Quality Improvement Bundle Research Articles

Lessening Urine Contamination in Children and Adolescents

Source: Hoover AC, Segal RS, Zimmerman MB, et al. Urine trouble: reducing midstream clean catch urine contamination among children 3–17 years old. Pediatrics. 2021;148(2):e2020049787. doi:10.1542/peds.2020-049787Investigators from the University of Iowa, Iowa City, IA, conducted a study to assess the effectiveness of a quality improvement intervention designed to reduce the rate of bacterial contamination in urine specimens collected by a clean catch technique. The intervention was developed by a multidisciplinary team, including representatives from inpatient and outpatient units and the emergency department at the University of Iowa Stead Family Children’s Hospital. A specific process was followed in developing the intervention, which included literature reviews, observations from various stakeholders, and an iterative approach in which different interventions were assessed. The final quality improvement intervention included use of a cleansing towelette with 0.13% benzalkonium chloride for urethral meatus cleansing, a set of instructions for obtaining a clean catch sample provided to the patient or caregiver, emphasis on a mid-stream collection, avoiding the insertion of dipsticks in the urine sample sent for culture, clarification that samples should arrive at the microbiology laboratory within 30 minutes of collection or be refrigerated, and real-time tracking of contamination rates.The primary study outcome was change in urine contamination rates before (April 2016 to September 2017) and after (April 2018 to September 2018) hospital-wide implementation of the quality improvement intervention. Sustainability of the intervention was assessed by assessing contamination rates during consecutive 12-month periods in 2018–2019 and 2019–2020. A standard definition for classifying a urine culture as contaminated was used, and all cultures were processed by a single microbiology laboratory. Chi-square tests were used to compare contamination rates prior to and after implementation of the quality improvement bundle; subgroup analyses, including by age groups (3–9, 10–15 and 16–17 years) and sex also were conducted.During the pre-intervention phase a total of 912 clean-catch urine cultures were obtained, of which 416 (45.6%) were contaminated. In the 6-month period following implementation of the quality improvement intervention, the contamination rate in 233 urine cultures was 30.9% (decrease of 14.7 percentage points; 95% CI, -21.5, -8.0). There were statistically significant decreases in contamination rates in female patients (52.7% to 40.1%, -12.6 percentage points; 95% CI, -21.1, -4.1) and in children 3-9 years old and those 10–15 years old; no significant decreases were observed in male patients or in those 16–17 years old. Although there was a significant decrease (-7.3 percentage points; 95% CI, -11.6, -2.9) in contamination rates throughout the entire follow-up period, rates increased to 38.3% during the 2018–2019 period and to 42.9% in 2019–2020 period.The authors conclude that implementation of a quality improvement intervention reduced the rates of bacterial contamination in clean catch urine cultures.Dr Sanchez-Kazi has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.The diagnosis of urinary tract infection is dependent on the quality of urine specimen collected. To lessen bacterial contamination in febrile infants and children up to 2 years of age, the AAP recommends that urine culture be obtained by urethral catheterization or suprapubic aspiration. (See AAP Grand Rounds. 2018:39[4]:39.)1 In toilet-trained children and adolescents, several clinical guidelines recommend obtaining urine by mid-stream clean catch with adequate cleaning of the urogenital area.2,3 In the current quality improvement study initiated by residents, bacterial contamination rate decreased with the combination of education regarding proper cleaning prior to urine collection and timely processing of the urine specimen. Similar interventions including development of specific digital apps were utilized in previous studies but with conflicting results.4,5Within 2 years of observation, the contamination rate slowly increased, albeit lower than the pre-intervention period. It is extremely helpful that the authors extended the period of observation to determine sustainability and, more importantly, to assess the role of performance bias in clinical intervention studies. The results of the current study reinforce the need for frequent review and constant reinforcement of the protocol with medical personnel and patients or caregivers in order to reduce the need for repeated urine testing, leading to conservation of both time and resources. It is interesting to note that the urine contamination rate obtained by catheterization is higher in the current study than in other reports.6Proper cleaning of the urogenital area and timely processing of collected urine specimens reduce bacterial contamination in toilet-trained children and in adolescents.

Effect of a Quality Improvement Bundle to Standardize the Use of Intravenous Fluids for Hospitalized Pediatric Patients

Given that hypotonic maintenance intravenous fluids (IVF) may cause hospital-acquired harm, in November 2018, the American Academy of Pediatrics released a clinical practice guideline recommending the use of isotonic IVF for patients aged 28 days to 18 years without contraindications. No recommendations were made regarding laboratory monitoring; however, unnecessary laboratory tests may contribute to health care waste and harm patients. To examine the effect of a quality improvement intervention bundle on (1) increasing the mean proportion of hours per hospital day with exclusive isotonic IVF use to at least 80% and (2) decreasing the mean proportion of hospital days with laboratory tests obtained. This stepped-wedge, cluster randomized clinical trial (Standardization of Fluids in Inpatient Settings [SOFI]) was sponsored by a national quality improvement collaborative and was conducted across 106 US pediatric hospitals. The SOFI intervention period was from September 2019 to March 2020. Hospital sites were exposed to educational materials, a clinical algorithm and order set for IVF use, electronic medical record interventions to reduce laboratory testing, and "harms of overtesting" cards. Primary outcomes were mean proportion of hours per hospital day receiving exclusive isotonic IVF and mean proportion of hospital days with laboratory test values obtained. Secondary measures included total IVF duration per hospital day, daily patient weight measurement while receiving IVF, serum sodium testing, and adverse events. Baseline data were collected for 2 months; intervention period data, 7 months. Outcomes were analyzed using linear mixed-effects regression models. A total of 106 hospitals were randomly assigned to 1 of 3 intervention start dates (wedges), and 100 hospitals (94%) completed the study. In total, 5215 hospitalizations were reviewed before the intervention, and 6724 hospitalizations were reviewed after the intervention. Prior to interventions, the mean (SD) proportion of hours per day with exclusive isotonic IVF use was 88.5% (31.7%). Interventions led to an absolute increase of 5.4% (95% CI, 3.9%-6.9%) above baseline in exclusive isotonic IVF use but did not change the proportion of hospital days during which a laboratory test value was obtained (estimated difference, 0.1%; 95% CI, -1.5% to 1.7%; P = .90), IVF use duration (estimated difference, -1.2%; 95% CI, -2.9% to 0.4%), serum sodium testing, or adverse events. There was an absolute increase of 4.4% (95% CI, 2.6%-6.2%) in the mean proportion of hospital days with a patient weight measurement while receiving IVF. In this stepped-wedge, cluster randomized clinical trial, an intervention bundle significantly improved the use of isotonic maintenance IVF without a concomitant increase in adverse events or electrolyte testing. Further work is required to deimplement laboratory testing. ClinicalTrials.gov Identifier: NCT03924674.

Evaluation of a quality improvement bundle aimed to reduce opioid prescriptions after Cesarean delivery: an interrupted time series study

PurposeTo evaluate whether opioid prescriptions at discharge after Cesarean delivery decreased following implementation of a quality improvement bundle.MethodsA quality improvement bundle was instituted at Mount Sinai Hospital in Toronto. Interventions included opioid prescribing instructions in resident orientation, nursing and patient education, and standard electronic prescriptions. We used an interrupted time series study design and included patients who had a Cesarean delivery six months pre intervention and six months post intervention. Primary outcome data (opioids prescribed at discharge in morphine milliequivalents [MME]), were aggregated (averaged) by calendar week and analyzed using interrupted time series. Secondary outcomes were assessed using bivariate methods and included opioid use for breakthrough pain in hospital, and amount of opioids prescribed by prescriber specialty and training level.ResultsWe included 2,578 women in our analysis. Based on the segmented regression analysis, prescribed opioids decreased from 97.6 MME in 2018 to 35.8 MME in 2019 (difference in means, − 61.7; 95% confidence interval [CI], − 72.2 to − 51.3; P < 0.001), and this decrease was sustained over the study period. Post intervention, there were no visits to our postnatal assessment clinic for inadequate pain control.ConclusionA quality improvement bundle was associated with a marked and sustained decrease in discharge prescriptions of opioids post Cesarean delivery at a large Canadian tertiary academic hospital.

Successful HPV Vaccination in Adolescents with Sickle Cell Disease Following a Quality Improvement Bundle Intervention

IntroductionHuman papilloma virus (HPV) infection can cause cervical, anal, penile, vaginal, and oropharyngeal cancer. The CDC recommends HPV vaccination as a 2 or 3-dose series at <15 or ≥15 years, respectively. Completion of the vaccine series decreases rates of cervical cancer in young women by 29%(Guo, F. et al. American Journal of Preventive Medicine 2018). For this reason, focus is currently on vaccinating younger patients to optimize benefit. Historically, adolescents have had low rates of completion of the HPV vaccine series. African Americans, in particular, have significantly lower rates than whites in receiving the full series (De, P. and H. Budhwani. Public Health 2017). Vaccine hesitancy in sickle cell disease (SCD) patients exists and is exemplified by a lower uptake in teenagers with SCD compared to non-SCD counterparts (Beverung, L. et al. American Journal of Hematology 2018). However, completion of 23-pneumococcal vaccine polyvalent (PPSV-23), which is routinely administered as a series during well-child visits, has notably been high. SCD programs serve as medical homes where primary care may also be provided. With this in mind, we introduced a quality improvement (QI) intervention to improve the uptake of HPV vaccination in the adolescent SCD clinic. A bundle intervention was developed including 1) provider education about HPV vaccination importance, 2) nurse review of each adolescent's vaccine records prior to clinic visit, 3) provider notification by the nurse regarding the need for HPV during the visit, 4) discussion of the vaccine benefits with the family, 5) provision of the vaccine in the SCD clinic after parent consent, and 6) offering of MOC points as incentive to providers for project participation. We sought to evaluate the impact of the QI bundle on completion of the HPV vaccine series. We hypothesized that implementation of the QI bundle would increase the rate of completion of the HPV vaccine series among adolescents with SCD. Secondary objectives included association between completion of the HPV vaccine series and frequency of outpatient visits to the SCD clinic, quality of life (QoL), SCD-specific knowledge, completion of the PPSV-23 series, and markers of socio-economic status (SES).MethodsRetrospective data was collected using the Sickle Cell Clinical Research and Intervention Program (SCCRIP) study database (Hankins JS, et al. Pediatr Blood Cancer 2018). Patients aged 12-18 years between October 1, 2018 and December 31, 2019 with any SCD genotype and who were enrolled on the SCCRIP study were included in analysis. The following variables were extracted: age, sex, race, ethnicity, age, economic hardship index (EHI), parental education level, household income, genotype, SCD-specific knowledge, and distance to healthcare facility. The prevalence of completed HPV series, defined as 2 doses ages <15 years and 3 doses ages ≥15 years, in the 12 months prior to implementation of the bundle vaccination program (before October 1, 2018) and after implementation of program (October 2, 2018 to December 31, 2019) was calculated using Fisher's exact. Demographic characteristics and QoL were compared between patients who completed the vaccine series and those who did not.ResultsIn total, 373 patients met inclusion criteria. Their median age was 15.2 (range 12-19), 50% were female, 225 (60.3%) had HbSS/Sβ 0-thalassemia, and 114 (29.7%) had HbC/Sβ +-thalassemia. The mean SES index was 70% (±27%) and the mean QoL score 73 (±14.6). HPV vaccine completion rates increased from 31% to 56.2% after the bundle implementation (Figure 1, p<0.01). Completion of the series was associated with higher SES index, completion of the PPSV-23 series, and higher frequency of outpatient visits. There was no significant association between completion of the vaccine series and QoL, distance from healthcare facility, and disease-specific knowledge (Table 1).DiscussionPrevention of communicable diseases such as HPV is imperative in the general population. However, baseline vaccination rates in adolescents with SCD is low. A QI intervention that includes provider education and incentives, active verification of HPV vaccination status, and promotes coordinated communication between the nurse, providers, and patients effectively increased completion of the HPV vaccine series among adolescents with SCD. Continued strategies are needed to further increase the rates of vaccine completion. [Display omitted] DisclosuresHankins: Vindico Medical Education: Consultancy; Global Blood Therapeutics: Consultancy; UpToDate: Consultancy; Bluebird Bio: Consultancy.

Decreasing Continuous Positive Airway Pressure Failure in Preterm Infants.

Many preterm infants stabilized on continuous positive airway pressure (CPAP) at birth require mechanical ventilation (MV) during the first 72 hours of life, which is defined as CPAP failure. Our objective was to decrease CPAP failure in infants ≤29 weeks' gestational age (GA). A quality improvement bundle named OPTISURF was implemented for infants ≤29 weeks' GA admitted on CPAP, consisting of stepwise escalation of CPAP and less invasive surfactant administration guided by fractional inspired oxygen concentration ≥0.3. The CPAP failure rate was tracked by using control charts. We compared practice and outcomes of a pre-OPTISURF cohort (January 2017 to September 2018) to a post-OPTISURF cohort (October 2018 to December 2019). Of the 216 infants ≤29 weeks' GA admitted to NICU on CPAP, 125 infants belonged to the pre-OPTISURF cohort (OSC) and 91 to the post-OSC. Compared with the pre-OSC, a higher proportion of infants in the post-OSC received CPAP 7 cm H2O within 4 hours of life (7% vs 32%; P < .01). The post-OSC also had lower rates of CPAP failure (54% vs 11%; P < .01), pneumothoraces (8% vs 1%; P < .03), need for MV (58% vs 31%; P < .01), and patent ductus arteriosus treatment (21% vs 9%; P = .02). Additionally, in a subgroup analysis, CPAP failure was lower in the post-OSC among infants 23 to 26 weeks (79% vs 27%; P < .01) and 27 to 29 weeks' GA (46% vs 3%; P < .01). Implementation of a quality improvement bundle including CPAP optimization and less invasive surfactant administration decreased CPAP failure and need for MV in preterm infants.

Delivery room thermal care interventions in preterm neonates.

Abiramalatha T, Ramaswamy VV, Bandyopadhyay T, Pullattayil AK, Thanigainathan S, Trevisanuto D, Roehr CC. Delivery Room Interventions for Hypothermia in Preterm Neonates: A Systematic Review and Network Meta-analysis. JAMA Pediatr. 2021 May 24:e210775. 10.1001/jamapediatrics.2021.0775. Epub ahead of print. PMID: 34028513; PMCID: PMC8145154. Preterm neonates are at increased risk for hypothermia after birth which is an independent predictor for neonatal mortality and morbidity.1, 2 Maintaining normal temperature is a key initial step in stabilisation of the newborn at birth.3 Several interventions to prevent hypothermia in the delivery room have been studied either solely or in combinations.4-7 The neonatal life support task force suggested using a combination of different interventions to prevent hypothermia on neonatal admission to the NICU.3 However, this suggestion was based on relatively old evidence with weak recommendations and very low certainty. This network meta-analysis was conducted on 34 randomised and quasi-randomised controlled trials including 3688 preterm, ≤36 weeks gestation and infants aiming to identify thermal care intervention in the delivery room that can best reduce neonatal hypothermia and improve clinical outcomes. The researchers compared eight interventions to routine care and found that most of the interventions were associated with higher core body temperature. They found that plastic bag or wrap alone, thermal mattress, and plastic bag or wrap with heated humidified gas were associated with reduced risk of moderate to severe hypothermia compared with routine care. The SUCRA analysis showed that the combination of plastic bag or wrap with a thermal mattress was the best intervention to improve core body temperature at admission, but direct evidence from pairwise comparisons indicated that this combination increases the risk of hyperthermia. In sensitivity analyses, plastic bag and plastic wrap were equally good at maintaining core body temperature, the effect of interventions in improving temperature was consistent among preterm infants ≤30 weeks gestation, and drying did not make a difference compared to no drying before the application of plastic bag or wrap. Authors found that the use of a plastic bag or wrap with heated humidified gas was associated with reduced risk of major brain injury and a plastic bag or wrap with a plastic cap was associated with lower risk of mortality. Major strengths of this study are the use of network meta-analysis which can inform comparative effectiveness in the presence of multiple interventions, the systematic search strategy, and clinically relevant interventions and outcomes. However, the study is limited by wide differences in the method of temperature measurement between included trials, inability to perform analysis of some secondary outcomes due to data limitation, small sample size of the included trials and low event rates for the primary outcome leading to possible selective reporting and publication bias, and inability to access unpublished data from the included studies.5 Although, the majority of thermal care interventions were associated with better core body temperature and decreased risk of moderate to severe hypothermia at admission or within the first 2 h of life compared with routine care, the certainty of evidence ranged from very low to moderate for the primary and secondary outcomes. Future, adequately powered, randomised controlled trials are needed to determine the best combination of interventions to prevent hypothermia with no risk of hyperthermia and to assess quality improvement bundle of hypothermia preventive measures to assess the individual benefit for each newborn. https://ebneo.org/preterm-thermal-care None.

Introduction of a Quality Improvement Bundle Is Associated with Reduced Exposure to Mechanical Ventilation in Very Preterm Infants

Introduction: Exposure to mechanical ventilation (MV) is a risk factor for bronchopulmonary dysplasia (BPD) in very preterm infants (VPTIs). We assessed the impact of a quality improvement (QI) bundle in VPTIs (<32 week gestation) on exposure to MV. Methods: We introduced a QI bundle consisting of deferred cord clamping (DCC), nasal bubble continuous positive airway pressure (bCPAP) in the delivery room (DR), and minimally invasive surfactant therapy (MIST). We compared respiratory outcomes and neonatal morbidity in historical pre-QI (July–December 2017) and prospective post-QI (February–July 2019) cohorts (QICs) of VPTIs. We pre-specified an adjusted analysis to account for the effects of gestational age, sex, antenatal steroids, and any demographic data that significantly differed between cohorts. Results: The pre-QI and post-QICs included 87 and 98 VPTIs, respectively. The post-QIC had decreased rates of MV in the DR (adjusted odds ratio [aOR] 0.26, 95% confidence interval [CI] 0.09–0.71), in the first 72 h of life (aOR 0.27, 95% CI 0.11–0.62) and during admission (aOR 0.28, 95% CI 0.12–0.66). Rates of BPD, combined BPD/death, and BPD severity were similar. The post-QIC was less likely to be discharged with home oxygen (aOR 0.27, 95% CI 0.08–0.91). Necrotising enterocolitis grade ≥2 increased (aOR 19.01, 95% CI 1.93–188.6) in the post-QIC. Conclusion: In this rapid-cycle QI study, implementation of a QI bundle consisting of DCC, early nasal bCPAP, and MIST in VPTIs was associated with reduced rates of MV in the DR, in the first 72 h of life and during admission, and reduced need for home oxygen.

A Quality Improvement Bundle to Reduce Ambulatory CLABSI: The Importance of a Multidisciplinary Team

In Brief Children’s Hospitals’ Solutions for Patient Safety (SPS) is a network of over 140 children’s hospitals who share the vision of working together to eliminate serious harm across all pediatric hospitals. The SPS network is built on the fundamental belief that by sharing successes and failures transparently and learning from one another, children’s hospitals can achieve their goals more effectively and quickly than working alone. Each year, SPS hosts National Learning Sessions to which members are invited to submit abstracts describing relevant safety research or improvement work. The following abstracts were among the top submitted for the SPS Spring 2021 National Learning Session.

Contextual Factors Affecting Implementation of In-hospital Pediatric CPR Quality Improvement Interventions in a Resuscitation Collaborative.

Pediatric quality improvement (QI) collaboratives are multisite clinical networks that support cooperative learning. Our goal is to identify the contextual facilitators and barriers to implementing QI resuscitation interventions within a multicenter resuscitation collaborative. A mixed-methods evaluation of the contextual facilitators and barriers to implementation of a resuscitation QI bundle. We administered a quantitative questionnaire, the Model for Understanding Success in Quality (MUSIQ), to the Pediatric Resuscitation Quality (pediRES-Q) Collaborative. Its primary goal is to optimize the care of children who experience in-hospital cardiac arrest through a resuscitation QI bundle. We also conducted semistructured phone interviews with site primary investigators adapted from the Consolidated Framework for Implementation Research qualitative interview guide. All 13 actively participating US sites completed the MUSIQ questionnaire. Total MUSIQ scores ranged from 86.0 to 140.5 (median of 118.7, interquartile range 103.6-124.5). Evaluation of the QI team subsection noted a mean score of 5.5 for low implementers and 6.1 for high implementers (P = 0.02). We conducted 8 interviews with the local QI team leadership. Contextual facilitators included a unified institutional approach to QI, a fail forward climate, leadership support, strong microculture, knowledge of other organizations, and prioritization of goals. Contextual barriers included low team tenure, no specific allocation of resources, lack of formalized QI training, and lack of support and buy-in by leaders and staff. Using mixed methods, we identified an association between the local QI team's strength and the successful implementation of the QI interventions.

Translational Simulation Improves Compliance with the NEAR4KIDS Airway Safety Bundle in a Single-center PICU.

Introduction:The National Emergency Airway Registry for Children (NEAR4KIDS) Airway Safety Quality Improvement (QI) Bundle is a QI tool to improve the safety of tracheal intubations. The ability to achieve targeted compliance with bundle adherence is a challenge for centers due to competing QI initiatives, lack of interdisciplinary involvement, and time barriers. We applied translational simulations to identify safety and performance gaps contributing to poor compliance and remediate barriers by delivering simulation-based interventions.Methods:This was a single-center retrospective review following translational simulations to improve compliance with the NEAR4KIDS bundle . The simulation was implemented between March 2018 and December 2018. Bundle adherence was assessed 12 months before simulation and 9 months following simulation. Primary outcomes were compliance with the bundle and utilization of apneic oxygenation. The secondary outcome was the occurrence of adverse tracheal intubation-associated events.Results:Preintervention bundle compliance was 66%, and the application of apneic oxygenation was 27.9%. Following the simulation intervention, bundle compliance increased to 93.7% (P < 0.001) and adherence to apneic oxygenation increased to 77.9% (P < 0.001). There was no difference in the occurrence of tracheal intubation-associated events.Conclusions:Translational simulation was a safety tool that improved NEAR4KIDS bundle compliance and elucidated factors contributing to successful implementation. Through simulation, we optimized bundle customization through process improvement, fostered a culture of safety, and effectively engaged multidisciplinary teams in this quality initiative to improve adherence to best practices surrounding tracheal intubations.

Implementation outcomes of policy and programme innovations to prevent obstetric haemorrhage in low- and middle-income countries: a systematic review.

Globally, obstetric haemorrhage (OH) remains the leading cause of maternal mortality. Much of the associated mortality is ascribed to challenges surrounding deployment of innovations rather than lack of availability. In low- and middle-income countries (LMICs), where the burden is highest, there is a growing interest in implementation research as a means to bridge the 'know-do' gap between proven interventions and their reliable implementation at scale. In this systematic review, we identified and synthesized qualitative and quantitative data across the implementation outcomes of OH prevention innovations in LMICs using a taxonomy developed by Proctor et al. We also identified service outcomes for the included innovations, as well as implementation strategies and implementation facilitators and barriers. Eligible studies were empirical, focused on the implementation of OH prevention programmes or policies and occurred in an LMIC. Eight databases were searched. Two authors independently assessed studies for selection and extracted data; the first author resolved discrepancies. Narrative synthesis was used to analyse and interpret the findings. Studies were predominantly focused in Africa and on primary prevention. Interventions included prophylactic use of uterotonics (n = 7), clinical provider skills training (n = 4) and provision of clinical guidelines (n = 1); some (n = 3) were also part of a multi-component quality improvement bundle. Various barriers were reported, including challenges among intervention beneficiaries, providers and within the health system; however, studies reported the development and testing of practical implementation solutions. These included training and monitoring of implementers, community and stakeholder engagement and guidance by external mentors. Some studies linked successful delivery to implementation outcomes, most commonly adoption and acceptability, but also feasibility, penetration and sustainability. Findings suggest that innovations to prevent OH can be acceptable, appropriate and feasible in LMIC settings; however, more research is needed to better evaluate these and other under-reported implementation outcomes.

MEDICAL SYSTEMS' QUALITY EVALUATED BY PERCEPTIONS OF NURSING CARE: FACING COVID 19 PANDEMIC

The aim of this qualitative systematic review is to review the studies on patient perceptions of nursing care quality. All the papers available in the first five pages of Google Scholar using time frames of any time and 2016-2020 (10 web pages) and 2020 (five web pages) were reviewed. The review found that surveys using many different types of measurement frameworks was the methodology of choice for a majority of works. Among the topics, framework validation, care dimensions and specific problems like AIDS, surgery patients and cancer patients were researched most. Many types of measurement frameworks have been used for measuring patient perceptions of nursing care quality. Factors related to the patient, care environment and nursing were identified by the researchers. Individualised care, communicating the truth, competent and prompt care and response to various personal care needs of the patient, timely attention to urgent calls, safety, avoiding medical errors, empathy and instilling trust and confidence in the patient are important care dimensions. Patient-related dimensions are mainly demographic. They include age, education, occupation, income, marital status and certain behavioural attributes, which are outside the control of hospitals. Nurses may be able to adjust to individual behavioural problems to some extent, but not of all patients all the time. Nursing dimensions like working environment, staff strength, leadership effectiveness, involvement or empowerment for independent decision making, strain and burnout and work-life balance problems affect their care quality at professional level. At their personal level, knowledge, skills, competence and training, positive attitude towards the profession are important determinants. A care quality improvement bundle can be designed by the hospital to facilitate the nurses to improve on these factors. The hospitals need to obtain periodical feedback on the administrative aspects of nursing care from the nurses and make any improvement required to provide the proper working conditions without strain and burnout and facilitating work-life balance.

An audit of community-acquired pneumonia antimicrobial compliance using an intervention bundle in an Irish hospital

ObjectivesHospitalisations with community-acquired pneumonia (CAP) are often not managed in accordance with antimicrobial guidelines. This study aimed to assess whether guideline-driven antimicrobial prescribing for CAP can be improved using an intervention bundle. Secondary measures assessed were hospital length of stay (LOS), mortality, duration of intravenous antibiotics and total antibiotics, improved uptake of appropriate investigations, and documentation of CURB-65 score. MethodsA retrospective cohort of hospitalised CAP patients from August–September 2018 was compared with a post-intervention prospective cohort from May–June 2019. The intervention bundle included a mobile audience response system, promotion of the antimicrobial app, development of a physical card with local guidelines, and incorporating CURB-65 into the unscheduled admission proforma. Local guidelines are in keeping with British Thoracic Society CAP guidelines. ResultsA total of 69 adult patients (aged >18 years) were included in the study (37 retrospective, 32 prospective). Overall compliance with local CAP guidelines improved from 21.6% to 62.5% (P < 0.001). No difference in initial intravenous antibiotic duration was seen (median 4 days vs. 4 days; P = 0.70) and total antibiotic duration was significantly shorter in the post-intervention group (median 9 days vs. 7 days; P = 0.01). No difference in LOS or mortality was seen between the groups. Documentation of CURB-65 improved from 5.4% to 46.9% (P < 0.001). Uptake of streptococcal urinary antigen testing improved from 18.9% to 40.6% (P = 0.024). ConclusionsA simple, low-cost quality improvement bundle can significantly increase appropriate antimicrobial prescribing and shorten the total antibiotic duration.

Perinatal quality improvement bundle to decrease hypothermia in extremely low birthweight infants with birth weight less than 1000 g: single-center experience over 6 years

Normothermia (36.5°C–37. 5°C) at the time of admission to the neonatal intensive care unit (NICU) in extremely low birthweight (ELBW) infants (birth weight <1000 g) is associated with decreased morbidity...

Quality Improvement Efforts Reduce Incidence of Surgical Necrotizing Enterocolitis and Related Deaths.

The aim of this study was to determine whether a regional quality improvement (QI) initiative decreased incidence and severity of surgical necrotizing enterocolitis (NEC) in very low birth weight (VLBW) infants. A retrospective review of all VLBW infants who received care at one of the three hospitals involved in a NEC QI initiative from 2011 to 2016. Primary outcome was the number of surgical NEC cases per year. Secondary outcomes included associated outcomes and mortality. Sixty-three infants with either a diagnosis of Stage III NEC (n = 40) or spontaneous intestinal perforation (SIP) (n = 23) were included. The incidence of medical and surgical NEC and the mortality rate of infants with surgical NEC decreased over time. Incidence and mortality of SIP did not significantly change. A regional QI bundle to reduce the overall incidence of NEC also significantly decreased the incidence of surgical NEC and all-cause mortality of infants diagnosed with surgical NEC. · QI reduces surgical necrotizing enterocolitis.. · Reduction in NEC rate improves mortality.. · Human milk does not change SIP incidence..

Assessment of an Unplanned Extubation Bundle to Reduce Unplanned Extubations in Critically Ill Neonates, Infants, and Children

Unplanned extubations (UEs) in children contribute to significant morbidity and mortality, with an arbitrary benchmark target of less than 1 UE per 100 ventilator days. However, there have been no multicenter initiatives to reduce these events. To determine if a multicenter quality improvement initiative targeting all intubated neonatal and pediatric patients is associated with a reduction in UEs and morbidity associated with UE events. This multicenter quality improvement initiative enrolled patients from pediatric, neonatal, and cardiac intensive care units (ICUs) in 43 participating children's hospitals from March 2016 to December 2018. All patients with an endotracheal tube requiring mechanical ventilation were included in the study. Participating hospitals implemented a quality improvement bundle to reduce UEs, which included standardized anatomic reference points and securement methods, protocol for high-risk situations, and multidisciplinary apparent cause analyses. The main outcome measures for this study included bundle compliance with each factor tested and UE rates on the center level and on the cohort level. Among the 43 children's hospitals, the quality improvement initiative was associated with an aggregate 24.1% reduction in UE events, from a baseline rate of 1.135 UEs per 100 ventilator days to 0.862 UEs per 100 ventilator days. Across ICU settings studied, the pediatric ICU and neonatal ICU demonstrated centerline shifts, with an absolute reduction in events of 20.6% (from a baseline rate of 0.729 UEs per 100 ventilator days to 0.579 UEs per 100 ventilator days) and 17.6% (from a baseline rate of 1.555 UEs per 100 ventilator days to 1.282 UEs per 100 ventilator days), respectively. Most UEs required reintubation within 1 hour (mean of 120 of 206 events per month [58.3%]), followed by UEs that did not require reintubation (mean of 78 of 206 events per month [37.9%]) and UEs that resulted in cardiovascular collapse (mean of 8 of 206 events per month [3.9%]). Cardiovascular collapse events represented the most significant consequence of UE studied, and the collaborative reduced these UE events by 36.6%, from a study baseline rate of 0.041 UEs per 100 ventilator days to 0.026 UEs per 100 ventilator days. This multicenter quality improvement initiative was associated with a reduction in UEs across different pediatric populations in diverse settings. A significant reduction in event rate and rate of harm (cardiovascular collapse) was observed, which was sustained over the time course of the intervention. This quality improvement process and UE bundle may be considered standard of care for pediatric hospitals in the future.

Intracorporeal VAD Outcomes in the ACTION Quality Improvement Network

The initial project of ACTION (Advanced Cardiac Therapies Improving Outcomes Network) is focused on improving stroke rates in patients implanted with a ventricular assist devices (VAD) in participating centers. The initial interventions targeted improving communication, anticoagulation, and blood pressure management. We sought to describe the characteristics and outcomes of patients implanted with intracorporeal, continuous flow VADs (cfVAD). The ACTION registry was used to determine the stroke frequency in cfVAD implanted patients between April 2018 and September 2019, the time from development of the quality improvement bundle to the present. Sixty two patients (33 Heartmate3 [HM3] and 29 Heartware [HVAD]) were identified (Table). The majority had dilated cardiomyopathy (76%). Of the 12 (20%) patients with congenital heart disease (CHD), 9 (75%) had single ventricle (SV) physiology. The HM3 patients were older (16.5 yr vs 12.8 yr) and larger (64.2 kg vs 51.9 kg) than the HVAD patients. No significant difference was observed in diagnosis, duration of support, device strategy, or clinical outcome. One patient (2%) experienced a stroke during 6,920 days of support. Forty of the 45 (89%) patients to reach a clinical endpoint experienced a positive outcome (transplant or explant for recovery) while 17 (27%) patients remain on device. The stroke rate is low and survival good among patients implanted with an intracorporeal cfVAD at ACTION centers using the clinical protocols developed within the network. The HVAD is currently being used more frequently in younger and smaller patients. There has been an appreciable increase in the number and frequency of implants in patients with CHD, especially SV disease, as compared to previous reports. Future efforts within ACTION will focus on improving clinical outcomes as devices are increasingly used at individual centers and as the number of VAD-supported patients with congenital heart disease continues to grow.

Antibiotic prophylaxis in a global surgical context

Surgical site infection (SSI) is a global problem, and has been highlighted as the foremost research priority for perioperative researchers across high-, middle- and low-income settings. Depending on the degree of intraoperative contamination, baseline patient risk and other infection control measures, as many as 50% of patients can suffer surgical wound infections within the 30-days after an operation. As a result, SSI has been the focus of several recent global initiatives including randomised controlled trials of health technologies, quality improvement bundle studies, and prospective cohort studies.

Five-layer border dressings as part of a quality improvement bundle to prevent pressure injuries in US skilled nursing facilities and Australian nursing homes: A cost-effectiveness analysis.

The BORDER III trial found that five‐layer silicone border dressings effectively prevented pressure injuries in long‐term care, but the value of this approach is unknown. Our objective was to analyse the cost‐effectiveness of preventing facility‐acquired pressure injuries with a quality improvement bundle, including prophylactic five‐layer dressings in US and Australian long‐term care. Markov models analysed the cost utility for pressure injuries acquired during long‐term care from US and Australian perspectives. Models calibrated outcomes for standard care compared with a dressing‐inclusive bundle over 18 monthly cycles or until death based on BORDER III outcomes. Patients who developed a pressure injury simulated advancement through stages 1 to 4. Univariate and multivariate probabilistic sensitivity analyses tested modelling uncertainty. Costs in 2017 USD and quality‐adjusted life years (QALYs) were used to calculate an incremental cost‐effectiveness ratio (ICER). Dressing use yielded greater QALYs at slightly higher costs from perspectives. The US ICER was $36 652/QALY, while the Australian ICER was $15 898/QALY, both of which fell below a willingness‐to‐pay threshold of $100 000/QALY. Probabilistic sensitivity analysis favoured dressings as cost‐effective for most simulations. A quality improvement bundle, including prophylactic five‐layer dressings, is a cost‐effective approach for pressure injury prevention in all US and Australia long‐term care residents.

A Quality Bundle to Support High-Risk Pediatric Ventricular Assist Device Implantation.

Pediatric ventricular assist device (VAD) implantation outcomes are increasingly promising for children with dilated cardiomyopathy and advanced decompensated heart failure (ADHF). VAD placement in patients with clinical features such as complex congenital cardiac anatomy, small body size, or major comorbidities remains problematic. These comorbidities have been traditionally prohibitive for VAD consideration leaving these children as a treatment-orphaned population. Here we describe the quality bundle surrounding these patients with ADHF considered high risk for VAD implantation at our institution. Over a 7-year period, a quality bundle aimed at the peri-operative care for children with high-risk features undergoing VAD implantation was incrementally implemented at a tertiary children's hospital. Patients were considered high risk if they were neonates (< 30days), had single-ventricle physiology, non-dilated cardiomyopathy, biventricular dysfunction, or significant comorbidities. The quality improvement bundle evolved to include (1) structured team-based peri-operative evaluation, (2) weekly VAD rounds addressing post-operative device performance, (3) standardized anticoagulation strategies, and (4) a multidisciplinary system for management challenges. These measures aimed to improve communication, standardize management, allow for ongoing process improvement, and incorporate principles of a high-reliability organization. Between January 2010 and December 2017, 98 patients underwent VAD implantation, 48 (49%) of which had high-risk comorbidities and a resultant cohort survival-to-transplant rate of 65%. We report on the evolution of a quality improvement program to expand the scope of VAD implantation to patients with high-risk clinical profiles. This quality bundle can serve as a template for future large-scale collaborations to improve outcomes in these treatment-orphaned subgroups.