QI Project Research Articles

DOES AGE, RACE, AND/OR RURALITY DETERMINE OLDER VETERANS' ABILITY TO ACCESS VA VIDEO CONNECT

Abstract The purpose of this project was to determine whether ability to use VA Video Connect (VVC) by older Veterans (OV) differed by age, race, or rurality. A service to help older Veterans learn to use VVC was developed. As part of an ongoing QI project, demographics, willingness to attempt a VVC test call and outcomes of test calls were collected on all referrals. Descriptive statistics, Chi-square, and Fisher’s exact test were used to examine differences in success rates by group. Of the 66 OV (age 60+) referred by their primary care providers, we were able to contact 63 by phone. Of those, 46 (73%) scheduled a VVC test call, 7 (11%) chose not to participate, and 10 (16%) were already using VVC for appointments. Of the 40 who continued the VVC test call, 31 (77.5%) were successful without issues, 7 (17.5%) were successful with help resolving issues, and 2 (5%) disconnected before finishing the call because it became too difficult. Of the 63 OV contacted, 38 (57.5%) had a successful VVC test call. However, those residing in rural (vs. urban) settings were less likely to have a successful test call (43% vs. 57%, p=0.04). There was no statistically significant difference in success rates for the test calls between whites vs. non-whites (52% vs. 48%, p= 0.2), or those aged 75 years or above vs. 60-74 years (53% vs. 46%, p=0.6). More work is needed to identify barriers to use of VVC, especially among OV living in rural settings.

696: FACTORS ASSOCIATED WITH SUCCESSFUL ERT IN CHILDREN WITH CONGENITAL HEART DISEASE

Introduction: In children with congenital heart disease, extubation readiness testing (ERT) is performed to evaluate mechanical ventilation liberation potential. There are minimal data suggesting what mechanical ventilation parameters are associated with successful ERT. We hypothesized that ERT success would be associated with mechanical ventilator parameters. Methods: Data on daily ERT assessments were recorded as part of an IRB approved QI project. As part of our RT-driven ventilator protocol, patients are assessed daily for ERT eligibility and tested daily, if eligible. Mechanical ventilation parameters were categorized a priori to evaluate differences in ventilator settings. The primary outcome was ERT success. ERT outcome was compared using the chi-square and Mann-Whitney test. Categorical data are reported as n (%), continuous data as median (interquartile range). Logistic regression was performed to evaluate factors associated with successful ERT and reported as odds ratio (OR). Results: We evaluated 780 ERTs from 320 subjects [median age 2.5 (0.6-6.5) months, 4.2 (3.3-6.9) kg]. 528 (68%) of ERTs were passed, 306 (58%) subjects were extubated after successful ERT and 30 (9.4%) were reintubated. There were significantly differences in ERT pass rate for ventilator mode (65% SIMV, 81% pressure support, 53% assist/control), PIP [17 (15-19) vs 19 (17-22) cmH2O], Δ pressure [12 (10-14) vs 14 (12-15) cmH2O], PEEP [5 (5-6) vs 6 (5-6) cmH2O], MAP [9 (8-10) vs 10 (9-11) cmH2O], and VD/VT [0.35 (0.28-0.42) vs 0.40 (0.33-0.46)] (all p< 0.001], but not for FiO2 [0.30 (0.21-0.40) vs 0.30 (0.23-0.35), p=0.14]. ERT success decreased with increases in PIP (87% ≤ 15 cmH2O, 66% 16-20 cmH2O, 50% 21-25 cmH2O, 27% 26-29 cmH2O), Δ pressure (85% ≤ 10 cmH2O, 63% 11-15 cmH2O, 51% 16-19 cmH2O, 22% ≥ 20 cmH2O), PEEP (73% ≤ 5 cmH2O, 63% 6 cmH2O, 42% 7 cmH2O), MAP (81% ≤ 8 cmH2O, 67% 9-10 cmH2O, 40% > 10 cmH2O, and VD/VT (75% < 0.30, 68% 0.31-0.40, 62% 0.41-0.50, 46% >0.50). Logistic regression revealed neonates, Δ pressure ≥11 cmH2O, and MAP > 10 cmH2O were associated with a decreased odds of ERT success while children aged 1-5 and an FiO2 0.31-0.40 had increased odds of ERT success. Conclusions: ERT pass rates decreased as ventilator support increased; however, some subjects passed ERT despite high ventilator support.

200. The Utility of a Rapid Multiplex PCR Assay in the Management of Staphylococcus Aureus Bacteremia at a Tertiary Care Center

Abstract Background Staphylococcus aureus bacteremia (SAB) is a major cause of community and healthcare-acquired bacteremia and is associated with a high burden of morbidity and mortality. Appropriately tailoring management based on methicillin sensitivity can help minimize unnecessary administration of broad-spectrum antibiotics and ensure adequate treatment of MSSA/MRSA. The Verigene® (Luminex Corporation) is a multiplex PCR assay that provides rapid identification of bloodstream pathogens. We performed a QI project to determine the utility of this assay in managing patients with SAB. Methods We performed a single-center retrospective cohort study of positive SAB cultures from May 2020 to May 2021. Electronic health record review was conducted to abstract patient demographics, clinical characteristics, outcomes, blood culture data, and antibiotic management. Statistical analysis was done with the unpaired t-test and fishers exact test to identify associations of statistical significance. Results We identified 97 cases of SAB: 66% MSSA (n = 64), 34% MRSA (n = 33). Patient characteristics included: mean age 61 years, 58.8% male, 42% immunocompromised, 83.5% with ID consult, 38.1% with ICU admission, mean length of stay 20.3d, and 24.7% mortality. Using the Verigene® assay, we noted 2.6% discordance with standard microbiological technique (n = 2). The timing of Verigene® results and provider response were as follows: The mean duration of SAB was 3.1d (MSSA = 2.8d, MRSA = 3.6d, p = 0.2477). There was a statistically significant difference in patient mortality with respect to methicillin sensitivity status: MSSA 15.6%, MRSA 42.4%, p = 0.0075, as well as mortality with ID consult 19.8% versus no ID consult 50%, p = 0.0223. Conclusion Despite the incorporation of a rapid multiplex PCR assay to detect bloodstream infections, the time to de-escalation for MSSA was sub-optimal (2.7 days). ID consultation continues to be an important component of SAB management as it improves patient outcomes and contributes to education of healthcare providers. Disclosures Lan Duong, PharmD, Johnson &amp; Johnson: Stocks/Bonds|Lilly USA: Stocks/Bonds|Novavax: Stocks/Bonds Princy N. Kumar, MD, American Gene Technologies: Grant/Research Support|BioHaven: Grant/Research Support|Eli Lilly: Grant/Research Support|Gilead: Advisor/Consultant|Gilead: Grant/Research Support|Gilead: Stocks/Bonds|GSK: Grant/Research Support|GSK: Stocks/Bonds|Johnson&amp;Johnson: Advisor/Consultant|Johnson&amp;Johnson: Stocks/Bonds|Merck: Advisor/Consultant|Merck: Grant/Research Support|Merck: Stocks/Bonds|Moderna: Stocks/Bonds|Pfizer: Stocks/Bonds|Regeneron: Grant/Research Support|TheraTechnologies: Grant/Research Support|ViiV: Advisor/Consultant Joseph G. Timpone, Jr., MD, Gilead: Stocks/Bonds|Merck: Stocks/Bonds.

Documentation of Just in Case (JiC) medication for end of life patients in care homes looked after by a general practice.

This project was undertaken to improve the documentation of Just in Case (JiC) medication in a general practice. The outcome of a Strengths, Weaknesses, Opportunities, Threats (SWOT) analysis highlighted this as an area where awareness within the practice could be improved. A Plan-Do-Study-Act (PDSA) approach was taken to the project and involved collaborative working and data collection from the general practice and relevant care homes. JiC medications are used to promptly manage symptoms experienced at the end of a patient's life and are part of the Gold Standard Framework (2006). Of the patients registered at the practice with JiC medication, 37.5% were incorrectly documented. This included errors/ inaccuracy with the clinical coding, orthe medication. Three patients on practice generated searches had no JiC medication in the care homes, and 4 patients had JiC boxes in the care home that was not identified by the search. This evaluation has identified documentation errors and discrepancies between practice and community records of JiC medication. A newly generated practice specific flowchart was created, with an aim of reducing the discrepancies. A guide of how to carry out a QI project like this was created for the RCGP and can be found on their website. A seminar at Bristol, North Somerset, and South Gloucestershire (BNSSG) CCG to present this project took place in 2021.

3. Spotting the [LDQUO]Red Flags[RDQUO] – Improving GMPs’ Confidence and Knowledge in Identifying Suspected Oral Cancer

Each month, Western Health and Social Care Trust (WHSCT) receives an average of 15 suspected oral cancer referrals from GMPs. These patients attend with heightened levels of anxiety regarding their suspected diagnosis. Many of these referrals turn out to be non-suspicious. A QI project was proposed to evaluate the knowledge of GMPs in the Western Trust and to monitor the quality of referrals of suspected oral cancer.

Effect of Optimizing Oxygen Saturation Targets on the Incidence of Retinopathy of Prematurity in a Quaternary NICU

Introduction: Retinopathy of prematurity (ROP) is a multifactorial disease and a preventable cause of blindness in childhood. Hyperoxia and hypoxia can cause retinal neovascularization resulting in retinal detachment and blindness if left untreated. Besides oxygen treatment, other reasons for ROP development are well known. We prospectively adopt various strategies to keep oxygen saturation (SpO₂) within targets^, between 91 and 95% for those on supplemental oxygen. By adapting this, we postulated that the incidence of severe ROP might be reduced. Methods: 2018–2019 provided pre-intervention and 2020 post-intervention data for the project. For all babies (≤32 weeks, ≤1,500 g with FiO₂ >0.21), target SpO₂ between 91 and 95% was measured as a percentage of time spent within and outside target SpO₂ during 1–4 weeks of life. Results: 112 and 60 preterm neonates were screened for ROP during the pre- and post-intervention phase. Twenty neonates (18.3%) during pre-intervention and 16 (26.7%) in the post-intervention phase developed severe ROP requiring treatment. Despite a statistically significant increase of 10 percent points in time spent within target SpO₂ (91–95%) in the post-intervention phase (p < 0.05), the incidence of severe ROP did not decline. Using a multivariate model, odds of ROP development decreased with gestational age (25%) while increasing with PDA requiring treatment (4.33 times) and glucose ≥10 mg/dL (4.15 times), considering one variable at a time, keeping others constant. Conclusion: Our QI project showed successful attainment of maximum time; the SpO₂ remained within targets during supplemental oxygen; however, the incidence of severe ROP had not declined. Factors other than SpO₂ might be responsible for a high incidence of ROP in our neonatal intensive care unit.

(143) A QI Project: Transforming Management of Agitation in the Medically Hospitalized Patient Through Resident Education

(143) A QI Project: Transforming Management of Agitation in the Medically Hospitalized Patient Through Resident Education

IMPROVEMENT IN BIRTHING EXPERIENCE FOLLOWING CHANGE IN EPISIOTOMY PRACTICES AT TEACHING HOSPITAL IN INDIA

Background:- Episiotomy or perineotomy is a minor surgical procedure performed in labour room to facilitate delivery of the baby and to prevent injury to perineum. The analysis of the labour room statistics revealed that the rate of episiotomy was extremely high (87%).The episiotomy wound related complications resulted in extended hospital stay and unsatisfactory birthing experience among the delivered women. Methodology:- Different methods of root cause analysis like Fish bone analysis and Five Why method were used at Pravara Rural hospital,Loni a tertiary care hospital. Necessary educational programmes were implemented and policy decisions regarding indications of episiotomy were made. Regular monitoring and analysis was done to sustain the results. Results:-The historical data of three months before project implementation revealed that the rate of episiotomy was 87.00% among 1691 deliveries conducted. The reduction in rate of episiotomy was predominantly observed in multipara. At the end of eight weeks of QI project, the rate of episiotomy in primipara and multipara was 70.20 % and 20.00% respectively. The overall incidence of surgical site infection (SSI) in the obstetric unit decreased from 3.2 percent to 2.5 percent. Conclusion:- Implementation of quality improvement project helped in significant reduction in the rate of episiotomy. It indirectly helped in reduction of episiotomy related complications and hospital stay.

DESIGN AND EVALUATION OF DELIRIUM MANAGEMENT GUIDELINES IN A TERTIARY CARE GENERAL HOSPITAL: A QUALITY IMPROVEMENT PROJECT

Delirium Management Guidelines in a General Hospital: QI project for Design and Evaluation

Improving plan-of-care visit completion.

288 Background: Plan of Care Visits (POCV) facilitate communicating daily plan of care among providers, nursing, and patients and their families together at the bedside. This discussion standardizes how patients and caregivers collaboratively develop treatment plans that provide the highest quality of care. Daily Plan of Care Visit Completion is expected to improve patient experience with regards to provider effectiveness and interaction. Improved opportunities for understanding, communication, and patient care planning amongst patients, patient family members, and caregivers are a function of Plan of Care Visits. The documented completion of daily POCV in 2020 on the inpatient solid oncology unit was 42% compared to an expected target of 80%. Methods: Team utilized A3 thinking and tools including process mapping, trips to gemba, brainstorming, 5 Whys and fishbone to determine which Potential Root Causes drove failure to complete POCV. Results: Team identified multiple root causes including: Lack of awareness amongst providers that POCV needs to be completed Lack of provider understanding of how to complete a POCV Inconsistent notification of the nurse and staff of when POCV are occurring. Providers unaware of the results of their POCV documentation completion rate Physician attestation templates do not include an option for proper POCV documentation. By implementing retraining and standard procedures for handoff and setting expectations at the start of each change of provider, the team was able increase POCV completion. The subsequent development of a routine to notify staff of their performance daily (and later weekly), and the integration of the POCV completion documentation option into their attestation enhanced completion from 42% in 2020 to 74% in 2021 to 85% in 2022. Conclusions: Following our QI project, POCV completion exceeded the original enterprise target of 55% and revised target of 80%. Improvement in POCV has been sustained for over a year. POCV completion led to improved communication between physicians and nurses on the inpatient unit. The standardization of the process led to consistent completion and improved interaction with the patient. The interdisciplinary care and team were a large contributor to the success of this process.

S1438 Incidence and Early Detection of Patients With Nonalcoholic Fatty Liver Disease: A QI Project

Introduction: Non-Alcoholic Fatty liver disease (NAFLD) is under-recognized in Primary care clinics. Early diagnosis in Primary care clinics is essential to help understand the magnitude of the burden and initiate measures to prevent its silent progression. With the rising incidence of NAFLD, it will soon become a major health care burden in the future. We aim to establish a screening algorithm for early detection of NAFLD and educate patients on primary preventive measures to avoid the development of cirrhosis from fatty liver. Methods: We created an algorithm that was tested in a cohort of patients recruited from the primary care center. Inclusion criteria: Presence of established Type two diabetes Mellitus (T2DM),Components of metabolic syndrome like BMI >27, CAD and dyslipidemia etc, Elevated Liver Enzymes or history of fatty liver by any imaging modality. Exclusion criteria : Alcoholics, known liver disease from other causes. Clinical and demographic data collected were age, sex, BMI, comorbidities, and lab results to calculate Fibrosis-4 and AST to Platelet Ratio Index (APRI) Scores. Patients with FIB-4 score greater than 1.45 and APRI score greater than 0.7 were instructed to get Fibroscan. Results: Between August 2020 and October 2021, 203 patients were screened in the primary care clinic for NAFLD. A total of 51 patients met the inclusion and exclusion criteria. A total of 7 people (13%) had insufficient data. The median age in our study was 60 years. In terms of comorbidities, 52 % had T2DM, 77 % had hypertension, 52 % had hyperlipidemia, and the median for the BMI over 30.9. 9% had APRI score between 0.7 and 0.99, and 16% had an APRI score of > 1. 34% of our patients had their FIB-4 index between 1.45 and 3.25 and the remaining 16% had a FIB-4 index more than 3.25. A total of 26 patients had a Fibroscan to determine the stage. The Kpa ranges between 5.3-7.2 and the CPA ranges between 246 and 361 dB/m. Patients with high APRI and FIB-4 score and abnormal fibroscan results are referred to Liver clinic for further management. (Figure) Conclusion: This study demonstrates that a stepwise prospective application of an algorithm using inclusion and exclusion criteria in clinical practice settings can lead to the early identification of patients with NAFLD. Increasing awareness among health care providers to implement screening strategies in Clinics is necessary. Further studies on implementation in larger size populations are needed along with education and long-term management of these patients. (Table)Figure 1.: Algorithm followed for the study Table 1. - Demographic and Clinical data of the study Demographics Total Patients (44) Male, N (%) 22 (50) Age, (Median, IQR) 60, (54.5- 68) BMI, Median (IQR) 30.9, (27.97- 35.08) Comorbidities Hypertension N, (%) 34, (77) Diabetes N, (%) 23, (52) Dyslipidemia N, (%) 23, (52) Laboratory Parameters Aspartate Aminotransferase- U/L, (Median, IQR) 28 (19- 37) Alanine Aminotransferase- U/L, (Median, IQR) 27 (21- 44) Fibrosis Lab assessment FIB4 %(< 1.45, 1.45- 3.25, >3.25) 50, 34,16 APRI % (< 0.7, 0.7- 0.99, >1) 75, 9, 16 Non-Invasive imagingLiver Elastography (Range) 5.3- 7.2 kPa. 247- 361 CAP score (dB/m)

Improving the breast MRI process: A longitudinal QI project at the Houston VA.

371 Background: The number of female veterans is increasing by more than 18,000 per year, and 700 veterans enrolled in VA healthcare are diagnosed with breast cancer each year. The American Cancer Society recommends screening MRI in women with 20-25% or greater lifetime risk of breast cancer, and primary care physicians and oncologists order breast MRIs regularly. The Michael E. DeBakey Veteran’s Affairs Medical Center (MEDVAMC) performs mammograms and ultrasounds on site, but breast MRI is not currently available. Care in the Community arranges for veterans to obtain these studies at outside facilities. This is a complex process, requiring coordination among multiple departments at the MEDVAMC, outside MRI facilities, and patients. Methods: We created a comprehensive process map for the current breast MRI ordering process to determine areas for improvement. We reviewed all breast MRI orders from 1/2019 to 5/2021 at the MEDVAMC and determined the cancellation rate and the rate of benign (BIRADS 1-2) vs non benign (BIRADS 0, 3-5) screening outcomes. We created a Pareto analysis of cancellation reasons. Our process measures were percentage of placed breast MRI orders that were cancelled and delay from MRI order to MRI performed. Our outcome measures were percentage of order cancellations due to incorrect or incomplete orders and delay from MRI order placement to results uploaded. Results: Of the 434 orders that were placed for breast MRIs, 64% were cancelled. Only 117 of the 167 patients that had MRIs ordered ultimately received one. Of the 104 patients without known malignancy who competed an MRI, 45% had non-benign findings requiring follow-up. Our pareto analysis showed that the top cancellation reason was incorrect orders, usually contrast or side verbiage. In June 2021, the CITC order set for MRI was changed from a free text box to discrete, clickable options for side and contrast. In December 2021, we held educational interventions on how to avoid delay or cancellation. Our p-chart of percentage of cancellations due to incorrect ordering shows an extremely promising decrease, with the last seven consecutive subgroups of 15 patients below the mean. The order cancellation percentage is also decreasing. The average delay pre-intervention from MRI order placement to results uploaded was 67 days. In January 2022, we implemented a breast MRI nurse navigator to help acquire results and expedite scheduling. Post-intervention, the average delay has decreased to 38.5 days. Using XmR and S charts, we have also shown an increase in precision. Conclusions: Providing discrete, clickable options within the MRI order set reduced the number of cancellations due to incorrect verbiage. Early data suggests that the educational intervention improved the cancellation rate. Instituting a nurse navigator decreased both the delay and variability for the time from order placement to results received, which will reduce the delay to follow-up of non-benign findings.

S56 Perfusing the Pancreas: A Quality Improvement Project to Optimize Pancreatitis Management in a Tertiary Academic Center

Introduction: Acute pancreatitis (AP) is one of the leading gastrointestinal (GI) causes of hospitalization. Numerous studies have addressed the role of early fluid resuscitation and nutrition initiation in reducing the morbidity and length of stay associated with AP. Multiple GI societies have developed guidelines on the optimal management of AP. At our institution, we observed variations in the management of AP from current guidelines. We aim to identify the trends in the management of AP and the barriers to guideline adherence. We plan to use this data to enact systematic interventions that improve adherence to guideline recommendations. Methods: We evaluated all patients hospitalized with a diagnosis of acute or acute-on-chronic pancreatitis (ACP) from September to December 2021. Pre-intervention data on fluid resuscitation and initiation of oral diet/enteral feeding were collected. A survey was also developed and sent to hospital medicine and teaching teams to identify potential barriers. A Pareto chart showed that knowledge was not the primary barrier. Rather, there were clinical concerns that aggressive fluid resuscitation and early nutrition initiation could lead to potential complications of volume overload and worsening pancreatitis severity. Results: We reviewed data for 74 patients admitted with a diagnosis of AP or ACP. 93% of patients received intravenous fluids (IVF) within the first 24 hours, but only 8.5% received the recommended resuscitation rate of at least 250 cc/hr. With regards to nutrition, 46% of patients admitted with AP received oral/enteral nutrition within the first 24 hours. A Pareto chart of these responses identified that the biggest barriers to aggressive IVF resuscitation were concern for volume overload and patient co-morbidities, such as congestive heart failure and chronic kidney disease. A subsequent secondary analysis showed that the concern for CHF and CKD may not be valid, as 81% of patients admitted for AP did not have these co-morbidities. For early nutrition, the biggest barriers were concern for clinical worsening and PO intolerance. Conclusion: Our QI project aims to optimize pancreatitis management at our institution by improving adherence to early fluid resuscitation and oral/enteral nutrition initiation. A pro forma is in development to standardize management and will be distributed to clinical staff. Post-intervention data will be collected to assess for improvement.

S311 Following Through on Positive Fecal Immunochemical Testing via FIT Navigation and a Direct-to-Colonoscopy Pathway: Preparing for the Next Wave

S311 Following Through on Positive Fecal Immunochemical Testing via FIT Navigation and a Direct-to-Colonoscopy Pathway: Preparing for the Next Wave

DON’T DIVIDE THE DOSE: ONCE DAILY (QD) AND TWICE DAILY (BID) EARLY CYCLE GONADOTROPIN (GND) DOSING HAVE EQUIVALENT ASSISTED REPRODUCTIVE TECHNOLOGY (ART) OUTCOMES– A QUALITY IMPROVEMENT (QI) PROJECT

For more than 25 years, our academic fertility center has prescribed GNDs BID between cycle start and the next monitoring visit 2-5 days later, when QD dosing is initiated. However, BID dosing is more complicated, leads to more medication errors and is less preferred by patients1. Studies evaluating the impact of GND timing on ART outcomes are limited and outdated2-4. Thus, we performed a QI project to assess whether changing early GND dosing to QD impacted ART outcomes.

Optimizing the patient handoff and progress note documentation efficiency in the EPIC EMR system within a neurosurgery residency: A quality improvement initiative

BackgroundHandoffs and documentation are a potentially modifiable source of medical error. However, little attention has been given toenhancementof these within the neurosurgical field. We aim to increase efficiency and accuracy of neurosurgical handoffs, including the neurological exam, thus decreasing medical documentation time within current duty-hour restrictions. MethodsThe existing Epic electronic medical record system was modified to include the neurological exam in the handoff: a tool used to generate lists including relevant patient clinical details and plans. The handoff tool was also converted into a subjective, objective, assessment, and plan (SOAP) format, which was leveraged to efficiently generate daily progress notes. A four-question survey was developed to assess the effectiveness of this new format. Mean note times were compared before and after the EPIC update using an independent samples t-test. ResultsAll of the surveyed neurosurgery residents at our institution reported a decrease in documentation time per progress note, felt the notes were more accurate, and found it easier to recall the neurological exams of patients. 8/9 residents felt that the new handoff made in-house call less stressful. There was a significant difference in mean note time, with the mean note time of 37.9 s after the EPIC upgrade compared to 120 s prior the upgrade. We project that over 241 h of documentation will be saved annually at our institution. ConclusionsThis QI project demonstrates how a low-effort initiative improved resident recall of patients’ neurological exams while saving time spent documenting daily progress notes.

P11.29: Improving Tissue Donation Referral Rates From the Emergency Department - A QI Project

Background: This project was undertaken by a Junior Dr a hospital Emergency Department (ED) in Scotland. The aim was to increase tissue donation referral rates for deceased patients, by referring at least 50% of potential donors. Eligbale potential donors were those who did not have dementia, haematological malignancy or blood borne virus. The number of potential donor deaths monthly was around 7, making tissue referrals a low frequency but high acuity event. It was a small project but so successful that the materials developed were rolled out Nationally. Method: Using the Plan Do Study Act approach, multiple departmental interventions were undertaken. These included surveying staff to identify barriers to tissue donation; focused teaching moments; posters to prompt staff in key clinical areas; development of a clear process algorithm, pocket sized laminated Tissue Donation Information cards for staff, as well as a suggested “script” to raise donation with families, and regular progress updates on referral rates both written and verbal. The Potential Donor Audit data was collected monthly from August 2017 until June 2019 by the Tissue Donor Co-ordinator on all deaths and referrals from the department. Prior to this there had been no referrals made. Before approaching families to discuss tissue donation the Tissue Donor Co-ordinator should be contacted to check the Organ Donor Register and confirm eligibility for donation. This is considered as a ‘referral’ for audit purposes irrespective of whether donation proceeds. Results: □The aim of referring 50% of eligible potential tissue donors to the tissue donor co-ordinator was achieved during the data collection period (average 55%). □The project commenced in August 2017 and data was collected until June 2019. □The interventions implemented are outlined in the table and correspond to the arrows on the chart. □Anecdotal feedback from staff involved has demonstrated many families took comfort from donation and staff felt more comfortable approaching families using the suggested wording. □In total, 2 hearts (for valve donation) and 26 eyes (for corneal donation) were donated by patients. Two further hearts were accepted for donation but unable to be retrieved due to operational reasons. Conclusion: This project resulted in significant improvement in referral rates. The cumulative effects of the interventions are most likely to have resulted in the improvement. Anecdotally staff fed back that the process flow chart and the pocket information cards have been the most helpful interventions in their day to day practice. The methods used in this Quality Improvement Project could readily be applied in other ED’s who are introducing tissue donation or looking to improve referral rates. During 2021 the prompt cards developed were disseminated Nationally to ED’s and Intensive Care Units in Scotland who are able to facilitate Tissue Donation.

366 Using a Serious Incident and Methods from High Reliability Organisations to Make Communications Safer Between A&amp;E and Surgery

Abstract Aim Healthcare is a high-risk environment and for patients’ safety, requires high reliability. Poor communication is one of the leading causes of healthcare error worldwide and was one of the reasons that led to an adverse event in A&amp;E. High Reliability Organisations (HROs) have set in place effective standards of safety where the probability of serious errors is very low. What translatable features can make the job of a Junior Surgical Doctor receiving patients from A&amp;E safer? Method The root cause analysis of the serious incidence was discussed in a Surgical Morbidly and Mortality meeting. Focus groups and observational studies were carried out over a period of 6 months. The results formed the basis of a Task Analysis. A literature review of the evidence of safe communication method was performed and its translatability to healthcare. Results A “work as done” against “work as imagined” task analysis of the handover process showed multiple areas of potential “work system” error with references to the SEIPS 101 model. Combining the literature review and task analysis, standardisation (using SBAR), a handover checklist, read-back, dual-modality communication and a handover zone may prove to increase redundancy and slack in the system – making it safer. Conclusions There are HRO evidenced methods in making communication safer in healthcare. The aviation industries “sterile cockpit” and “crew management resource” methods are proven and effective. Their use of the above techniques can be implemented in healthcare communication. A designated “Handover Zone” could address potential errors. A QI project is required hereafter.

478 Enhancing Technology Interface in the Dissection Room (DR)

Abstract Aim Anatomy teaching increasingly utilises technology alongside dissection to improve anatomy teaching. Student use of the touchscreen computers in dissection sessions at the University of St. Andrews was infrequent, with students lacking confidence in touchscreen use. The aim of this QI project was to improve medical student confidence and increase the use of touchscreen computers in the DR during dissection sessions. Method A data-collection tool was designed and tested. It included 4 Likert-style and one blank space question. 111 baseline responses from 3rd-year medical students were collected over 1 week in November 2021. Documentation was optimised for touchscreen usage. Cycle 2 was collected from the same cohort, with 83 responses. The second intervention introduced styluses. Cycle 3, with 85 responses, was collected. Results Question 1 examined awareness of touchscreen function. Positive responses (agree and strongly agree) increased from 76.5% to 95.2%, then 97.7% after interventions 1 and 2 respectively. Positive responses for question 2, examining confidence, improved from 53.2% to 88.0%, then 96.5%. Positive responses to question 3, examining the frequency of touchscreen use, improved from 49.6% to 91.6% then 92.9%. Positive responses for question 4, examining how useful touchscreens were for student learning, improved from 70.3% to 94.0%, then 97.7%. Blank space questions demonstrated positive opinions of changes made in the dissection room. Conclusions The significant and sustained increase in positive responses regarding student confidence, touchscreen use and the usefulness of touchscreens as an adjunct to dissection in the DR demonstrated significant improvement in the use of the facilities and student educational experience.

839 Improving Oxygen Prescribing on Kardex in Ward Level Care

Abstract Aim The aim of the QIP was to raise awareness about the importance of oxygen prescription amongst healthcare staff and improve the oxygen prescription rate on Kardex by 50% in 3 weeks at both surgical and medical wards. Background Oxygen is considered a type of drug and should be prescribed on the Kardex. The administration of inappropriate oxygen concentration can have fatal consequences such as prolonged hypoxaemia or hyperoxia. Therefore, it is good practice to prescribe oxygen on the Kardex. Method Data was collected from 25 patients from surgical and medical wards once weekly. 3 plan-do-study-act (PDSA) interventions were undertaken. Source of information were the Kardex, NEWS observation chart, direct observation of oxygen delivery at patient's bedside and ward round documentation. The reason both surgical and medical wards were selected was to showcase just how prevalent the use of oxygen is in the hospital regardless of the underlying diagnosis. Results In PDSA 1, only 8% of the patients had oxygen prescribed. First intervention was to educate the doctors and nurses at the wards on the importance of oxygen prescription and the harmful effects of inaccurate target oxygen saturations. Following this, oxygen prescription increased to 45% in PDSA 2. In the second intervention, visual prompts were displayed in the wards. The oxygen prescription rate in PDSA 3 reached 53%. Conclusions We achieved our goal of this QI project through 3 PDSA cycles, which is to improve oxygen prescription by 50%. However, there is still room for improvement to sustain this good clinical practice.