,200 to $50,300 with US average of $69,700. Black population made up 34.6% on average and ranging from 23% to 56% compared to national average of 12%. And rurality averaged 47.4% ranging 25.4% to 65.6% compared to national average of 19.3%. Conclusions: This project demonstrates the ability to impact the collaboration between hematology and our gynecology colleagues in identifying undiagnosed bleeding disorders. This study also addresses the disparities faced in medically underserved regions as well as those who have financial and social barriers to care. The rate of positive screening reflects a population of patients who would otherwise not undergo diagnostics at this time potentially missing patients with an untreated bleeding disorder. By better identifying bleeding disorders that complicate gynecologic bleeding, we can develop improved treatment plans to enhance the efficacy of gynecologist control of patient's symptoms. We can also improve the recognition of bleeding disorders by a group of physicians, our OB/Gyn team, who often are the primary providers for many young women in rural Eastern NC.

Utilisation of physician reminders about smoking cessation improves patient outcome

Background: Smoking is a major risk factor for cardiovascular disease and is prevalent amongst 18-64-year-olds (31.9%) in Qatar. Disease prevention through health promotion remains the cornerstone of physicians workload in primary care. Physician reminders (PR) be it electronic or physical can prompt doctors to offer smoking cessation services, hopefully reducing disease burden. The objective was to improve the identification of smokers and provision of smoking cessation services using a PR system in primary care. Methods: A prospective quality improvement project in a primary care health centre focusing on physician practices towards smokers. We analyzed physicians’ documentation post consultation looking for specific end points like use of the code “smoker” and referral rates to the smoking cessation clinic (SCC). Data was collected with and without use of a PR (used to identify smoker) and then compared for the difference in documentation and services offered. Results: The use of a physician reminder vastly improved the identification of smokers. This led to an increase in the use of the code ‘smoker’ by physicians by 43.5%. Documentation of smoking status and the provision of smoking cessation counselling both improved by 32.8%. There was an increase in referral rates (18.8%) to the SCC due to use of the physician reminder. There was a 7.9% rise in smokers attending the SCC. Conclusions: Using a physician reminder helped to improve the identification of smokers and patient provision of smoking cessation services such as referral to the SCC. Repeating the study using an electronic physician reminder incorporated within the EMR system would be beneficial given the findings from this study.

FTP4.1 Compliance With Antimicrobial Prescribing Guideline Recommendations

Abstract Aims Due to concerns regarding the quality of antimicrobial prescribing in the General Surgery department at a District General Hospital, a prospective quality improvement project was undertaken to guide local antimicrobial stewardship. To assess the compliance of the General Surgery department with local antimicrobial prescribing guidelines and policies, and recommendations in the BNF and electronic medicines compendium (EMC). The aim was to evaluate the extent of change in compliance of the General Surgery junior doctors during after intervention. Methodology Prospectively collected data on the patients admitted and started on antimicrobial agents over two 3-week periods under the General Surgery department. Educational interventions were initiated in the interval between the periods of data collection. Results 91 patients were audited in Cycle 1 with a median age of 57 (9-93) years including 36 males and 55 females. Cycle 2 involved 89 patients with a median age of 60 (9-87) with 48 males and 41 females. After intervention, there was an increase in correct prescribing regime (51.6 to 56.2%), correct dose (91.2 to 98.9%), correct frequency (59.3 to 79.8%), and correct duration; when included (78.8 to 83.3%). There was a decrease in the duration being included on the prescription (36.3 to 33.7%). The increases in correct antimicrobial dosing and correct antimicrobial frequency prescriptions were statistically significant at p ≤ 0.05. Conclusion Areas for improvement in the compliance to prescribing guidelines in the department could be influenced successfully through appropriate intervention. The audit highlighted particular areas to be targeted by education.

The Impact of Medication Synchronization on Proportion of Days Covered within the Pediatric Setting.

Poor adherence to medication regimens accounts for the substantial worsening of disease, death, and increased healthcare costs of approximately $100 billion annually in the United States. Patients participating in medication synchronization had 3.4 to 6.1 times increased odds of adherence, depending on the drug class. Abundant literature supports medication synchronization within the adult population. This IRB-exempt, prospective quality improvement project is an example of implementing and assessing medication synchronization inclusive of the pediatric setting. This study is a single-center, prospective, quality improvement project for patients seen at Nationwide Children's Hospital (NCH) Complex Care Clinic that also fill prescriptions at NCH Outpatient Pharmacies. The project assessed patient medication adherence using the Proportion of Days Covered and the number of trips to the pharmacy 90 days before and 90 days postimplementation. We also assessed patient and pharmacy staff satisfaction 3 months after project implementation. There was a statistically significant increase in the number of days covered for patients 90 days postimplementation compared to 90 days before implementation (Difference: 3.60; 95% confidence interval: 1.87, 5.33; P = 0.001). Additionally, there was a statistically significant decrease in pharmacy trips pre- and postimplementation (Difference: 2.17; 95% confidence interval: 1.26, 3.07; P < 0.001). Overall, pharmacy staff and patients reported satisfaction with the service. Implementing a medication synchronization service improved medication adherence and decreased trips to the pharmacy within the pediatric population.

National Early Warning Score Deployment in a Veterans Affairs Facility: A Quality Improvement Initiative and Analysis.

Early warning scores are algorithms designed to identify clinical deterioration. Current literature is predominantly in non-Veteran populations. Studies in Veterans are lacking. This study was a prospective quality improvement project deploying and assessing the National Early Warning Score (NEWS) at Kansas City VA Medical Center. Performance of NEWS was assessed as follows: discrimination for predicting a composite outcome of intensive care unit transfer or mortality within 24 hours via area under the receiver operating curve. A total of 4781 Veterans with 142 375 NEWS values were included. The NEWS area under the receiver operating curve for the composite outcome was 0.72 (95% CI, 0.71-0.74), indicating acceptable predictive accuracy. A NEWS of ≥7 was more likely associated with the composite outcome versus <7 (13.6% vs 0.8%; P < 0.001). This is one of the first studies to demonstrate successful deployment of NEWS in a Veteran population, with resultant important implications across the Veterans Health Administration.

Changing prescribing practice for rapid tranquillization-a quality improvement project based on the Plan-Do-Study-Act method.

It is unclear how the evidence from clinical trials best translates into complex clinical settings. The aim of this quality improvement (QI) project was to change prescribing practice for rapid tranquillization in inpatient mental health care services examining the effectiveness of the Plan-Do-Study-Act (PDSA) method. A prospective QI project was conducted to ensure that intramuscular (IM) diazepam was substituted with IM lorazepam for benzodiazepine rapid tranquillization in inpatient mental health care. We monitored the prescription and administration of medication for rapid tranquillization before (N = 371), during (N = 1130) and after (N = 364) the QI intervention. Seven iterative PDSA cycles with a multiple-component intervention approach were conducted to gradually turn the prescribing practice in the desired direction. Simultaneously, a standard monitoring regimen was introduced to ensure patient safety. Lorazepam administrations gradually replaced diazepam during the intervention period which was sustained post-intervention where lorazepam comprised 96% of benzodiazepine administrations for rapid tranquillization. The mean dose of benzodiazepine administered remained stable from pre (14.40mg diazepam equivalents) to post (14.61mg) intervention phase. Close to full compliance (> 80%) with vital signs monitoring was achieved by the end of the observation period. It was possible to increase the quality of treatment of acute agitation in a large inpatient mental health care setting using a stepwise approach based on iterative PDSA cycles and continuous data feedback. This approach might be valuable in other prescribing practice scenarios with feedback from local stakeholders and opinion leaders.

User Testing of the Veteran Delegation Tool: Qualitative Inquiry

Informal caregivers, or care partners, provide critical support to care recipients when managing health care. Veterans Health Administration (VHA) priorities identify care partners as vital in supporting veterans' care management. The Veteran Delegation Tool (VDT) is VHA's Health Insurance Portability and Accountability Act-compliant solution for care partners to comanage veterans' care through VHA's electronic health portal. Human-centered design approaches in VDT development are needed to inform enhancements aimed at promoting uptake and sustained use. The objective of this prospective descriptive quality improvement project was to use a human-centered design approach to examine VDT use perceptions and practical experiences. This project was conducted using a 4-phase approach: frame, discover, design, and deliver. The frame phase designed the protocol and prepared the VDT system for testing. This paper reports on the discover phase, which used semistructured and follow-up interviews and user testing to examine VDT's benefits, facilitators, and barriers. The discover phase data informed the design and deliver phases, which are underway. Veterans (24/54, 44%), care partners (21/54, 39%), and individuals who represented dual roles (9/54, 17%)-namely veteran care partner (4/54, 7%), veteran clinical provider (2/54, 4%), and care partner provider (3/54, 6%)-participated in semistructured interviews in the discover phase. A subsample of these participants (3/54, 6%) participated in the follow-up interviews and user testing. Analysis of the semistructured interviews indicated convergence on the respondents' perceptions of VDT's benefits, facilitators, and barriers and recommendations for improving VDT. The perceived benefits were authorized access, comanagement of care needs on the web, communication with the clinical team, access to resources, and ease of burden. Perceived barriers were nonrecognition of the benefits of VDT, technical literacy access issues, increased stress in or burden on care partners, and personal health information security. Participant experiences across 4 VDT activity domains were upgrade to My HealtheVet Premium account, registration, sign-in, and use. User testing demonstrated users' challenges to register, navigate, and use VDT. Findings informed VDT development enhancements and recommendations. Care partners need Health Insurance Portability and Accountability Act-compliant access to electronic health portals to assist with care management. VDT is VHA's solution, allowing communication among delegates, veterans, and clinical care teams. Users value VDT's potential use and benefits, while access and navigation improvements to ensure uptake and sustained use are needed. Future efforts need to iteratively evaluate the human-centered phases, design and deliver, of VDT to target audiences. Continued efforts to understand and respond to care partners' needs are warranted.

Protecting Sleep Hygiene in the PICU: A Quality Improvement Project.

To increase the number of nights without sleep interruptions for routine tasks in recovering PICU patients. Prospective quality improvement project. Single-center, free-standing, tertiary children's hospital. Patients admitted to the PICU for greater than 72 hours and eligible for early mobilization. A multidisciplinary sleep hygiene team was created to improve sleep hygiene in critically ill patients eligible for early mobilization. This team rewrote local nursing policies to avoid routine tasks between 11 pm and 5 am . The team provided periodic control chart updates to staff detailing progress made protecting sleep. Discussions of sleep hygiene were added to the daily goal sheet and a sleep hygiene order set was created. Finally, the PICU quality dashboard was modified to show whether a sleep hygiene order set was initiated in eligible patients. Routine tasks were defined as daily chest radiographs, baths, routine tracheostomy care, central line dressing changes, twice daily medications, weights, and Foley care. After a year of data collection, avoidance of routine pupillary examinations was added to the sleep protection criteria. Baseline data was collected for 2 months prior to the creation of the sleep hygiene team. Screening of eligible patients occurred 1 week each month. The data were analyzed utilizing control charts. Baseline data demonstrated 32% of PICU patients without sleep interruptions. The centerline increased to 58% after the initial interventions but dropped to 33% after inclusion of pupillary checks. Following the introduction of the daily goal sheet, sleep hygiene order set, and tracking on the quality board, 49% of patients went without interruptions. The initiation of a sleep hygiene team along with retiming routine tasks, daily discussions on rounds with the daily goal sheet, introduction of a sleep hygiene order set, and transparent tracking improved the percentage of patients with protected sleep.

Evaluation of an implementation package to deliver the COPD CARE service

Chronic obstructive pulmonary disease (COPD) is the third leading cause of death worldwide and is estimated to be the leading cause of death in the next 15 years. Patients with...

Antimicrobial stewardship, procalcitonin testing, and rapid blood-culture identification to optimize sepsis care in critically ill adult patients: A quality improvement initiative.

We examined the effect of an antimicrobial stewardship program (ASP), procalcitonin testing and rapid blood-culture identification on hospital mortality in a prospective quality improvement project in critically ill septic adults. Secondarily, we have reported antimicrobial guideline concordance, acceptance of ASP interventions, and antimicrobial and health-resource utilization.

Implementation of Frailty Assessment Improves Veterans Affairs Surgical Quality Improvement Program Risk Assessment in General and Vascular Surgery Patients

INTRODUCTION: Frailty has been recognized as an important factor in preoperative risk evaluation. The Veterans Affairs Surgical Quality Improvement Program (VASQIP) Surgical Risk Calculator, derived from chart elements, predicts surgical risk and incorporates many factors now recognized as markers of frailty. We examined the impact on VASQIP Surgical Risk prediction after implementation of a robust frailty assessment. METHODS: A prospective frailty assessment quality improvement project was implemented in general surgery (GenS) and vascular surgery (VascS) for new and preoperative VA patients starting October 2020. We examined the effectiveness of this assessment by comparing VASQIP Surgical Risk prediction with and without use of frailty assessment data. For comparison purposes, 3 operative case complexity groups were identified. RESULTS: A total of 205 patients were screened: 145 (71%) GenS and 60 (29%) VascS. Frailty screening identified issues not captured on routine surgical assessment in 77 (38%) patients; 20 (26%) of these patients were less than 65 years of age. The most common frailty factors captured include cognitive impairment (46% GenS, 47% VascS), dyspnea (19% GenS, 20% VascS), and impaired functional status (14% GenS, 13% VascS). Frailty identification increased VASQIP risk prediction with significant differences post–frailty assessment (p < 0.005; Table 1). Risk of 30-day surgical site infection, ICU admission, and postoperative admission also increased: 1% to 1.2%, 23% to 27.4%, and 72% to 79%, respectively (p < 0.001). Increasing case complexity was associated with higher score differences (p < 0.0001; Table 1). Table 1. - VASQIP Surgical Risk Score Comparison Variable 30-d mortality risk: pre-/postscreen * 180-d mortality risk: pre-/postscreen * 30-d morbidity risk: pre-/postscreen * p Value † Entire group 0.24%/0.31% 1.03%/1.17% 3.55%/3.84% <0.0001 Cases with differences 0.33%/0.61% 1.27%/2.21% 4.18%/4.77% <0.0001 Low case complexity 0.13%/0.15% 0.53%/0.66%‡ 1.78%/1.78%‡ <0.005‡ Moderate case complexity 0.17%/0.20% 0.85%/1.14% 2.14%/2.62% <0.0001 High case complexity 0.30%/0.38% 1.11%/1.42% 4.8%/6.14% <0.0001 Vascular surgery 0.51%/0.62% 1.20%/1.52% 4.24%/4.29% <0.005 General surgery 0.14%/0.18% 0.71%/1.01% 2.80%/3.48% <0.0001 *Median risk percentage displayed. Risk scores calculated with VASQIP Surgical Risk Calculator.†Wilcoxon Signed Ranks Test performed.‡Only 30-day mortality is <0.005; 180-day morality and 30-day morbidity differences were not statistically significant. CONCLUSION: Implementation of frailty assessment, in general, and vascular surgery patients significantly improves VASQIP Surgical Risk prediction. These findings emphasize the prevalence of frailty and the importance of presurgical frailty assessment for both geriatric and nongeriatric patients.

Real-time detection of neonatal seizures improves with on demand EEG interpretation

ObjectiveUnder- and overtreatment of seizures may result in adverse outcomes; thus, early, reliable seizure identification is crucial. Continuous conventional ElectroEncephaloGram (cEEG) is the gold standard, but amplitude integrated EEG (aEEG) is most widely-used in the Neonatal Intensive Care Unit (NICU). We aimed to determine whether a novel pathway combining cEEG and aEEG for seizure detection would improve real-time seizure identification. MethodsA single-center, prospective quality improvement project cohort. Patients at-risk of seizures were monitored by cEEG and aEEG concurrently, with the option for the neonatologist to contact a neurologist for real-time cEEG interpretation. The primary outcome was correct identification of seizures by the new combined pathway compared to aEEG alone. ResultsSeizure detection using aEEG had a sensitivity of 46.2%; specificity of 93.3%; PPV of 66.7%; and NPV of 85.7%. Utilizing the new on-demand, real-time cEEG interpretation by a neurologist, correct seizure identification increased by 27% (95%CI: 10–56%). Over-diagnosis of seizures was avoided in 33.3% (95% CI: 12.1–64.6%) and misuse of anti-seizure medication was prevented. ConclusionsCombining aEEG with on-demand cEEG interpretation improved accurate seizure detection in a high-risk NICU population, with the potential to avoid over-treatment. SignificanceWe describe a novel combined EEG monitoring pathway to improve seizure detection, and prevent unnecessary treatment.

Impact of laparoscopic surgical algorithm to triage timing of tumor reductive surgery on overall survival in newly diagnosed advanced ovarian cancer (548)

<b>Objectives:</b> To estimate the effects of implementing a laparoscopic scoring algorithm to triage timing of tumor reductive surgery (TRS) in patients with newly diagnosed advanced-stage ovarian cancer on overall survival. <b>Methods:</b> In April 2013, we initiated a prospective quality improvement project utilizing laparoscopic scoring assessment to determine primary resectability in patients with newly diagnosed advanced- stage ovarian cancer in order to improve complete gross resection rates (R0). Current data were analyzed through March 2021. Patients who were medically inoperable or had distant metastatic disease did not undergo laparoscopic assessment and received neoadjuvant chemotherapy (NACT). A validated scoring method was used, and patients with predictive index value (PIV) > 10 received NACT, and those with PIV < 10 were offered primary TRS (algorithm updated from PIV <8 on March 1, 2018). Univariate and multivariate analysis was performed for effects of overall survival (OS). <b>Results:</b> A total of 1,124 patients were included in our analysis; the median follow-up was 28 months (1-96 months). Three hundred forty-five patients (31%) underwent laparoscopic scoring assessment, of which 206 patients (59%) had PIV <10, 112 patients (32%) had PIV > 10, 10 patients (3%) were unscorable, and 17 patients (5%) had an outside laparoscopic assessment with score unknown. Six hundred sixty-four (59%) patients were triaged directly to NACT without laparoscopic assessment. Patients triaged to primary TRS had a lower median CA-125 (404 vs 647 U/mL, p<0.001) and lower median platelet count at diagnosis (312 vs 365, p<0.001) compared to those triaged to NACT by laparoscopy. There was no difference in complete gross resection rates (R0) between those patients triaged to primary TRS versus NACT (84% vs 75%, p=0.32); however, 13% of patients triaged to NACT (p<0.001) were not candidates for interval TRS due to either stable disease (4%) or death (6%). Patients who underwent primary TRS had a significantly longer OS (85.4 months) compared to those who underwent NACT following laparoscopy (36.6 months) or were triaged to NACT and not candidates for laparoscopic assessment (38.5 months, p<0.001). Age (p<0.001), advanced stage (p<0.001), Charlson comorbidity index (p<0.001), platelet count at diagnosis (p=0.001), germline <i>BRCA</i> mutation status (p<0.001), and complete gross resection at TRS (<0.001) were factors significantly associated with OS in our patient population. <b>Conclusions:</b> Implementation of laparoscopic scoring triage in patients with newly diagnosed advanced-stage ovarian patients resulted in high complete gross resection rates at TRS and appropriately triaged select patients to primary TRS who had significantly longer OS. Laparoscopic scoring assessment is a valuable tool to incorporate into surgical practice in advanced ovarian cancer.