Quality Improvement Initiative Research Articles

Quality improvement initiative: implementing and redefining video review of real-time neonatal procedures using action research

Video review (VR) of procedures in the medical environment can be used to drive quality improvement. However, first it has to be implemented in a safe and effective way. Our...

Implementation Barriers Encountered During a Universal Suicide Screening Program in Pediatric Emergency Departments.

Because understanding barriers to universal suicide risk screening in pediatric emergency departments (PEDs) may improve both identification and management of suicidal behaviors and ideation, this study assessed barriers to a quality improvement initiative examining the use of a novel computerized adaptive test (CAT), the Kiddie-CAT, in 2 PEDs. Research assistants (RAs) trained in Rapid Assessment Procedures-Informed Clinical Ethnography methods documented barriers related to the environment, individuals, and workflow as encountered during screening shifts, categorizing the barriers' impacts as either general to a screening shift or related to screening an individual youth/caregiver dyad. Using thematic content analysis, investigators further categorized barriers based on type (eg, workflow, language/comprehension, clinician attitudes/behaviors) and relationship to the limited integration of this initiative into clinical protocols. Reasons for refusal and descriptive data on barriers are also reported. Individual screen barriers were most often related to workflow (22.9%) and youth/caregiver language/comprehension challenges (28%). Similarly, workflow issues accounted for 48.2% of all general shift barriers. However, many of these barriers were related to the limited integration of the initiative, as RAs rather than clinical staff conducted the screening. Although this study was limited by a lack of complete integration into clinical protocols and was complicated by the COVID-19 pandemic impacts on PEDs, the findings suggest that considerable attention needs to be directed both to physician education and to workflow issues that could impede universal screening efforts.

Defining Benchmarks for Pelvic Exenteration Surgery: A Multicentre Analysis of Patients with Locally Advanced and Recurrent Rectal Cancer.

To establish globally applicable benchmark outcomes for pelvic exenteration (PE) in patients with locally advanced primary (LARC) and recurrent rectal cancer (LRRC), using outcomes achieved at highly specialised centres. PE is established as the standard of care for selected patients with LARC and LRRC. There are currently no available benchmarks against which surgical performance in PE can be compared for audit and quality improvement. This international multicentre retrospective cohort study included patients undergoing PE for LARC or LRRC at 16 highly experienced centres between 2018 and 2023. Ten outcome benchmarks were established in a lower-risk subgroup. Benchmarks were defined by the 75th percentile of the results achieved at the individual centres. 763 patients underwent PE, of which 464 patients (61%) had LARC and 299 (39%) had LRRC. 544 patients (71%) who met predefined lower risk criteria formed the benchmark cohort. For LARC patients, the calculated benchmark threshold for major complication rate was ≤44%; comprehensive complication index (CCI): ≤30.2; 30-day mortality rate: 0%; 90-day mortality rate: ≤4.3%; R0 resection rate: ≥79%. For LRRC patients, the calculated benchmark threshold for major complication rate was ≤53%; CCI: ≤34.1; 30-day mortality rate: 0%; 90-day mortality rate: ≤6%; R0 resection rate: ≥77%. The reported benchmarks for PE in patients with LARC and LRRC represent the best available care for this patient group globally and can be used for rigorous assessment of surgical quality and to facilitate quality improvement initiatives at international exenteration centres.

Emergency department pediatric readiness of United States trauma centers in 2021: Trauma center facility characteristics and opportunities for improvement.

Emergency department (ED) pediatric readiness has been associated with lower mortality for injured children but has historically been suboptimal in non-pediatric trauma centers. Over the past decade, the National Pediatric Readiness Project (NPRP) has invested resources in improving ED pediatric readiness. This study aimed to quantify current trauma center pediatric readiness and identify associations with center-level characteristics to target further efforts to guide improvement. The study cohort included all centers that responded to the 2021 NPRP national assessment and contributed data to the National Trauma Databank (NTDB) the same calendar year. Center characteristics and pediatric (0-15y) volume from the NTDB were linked to weighted pediatric readiness scores (wPRS) obtained from the NPRP assessment. Univariate and multivariable analyses were used to determine associations between wPRS and trauma center type as well as center-level facility characteristics. The wPRS was reported for 77% (749/973) of centers that contributed to the NTDB. ED Pediatric Readiness was highest in ACS level one pediatric trauma centers (PTCs), but wPRS in the highest quartile was seen among all adult and pediatric trauma center types. Independent predictors of high wPRS included ACS level one PTC verification, pediatric trauma volume, and the presence of a PICU. Higher-level adult trauma centers and pediatric trauma centers were more likely to have pediatric-specific physician requirements, pediatric emergency care coordinators, and pediatric quality improvement initiatives. ED pediatric readiness in trauma centers remains variable and is predictably lower in centers that lack inpatient resources. There is, however, no aspect of ED pediatric readiness that is constrained to high-level pediatric facilities, and a highest quartile wPRS was achieved in all types of adult centers in our study. Ongoing efforts to improve pediatric readiness for initial stabilization at non-pediatric centers are needed, particularly in centers that routinely transfer children out. Epidemiologic, Level III.

Barriers and Facilitators to Health Professionals' Engagement in Quality Improvement Initiatives: A Mixed-Methods Systematic Review.

Background Quality improvement (QI) initiatives in healthcare are crucial for enhancing service quality and healthcare outcomes. The success of these initiatives depends on the active engagement of healthcare professionals, which can be influenced by several factors within the healthcare system. This systematic review synthesised the factors influencing healthcare professionals' engagement in QI projects, focusing on identifying both barriers and facilitators. Methods A mixed methods systematic review (MMSR) was conducted using the JBI methodology for MMSR. Databases such as MEDLINE, CINAHL, Scopus, and Embase were searched for studies that explored barriers and facilitators to QI engagement of health professionals in the clinical setting. Methodological quality was assessed using the Mixed Methods Appraisal Tool (MMAT). The extracted data were synthesised using the JBI convergent integrated approach to MMSR. Results Eighteen studies (seven qualitative, nine quantitative, and two mixed-methods) published between 2007 and 2023 were included in the review. The analysis revealed barriers and facilitators to engagement in QI initiatives at different levels of the health system. At the QI program level, the engagement of health professionals to QI was influenced by the approach to QI, evidence underpinning the QI initiative, QI knowledge and training and access to QI specialists. At the health professional level, barriers and facilitators were related to their organisational role, motivation, perceptions about QI, and collaborations with individuals and groups. At the organisational level, factors related to culture and climate, leadership, available resources (including human resource and workload, infrastructure, and incentives) and institutional priorities influenced health professionals' participation in QI. Conclusion This review highlights the complex interplay of organisational, individual and QI program level factors that influence the engagement of healthcare professionals in QI. Overcoming these complex barriers and leveraging facilitators is crucial for enhancing participation in QI efforts. The findings underscore the need for a multi-level strategy that focuses on creating a conducive organisational culture, providing robust leadership, and ensuring adequate resources and training for healthcare professionals. Such strategies hold the potential to enhance the effectiveness and sustainability of QI initiatives in healthcare settings.

Improving patient education in hospitalized patients with chronic obstructive pulmonary disease: A quality improvement initiative using LEAN methodology.

Chronic obstructive pulmonary disease (COPD) is a costly chronic disease affecting more than 15 million Americans. The prevalence among US veterans is 3 times higher than the general population. The Veteran Health Administration developed a standardized, evidence-based COPD educational tool called Green Light to Go (GLTG) designed to educate patients on managing their COPD symptoms at home. Despite the availability of this resource, inpatient education on COPD self-management practices is highly variable across different medical teams. This quality improvement (QI) initiative sought to standardize inpatient COPD patient education using the GLTG tool. This initiative also assessed whether patients receiving standardized patient education during their index hospitalization had lower COPD 30-day readmission rates. The QI initiative followed the LEAN methodology and the A3 framework. The team performed rapid tests of change (plan-do-study-act cycles) to increase the percentage of veterans receiving COPD education. The interventions implemented for this QI initiative focused on clinical, patient, and system improvements. This initiative standardized COPD patient education and increased the percentage of veterans receiving (a) daily COPD education from 0% to 66%, (b) verbal COPD education on discharge from a baseline of 20% to 100%, (c) receipt of written educational material on discharge from 20% to 100%, and (d) the cohort all-cause 30-day readmission rate declined from 19.3% to 14.3%. Given the substantial economic burden of COPD readmissions on the health care system and patients, evidence-based educational interventions may potentially improve outcomes and reduce hospital readmissions in this veteran population.

Supportive Care Needs of Patients With Temporary Ostomy in Enhanced Recovery After Surgery: A Mixed-Methods Study.

Enhanced recovery after surgery (ERAS), a global surgical quality improvement initiative, reduces the length of stay in the hospital. Temporary stoma care for rectal cancer is complex, and patients require prolonged care services to adjust to the stoma. The shorter stay durations in the new model challenge the conventional care pathways and create new patient needs. This study was designed to explore the supportive care needs of patients under the new surgical model to provide a reference for the design of ERAS nursing care plans. A convergent parallel mixed-methods design was used in this study. Patients with temporary stomas for rectal cancer were recruited using a convenience sampling method in gastrointestinal surgery wards and wound & stoma clinics in two public tertiary care hospitals in China. Standardized questionnaires were administered to 140 patients to collect quantitative data, and semistructured interviews were conducted individually with 13 patients to collect qualitative data. The questionnaire data were analyzed using descriptive statistics, and the interview data were analyzed using thematic analysis. "Health system and information needs" and "care and support needs" were identified in both the qualitative and quantitative analyses as the most significant unmet needs of the participants. In addition, the qualitative analysis identified receiving focused stoma care instructions and easily understandable information as essential to fulfilling health system and information needs. Care and support needs included access to continued postdischarge services and attention from medical professionals. The participants in this study experienced a variety of unmet supportive care needs under the ERAS protocol, with gaps particularly notable in two categories: "health system and information needs" and "care and support needs." Increased perioperative care and shorter hospital stays under the ERAS protocol reduce opportunities for patients to receive targeted instruction and shift much of the ostomy education and care workload out of the hospital, requiring greater attention from clinical nurses to ensure quality of care.

Impact of Implementing Serious Illness Conversations Across a Comprehensive Cancer Center Using an Interdisciplinary Approach.

Gaps in communication of end-of-life care preferences increase risk of patient harm. Adoption of oncology practice guidelines advocating serious illness communication for patients with advanced cancer is limited. (1) Increase Serious Illness Conversation (SIC) use across oncology teams via an interdisciplinary quality improvement (QI) approach and (2) assess patient reported shared decision making (SDM) experiences with clinicians engaged in SIC implementation. QI methodology was applied to spread the implementation of SIC across 4 oncology teams. CollaboRATE scores were used to evaluate patient reported outcomes of SDM for patients with advanced cancer. The SIC QI initiative was a component of the Promise Partnership Learning Health System (PPLHS) piloted in the Dartmouth Cancer Center, Lebanon, NH, USA. (1) The percentage of eligible patients with documented SIC and (2) a comparison of a patient reported measure of SDM (CollaboRATE) among SIC eligible patients in encounters with providers who took part in the implementation versus those who did not. Oncology teams screened a total of 538 patients, identified 278 eligible patients, and completed 144 SIC conversations. The teams improved the proportion of documented SIC among eligible patients from near 0% to a collective frequency of 52%. For clinicians' top-box CollaboRATE scores, a chi-squared test demonstrated a statistically significant association between providers implementing SIC into practice and patient reported shared decision making (.16, p = .031). This approach allows for tailoring of iterative improvement cycles to mitigate barriers and improve the practice of SIC among oncology teams.

Telehealth‐based pre‐operative education session for robot‐assisted radical prostatectomy patients—A 2‐year follow‐up study

AbstractIntroduction and ObjectivesAs a quality improvement initiative, our institution's pre‐operative education program for patients undergoing robotic radical prostatectomy (Robocare) was changed into a telehealth‐based program (Tele‐Robocare). During the pre‐surgery evaluation process, tele‐Robocare was deemed useful (92%) and adequate (100%) in addressing pre‐operative needs of patients. Follow‐up was deemed necessary to compare patient feedback post‐surgery.Materials and Methods2 years since the complete adoption of the Tele‐Robocare program in our institution, a follow‐up study was conducted on the participants who attended the original quality improvement initiative (n = 147). An 8‐question survey was created via Redcap. A survey link was sent to all participants: 144 via email link and 3 via QR code sent via postal mail. All responses were logged onto the Redcap database.ResultsA total of 87 patients (59.2%) completed the survey. 86 patients completed the survey via email link and 1 patient accessed the survey via the mailed QR code.The percentage of patients who found Tele‐Robocare useful in the following sections are: pre‐surgery preparation (90%), discharge care (89%), catheter care (82%), follow‐up (93%), troubleshooting (80%).When asked about what should remain as a part of the program handout and presentation, the findings were similar: pre‐surgery preparation (94%), hospital stay information (92%), discharge information (93%), follow‐up (90%), access to allied health (90%). The most requested topics that needed additional emphasis were sexual health (n = 5) and impact on mental health (n = 3).78% agree or strongly agree that telehealth was sufficient in receiving patient education programs such as Tele‐Robocare. The most common advice from patients (n = 25) to improve the patient experience and sense of preparedness was to actively seek additional information from the healthcare team, patients and/or patient advocates.ConclusionTele‐Robocare is now the standard method in delivering pre‐prostatectomy patient education in our institution. However, these follow‐up findings highlight the importance of sufficient follow‐up and support of patients after surgery as their needs change along with their recovery and outcomes.

Quality improvement initiative: improving obstetric triaging practices in a rural maternal hospital in central India

Triaging of obstetric patients by emergency care providers is paramount. It helps provide appropriate and timely management to prevent further injury and complications. Standardised trauma acuity scales have limited applicability...

Introduction of oral feeding in premature infants on high flow nasal cannula in a level IV neonatal intensive care unit: a quality improvement initiative.

Failure to reach full oral feeding remains a significant barrier for premature infants to discharge home. Postmenstrual age (PMA) at first oral feeding is significantly associated with the length of hospital stay (LOS). Single-center QI to introduce oral feeding to infants on high-flow nasal cannula (HFNC) by reducing the flow to 2 L during feeds. To reduce PMA at first oral feeding and reduce the LOS. To introduce oral feeds in 40% of infants who are on ≤4 L HFNC by the end of 12 months. Over 12 months, SMART aim reached with 100% enrollment. PMA at first oral feeding decreased from a median of 42.4w ((IQR) (40,46.6) to 37.8w (35.8,43.2), PMA at discharge decreased from 47w (44.6,50.7) to 42.6w (41.3,48.8). Allowing oral feeding in infants while on HFNC is feasible. This approach can significantly reduce PMA at first and full oral feeding.

Implementing Mental Health Screening for Adolescent Hematology and Oncology Patients: A Quality Improvement Initiative.

Purpose: Adolescents and young adults (AYA) with chronic illnesses experience an increase in mental health concerns. A mental health screening (MHS) process for hematology and oncology patients was implemented in a single institution. The quality improvement project was conducted to integrate a MHS process, educate providers about the importance of mental health in this patient population, and evaluate the process. Methods: The COM-B (capability, opportunity, motivation-behavior) model for behavior change was used to inform strategic planning and Plan-Do-Study-Act (PDSA) methodologies for process improvement. Retrospective chart reviews and surveys were conducted to determine missed screening rates and providers' perceptions, knowledge, attitudes, and skills of the MHS process. Results: Of 334 eligible patient encounters, the missed screening rate was 15.0%, the overall error rate of completing the screening was 3.8%, the error rate of completing the suicide or self-harm indicator was 2.6%, and the missed medical social worker touch point was 4.8%. Conclusion: The rising rates of mental health concerns in AYA hematology and oncology patients call for streamlined MHS processes to improve the identification of patients who may need intervention and services. Processes should be tailored to workflows and available resources. Future PDSA cycles will include providing dedicated nursing education and determining the cost needed to meet the rising mental health needs of the AYA hematology and oncology population.

Most preoperative stress tests fail to comply with practice guideline indications and do not reduce cardiac events.

There is wide variation in stress test utilization before major vascular surgery and adherence to practice guidelines is unclear. We defined rates of stress test compliance at our institution and led a quality improvement initiative to improve compliance with American Heart Association (ACC/AHA) guidelines. We implemented a stress testing order set in the electronic medical record at one tertiary hospital. We reviewed all patients who underwent elective, major vascular surgery in the 6 months before (Jan 1, 2022 - Jul 1, 2022) and 6 months after (Aug 1, 2022 - Jan 31, 2023) implementation. We studied stress test guideline compliance, changes in medical or surgical management, and major adverse cardiac events (MACE). Before order set implementation, 37/122 patients (30%) underwent stress testing within the past year (29 specifically ordered preoperatively) with 66% (19/29) guideline compliance. After order set implementation, 50/173 patients (29%) underwent stress testing within the past year (41 specifically ordered preoperatively) with 80% (33/41) guideline compliance. In the pre- and postimplementation cohorts, stress testing led to a cardiovascular medication change or preoperative coronary revascularization in 24% (7/29) and 27% (11/41) of patients, and a staged surgery or less invasive anesthetic strategy in 14% (4/29) and 4.9% (2/41) of patients, respectively. All unindicated stress tests were surgeon-ordered and none led to a change in management. There was no change in MACE after order set implementation. Electronic medical record-based guidance of perioperative stress testing led to a slight decrease in overall stress testing and an increase in guideline-compliant testing. Our study highlights a need for improved preoperative cardiovascular risk assessment prior to major vascular surgery, which may eliminate unnecessary testing and more effectively guide perioperative decision-making.

Abstract PO5-05-04: Advancing Treatment and Management of Patients with HR+/HER2- Breast Cancer: Findings from a Quality Improvement Initiative

Abstract Background: With the advent of novel oral oncolytics, the cancer care delivery model for HR+/HER2- breast cancer (BC) is evolving, shifting the responsibility for medication adherence and monitoring and managing of side effects to patients and their caregivers. In this quality improvement (QI) initiative, we aimed to uncover and address gaps in patient and provider education, risk reduction, adverse event management, and shared decision-making in order to improve outcomes for HR+/HER2+ patients on oral oncolytics. Methods: From 9/2022 to 12/2022, 54 HCPs who treat breast cancer and 111 HR+/HER2- BC patients from 4 US community oncology clinics completed surveys assessing attitudes, values, and challenges related to practice patterns, education, and therapy adherence in HR+/HER2- BC. HCPs participated in audit-feedback sessions to reflect on survey results and their own practice, and developed action plans to improve care, which were implemented in subsequent collaborative patient-provider learning sessions. Results: Top reported HCP challenges in HR+/HER2- BC care include providing patient-centered supportive care measures (32%), patient adherence/lack of follow up (22%), and individualizing treatment plans (17%). Additionally, 43% of providers reported that improved collaboration across interprofessional teams would most improve care. Top reported patient challenges include worry about and/or difficulty managing side effects from treatment (26%), difficulty scheduling visits with many different HCPs/following up (24%), and difficulty communicating with healthcare teams (16%). In surveys, 28% of patients reported frequently or very frequently missing/skipping doses of oral breast cancer medication. Top reasons for missing/skipping doses included forgetting or not having it nearby (36%), cost (21%), and side effects (20%). To address the top challenges identified in baseline surveys, HCPs developed and implemented action plans, such as improving the identification of patients at high risk of recurrence, establishing patient-provider educational sessions, increasing the use of patient navigators, incorporating oral adherence toolkits, and educating patients and staff about available supportive care resources. After implementation of patient-provider collaborative education sessions at community clinics, patients reporting high levels of knowledge about BC treatment options and communicating side effects/symptoms increased from 27% to 57%, and 37% to 77%, respectively. At 60-day follow-up, 58% of patients reported taking a more active role in treatment decision-making, and 52% reported setting reminders/alarms/using apps to remember to take medication on time. Conclusions: Patient adherence to oral oncolytic medications remains a challenge in BC treatment. This quality improvement initiative uncovered underlying barriers to effective treatment management of HR+/HER2- breast cancer patients on oral oncolytics. Action plans and educational resources were developed and implemented to address identified barriers and optimize treatment management for HR+/HER2- BC. These methods and findings represent key opportunities for improvement that can be implemented in community oncology practices to improve adherence to oral oncolytics and overall HR+/HER2- breast cancer care. Citation Format: Jane Meisel, Chelsie Anderson, Ilona Dewald, Jeffrey Carter, Cherilyn Heggen, Kelly McKinnon. Advancing Treatment and Management of Patients with HR+/HER2- Breast Cancer: Findings from a Quality Improvement Initiative [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO5-05-04.

Abstract PO4-04-03: Empowering Oncologists to Develop Individualized Management Strategies for HER2+ Metastatic Breast Cancer: Findings from a Quality Improvement Initiative

Abstract Background: Rapidly evolving evidence in the treatment of metastatic HER2+ metastatic breast cancer (MBC) can present challenges in aligning practice with the latest clinical data and guideline recommendations. In this ongoing quality improvement initiative, we identify and address real-world challenges healthcare professionals (HCPs) face in individualizing treatment plans, adverse event management, and patient-centered care for HER2+ MBC. Methods: From 9/2022 to 12/2022, 22 HCPs who treat patients with breast cancer (BC) along with 52 patients with HER2+ MBC from 2 large US community oncology clinics completed tethered surveys assessing practice patterns, challenges, and attitudes related to individualized and patient-centered care for HER2+MBC. Patient charts (n=100) were audited to assess current practice patterns and to track changes over time. Inclusion criteria included a confirmed HER2+ MBC diagnosis, prescription for two or more lines of HER2+ breast cancer treatment, and ≥ 1 visit in the one-year chart abstraction period. HCPs participated in audit-feedback sessions to assess site-specific challenges and gaps and developed action plans for improvement. Follow-up chart audits and HCP surveys will evaluate changes in practice patterns 6 months after the educational intervention. Results: The most frequently reported HCP challenges included coordination of care (41%) and individualizing treatment plans (32%). The most frequently reported patient challenges included feeling confident in treatment plan (30%) and being unable to meet work or home responsibilities (22%). In tethered surveys, there were discordant findings between patient and HCP perceptions related to goals for treatment, patient education, and patient-centered care. For example, 82% of HCPs reported often or always asking patients about treatment preferences, but only 8% of patients reported their doctor asked. While HCPs overwhelmingly thought surviving as long as possible was their patients’ top goal (82%), patients reported their top goals for treatment were improving quality of life (57%) and controlling symptoms (41%). Additionally, while HCPs thought patients had the most difficulty managing nausea/vomiting (68%) and diarrhea (59%), patients reported they have the most difficulty managing fatigue (46%) and hair loss (44%). Baseline chart audits highlighted several areas for improvement in guideline-aligned care, including treatment selection, sequencing, and supportive care. Based on identified gaps, providers developed and implemented action plans, such as increasing use of patient navigators, referring patients for palliative care at time of diagnosis, improving multidisciplinary team-based approaches, and implementing tools and resources to stay up-to-date on clinical evidence and guidelines. Full findings from baseline surveys and chart audits will be presented, along with follow-up surveys and chart audits to measure impact. Conclusions: Through this QI initiative, we identified gaps in individualized, guideline-aligned, patient-centered care for patients with HER2+ MBC, and HCPs developed and are implementing action plans for improvement. The methods and findings from this initiative demonstrate key opportunities to improve outcomes for patients with HER2+ MBC in community oncology clinics. Citation Format: Reshma Mahtani, Erika Hamilton, Ilona Dewald, Chelsie Anderson, Jeffrey Carter, Cherilyn Heggen, Kelly McKinnon. Empowering Oncologists to Develop Individualized Management Strategies for HER2+ Metastatic Breast Cancer: Findings from a Quality Improvement Initiative [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO4-04-03.

Rapid recognition and optimal management of hemophilia in the emergency department: A quality improvement project.

This study aimed to assess the effectiveness of a continuous quality improvement initiative at the University of Florida Health Physicians practice in reducing the time to administer factor replacement therapy (FRT) for hemophilia patients presenting with bleeding in the emergency department (ED). The study, a quasi-experimental, interventional design, was conducted between January 2020 and January 2023. The intervention, implemented in September 2021, involved training ED physicians, creating a specialized medication order set within the electronic health record (EHR), and a rapid triage system. The effectiveness was measured by comparing the time from ED arrival to factor administration before and after the intervention and benchmarking it against the National Bleeding Disorders Foundation's Medical and Scientific Advisory Council (MASAC)-recommended 1-hour timeline for factor administration. An interrupted time series (ITS) analysis with a generalized least squares model assessed the intervention's impact. A total of 43 ED visits (22 pre-intervention and 21 post-intervention) were recorded. Post-intervention, the average time from ED arrival to factor administration decreased from 5.63 to 3.15hours. There was no significant increase (27%vs. 29%) in the patients receiving factor within 1-hour of ED arrival. The ITS analysis predicted a 20-hour reduction in the average quarterly time to administer factor by the end of the study, an 84% decrease. The quality improvement program decreased the time to administer FRT for patients with hemophilia in the ED. However, the majority of patients did not achieve the 1-hour MASAC-recommended timeline for factor administration after ED arrival.

Challenges with sweat testing – A quality improvement initiative

Challenges with sweat testing – A quality improvement initiative

Enhanced recovery program in ambulatory pediatric urology: A quality improvement initiative

Enhanced Recovery After Surgery (ERAS) was established in 2001 for adult patients undergoing complex procedures. ERAS in adult ambulatory surgery later followed with similar positive outcomes. For the pediatric population, ERAS implementation has shown promising results in complex surgeries such as bladder reconstruction. Its application in pediatric ambulatory surgery has only recently been reported. We hereby report a Quality Improvement initiative in implementing an Enhanced Recovery Protocol (ERP) for pediatric urology in an ambulatory surgery center. A project was launched to evaluate and implement enhanced recovery elements into an institutional Enhanced Recovery Protocol (ERP). These included reliance on peripheral nerve blocks for all inguinal and genital cases and reduction of opioids intraoperatively and postoperatively. Improvements were placed into a project plan broken into one preparation phase to collect baseline data and three implementation phases to enhance existing and implement new elements. The implementation phase went through iterative Plan-Do-Study-Act (PDSA) cycles for all sub-projects. Team countermeasures were based on available evidence. A consensus process was used to resolve disagreement. Monthly meetings were held to share real-time data, gather new feedback, and modify plans as needed. The primary outcome measures selected were percent intraoperative opioid use, percent opioid prescribing, mean PACU length of stay, and average number of opioid doses prescribed. Secondary outcome measures were mean maximum pain score in PACU, PACU rescue rate for PONV, and patient/family satisfaction scores. Post-implementation data for 18 months was included for evaluation. Statistical process control methodology was used. The total number of participants was 3306: 561 (baseline), 220 (Phase 1) 356 (Phase 2) and 527 (Phase 3), 1642 (post-implementation). Intraoperative opioid use was eliminated in >99% of cases. Post-operative opioid prescribing was reduced from 30% to 15% of patients. The number of opioid doses was also reduced from an average of 7.6 to 6.1 doses. There was no change for the mean maximum pain score in the recovery room despite elimination of opioids. Patient/family satisfaction scores were high and sustained throughout the period of study (9.8/10). Balancing measures such as return to the operating room within 30 days and return to the emergency department within 7 days were unchanged. This QI project demonstrated the feasibility of a pediatric enhanced recovery protocol in a urology ambulatory surgery setting. With implementation of this protocol, intraoperative opioid use was virtually eliminated, and opioid prescribing was reduced without affecting pain scores or post-operative complications.

307 IMPROVING ADENOMA DETECTION RATE THROUGH FEEDBACK, EDUCATION, AND INCENTIVE - A QUALITY IMPROVEMENT INITIATIVE

307 IMPROVING ADENOMA DETECTION RATE THROUGH FEEDBACK, EDUCATION, AND INCENTIVE - A QUALITY IMPROVEMENT INITIATIVE

Strategic Integration of Technology and Practice Model Enhances the Standard of Care for Inpatient Blood Draws

This case study details an evolution in blood draw practice at a US acute care hospital, informed by in-depth semi-structured interviews with hospital leaders. The comprehensive initiative included adopting a needle-free blood collection device followed by an innovative nursing practice model. The strategic shift enhanced device utilization, streamlined clinical workflow, facilitated better integration of blood draws into nursing care, and improved patient satisfaction and outcomes. Our summary illustrates the importance of considering both the technology and the practice model in quality improvement initiatives. Furthermore, we highlight important aspects of this initiative that led to success, to instruct other facilities.