Quality Improvement Interventions Research Articles

Diagnostic stewardship in infectious diseases: a scoping review

Introduction. The term ‘diagnostic stewardship’ is relatively new, with a recent surge in its use within the literature. Despite its increasing popularity, a precise definition remains elusive. Various attempts have been made to define it, with some viewing it as an integral part of antimicrobial stewardship. The World Health Organization offers a broad definition, emphasizing the importance of timely, accurate diagnostics. However, inconsistencies in the use of this term still persist, necessitating further clarification. Gap Statement. There are currently inconsistencies in the definition of diagnostic stewardship used within the academic literature. Aim. This scoping review aims to categorize the use of diagnostic stewardship approaches and define this approach by identifying common characteristics and factors of its use within the literature. Methodology. This scoping review undertook a multi-database search from date of inception until October 2022. Any observational or experimental study where the authors define the intervention to be diagnostic stewardship from any clinical area was included. Screening of all papers was undertaken by a single reviewer with 10% verification by a second reviewer. Data extraction was undertaken by a single reviewer using a pre-piloted form. Given the wide variation in study design and intervention outcomes, a narrative synthesis approach was applied. Studies were clustered around common diagnostic stewardship interventions where appropriate. Results. After duplicate removal, a total of 1310 citations were identified, of which, after full-paper screening, 105 studies were included in this scoping review. The classification of an intervention as taking a diagnostic stewardship approach is a relatively recent development, with the first publication in this field dating back to 2017. The majority of research in this area has been conducted within the USA, with very few studies undertaken outside this region. Visual inspection of the citation map reveals that the current evidence base is interconnected, with frequent references to each other’s work. The interventions commonly adopt a restrictive approach, utilizing hard and soft stops within the pre-analytical phase to restrict access to testing. Upon closer examination of the outcomes, it becomes evident that there is a predominant focus on reducing the number of tests rather than enhancing the current test protocol. This is further reflected in the limited number of studies that report on test performance (including protocol improvements, specificity and sensitivity). Conclusion. Diagnostic stewardship seems to have deviated from its intended course, morphing into a rather rudimentary instrument wielded not to enhance but to constrict the scope of testing. Despite the World Health Organization’s advocacy for an ideology that promotes a more comprehensive approach to quality improvement, it may be more appropriate to consider alternative regional narratives when categorizing these types of quality improvement interventions.

Predictive modelling of transport decisions and resources optimisation in pre-hospital setting using machine learning techniques.

The global evolution of pre-hospital care systems faces dynamic challenges, particularly in multinational settings. Machine learning (ML) techniques enable the exploration of deeply embedded data patterns for improved patient care and resource optimisation. This study's objective was to accurately predict cases that necessitated transportation versus those that did not, using ML techniques, thereby facilitating efficient resource allocation. ML algorithms were utilised to predict patient transport decisions in a Middle Eastern national pre-hospital emergency medical care provider. A comprehensive dataset comprising 93,712 emergency calls from the 999-call centre was analysed using R programming language. Demographic and clinical variables were incorporated to enhance predictive accuracy. Random Forest (RF), Support Vector Machine (SVM), Extreme Gradient Boosting (XGBoost), and Adaptive Boosting (AdaBoost) algorithms were trained and validated. All the trained algorithm models, particularly XGBoost (Accuracy = 83.1%), correctly predicted patients' transportation decisions. Further, they indicated statistically significant patterns that could be leveraged for targeted resource deployment. Moreover, the specificity rates were high; 97.96% in RF and 95.39% in XGBoost, minimising the incidence of incorrectly identified "Transported" cases (False Positive). The study identified the transformative potential of ML algorithms in enhancing the quality of pre-hospital care in Qatar. The high predictive accuracy of the employed models suggested actionable avenues for day and time-specific resource planning and patient triaging, thereby having potential to contribute to pre-hospital quality, safety, and value improvement. These findings pave the way for more nuanced, data-driven quality improvement interventions with significant implications for future operational strategies.

Determinants of the optimal selection of vascular access devices: A systematic review underpinned by the COM-B behavioural model.

Optimal selection of vascular access devices is based on multiple factors and is the first strategy to reduce vascular access device-related complications. This process is dependent on behavioural and human factors. The COM-B (Capability, Opportunity, Motivation, Behaviour) model was used as a theoretical framework to organize the findings of this systematic review. To synthesize the evidence on determinants shaping the optimal selection of vascular access devices, using the COM-B behavioural model as the theoretical framework. Systematic review of studies which explore decision-making at the time of selecting vascular access devices. The Medline, Web of Science, Scopus and EbscoHost databases were interrogated to extract manuscripts published up to 31 December 2021, in English or Spanish. Among 16 studies included in the review, 8/16 (50%) focused on physical capability, 8/16 (50%) psychological capability, 15/16 (94%) physical opportunity, 12/16 (75%) social opportunity, 1/16 (6%) reflective motivation and 0/16 (0%) automatic motivation. This distribution represents a large gap in terms of interpersonal and motivational influences and cultural and social environments. Specialist teams (teams created for the insertion or maintenance of vascular access devices) are core for the optimal selection of vascular access devices (75% physical capability, 62% psychological capability, 80% physical opportunity and 100% social opportunity). Specialist teams predominantly lead all actions undertaken towards the optimal selection of vascular access devices. These actions primarily centre on assessing opportunity and capability, often overlooking motivational influences and social environments. A more implementation-focused professional approach could decrease inequity among patients and complications associated with vascular access devices. Optimal selection of vascular access devices is the primary strategy in mitigating complications associated with these devices. There is a significant disparity between interpersonal and motivational influences and the cultural and social environments. Furthermore, specialized teams play a pivotal role in facilitating the optimal selection of vascular access devices. The study can benefit institutions concerned about vascular access devices and their complications. This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. No Patient or Public Contribution. WHAT DOES THIS ARTICLE CONTRIBUTE TO THE WIDER GLOBAL CLINICAL COMMUNITY?: Optimal selection of vascular devices remains a growing yet unresolved issue with costly clinical and patient experience impact. Interventions to improve the optimal selection of vascular devices have focused on training, education, algorithms and implementation of specialist vascular teams; alas, these approaches do not seem to have substantially addressed the problem. Specialist vascular teams should evolve and pivot towards leading the implementation of quality improvement interventions, optimizing resource use and enhancing their role.

Hospital-Based Pediatric Quality Improvement Interventions and Health Disparities: A Scoping Review of the Literature.

Quality improvement (QI) has the potential to reduce health disparities through multiple mechanisms, including by standardizing care and addressing social barriers to health. National organizations require that hospital systems integrate equity into quality efforts, but effective approaches remain unclear. We aimed to examine the association of hospital-based pediatric QI interventions and racial and ethnic, language, and socioeconomic disparities in health outcomes. Quantitative studies from January 1, 2000 to December 11, 2023 reporting the effects of pediatric hospital-based QI were selected from PubMed and Embase. Studies were excluded if outcomes were not stratified by race and ethnicity, language, or socioeconomic status. Studies were reviewed in duplicate for inclusion and by 1 author for data extraction. A total of 22 studies were included. Most studies (n = 19, 86%) revealed preexisting disparities, and 68% of those (n = 13) found disparities reductions post-intervention. Studies with disparity-focused objectives or interventions more commonly found reduced disparities than studies of general QI (85% vs 33%). Hospital-based process standardization was associated with reduced disparities in provider practices. Most interventions associated with reduced disparities in patient-facing outcomes involved community/ambulatory partnership. Limitations included potential exclusion of relevant studies, topic heterogenity, and risk of bias. Although the authors of few published hospital-based QI initiatives assessed their equity effect, intentionally designed QI studies were associated with reduced disparities. Interventions focused on care standardization may reduce disparities in care quality, although multilevel interventions are likely needed to affect the health care structures that influence more significant patient outcomes.

Perspectives on supporting Veterans’ social needs during hospital to home health transitions: findings from the Transitions Nurse Program

BackgroundVeterans who need post-acute home health care (HHC) are at risk for adverse outcomes and unmet social needs. Veterans’ social needs could be identified and met by community-based HHC clinicians due to their unique perspective from the home environment, acuity of Veterans they serve, and access to Veterans receiving community care. To understand these needs, we explored clinician, Veteran, and care partner perspectives to understand Veterans’ social needs during the transition from hospital to home with skilled HHC.MethodsQualitative data were collected through individual interviews with Veterans Health Administration (VHA) inpatient & community HHC clinicians, Veterans, and care partners who have significant roles facilitating Veterans’ hospital to home with HHC transition. To inform implementation of a care coordination quality improvement intervention, participants were asked about VHA and HHC care coordination and Veterans’ social needs during these transitions. Interviews were recorded, transcribed, and analyzed inductively using thematic analysis and results were organized deductively according to relevant transitional care domains (Discharge Planning, Transition to Home, and HHC Delivery).ResultsWe conducted 35 interviews at 4 VHA Medical Centers located in Western, Midwestern, and Southern U.S. regions during March 2021 through July 2022. We organized results by the three care transition domains and related themes by VHA, HHC, or Veteran/care partner perspective. Our themes included (1) how social needs affected access to HHC, (2) the need for social needs screening during hospitalization, (3) delays in HHC for Veterans discharged from community hospitals, and (4) a need for closed-loop communication between VHA and HHC to report social needs.ConclusionsHHC is an underexplored space for Veterans social needs detection. While this research is preliminary, we recommend two steps forward from this work: (1) develop closed-loop communication and education pathways with HHC and (2) develop a partnership to integrate a social risk screener into HHC pathways.

Exploring women’s experiences of care during hospital childbirth in rural Tanzania: a qualitative study

BackgroundWomen’s childbirth experiences provide a unique understanding of care received in health facilities from their voices as they describe their needs, what they consider good and what should be changed. Quality Improvement interventions in healthcare are often designed without inputs from women as end-users, leading to a lack of consideration for their needs and expectations. Recently, quality improvement interventions that incorporate women’s childbirth experiences are thought to result in healthcare services that are more responsive and grounded in the end-user’s needs.AimThis study aimed to explore women’s childbirth experiences to inform a co-designed quality improvement intervention in Southern Tanzania.MethodsThis exploratory qualitative study used semi-structured interviews with women after childbirth (n = 25) in two hospitals in Southern Tanzania. Reflexive thematic analysis was applied using the World Health Organization’s Quality of Care framework on experiences of care domains.ResultsThree themes emerged from the data: (1) Women’s experiences of communication with providers varied (2) Respect and dignity during intrapartum care is not guaranteed; (3) Women had varying experience of support during labour. Verbal mistreatment and threatening language for adverse birthing outcomes were common. Women appreciated physical or emotional support through human interaction. Some women would have wished for more support, but most accepted the current practices as they were.ConclusionThe experiences of care described by women during childbirth varied from one woman to the other. Expectations towards empathic care seemed low, and the little interaction women had during labour and birth was therefore often appreciated and mistreatment normalized. Potential co-designed interventions should include strategies to (i) empower women to voice their needs during childbirth and (ii) support healthcare providers to have competencies to be more responsive to women’s needs.

Prospective Study of a System-Wide Adrenal Incidentaloma Quality Improvement Initiative.

Appropriate follow-up of incidental adrenal masses (IAMs) is infrequent. We implemented a quality improvement (QI) program to improve management of IAMs. This system-wide initiative targeted primary care providers (PCPs) after IAM detection. It incorporated (1) chart-based messages and emails to PCPs, (2) an evidence-based IAM evaluation algorithm, (3) standardized recommendations in radiology reports, and (4) access to a multispecialty adrenal clinic. Patients diagnosed with an IAM from January 1, 2018, to December 31, 2019, were prospectively included (the "QI cohort") and compared with a historical, preintervention cohort diagnosed with IAMs in 2016. The primary outcomes were the initiation of an IAM investigation by the PCP, defined as relevant clinical history-taking, laboratory screening, follow-up imaging, or specialist referral. The QI cohort included 437 patients and 210 in the historical cohort. All patients had 12 months or more of follow-up. In the QI cohort, 35.5% (155 of 437) met the primary endpoint for PCP-initiated evaluation, compared with 27.6% (58 of 210) in the historical cohort (p = 0.0496). Among the subgroup with a documented PCP working within our health system, 46.3% (74 of 160) met the primary endpoint in the QI cohort vs 33.3% (38 of 114) in the historical cohort (p = 0.035). After adjusting for insurance status, presence of current malignancy, initial imaging setting (outpatient, inpatient, or emergency department), and having an established PCP within our health system, patients in the QI cohort had 1.70 times higher odds (95% CI 1.16 to 2.50) of undergoing a PCP-initiated IAM evaluation. Adrenal surgery was ultimately performed in 2.1% (9 of 437) of QI cohort patients and 0.95% (2 of 210) of historical cohort patients (p = 0.517). This simple, moderately labor-intensive QI intervention was associated with increased IAM evaluation initiated by PCPs.

Accrual Quality Improvement Program for clinical trials.

The Early Phase Cancer Prevention Clinical Trials Program (Consortia), led by the Division of Cancer Prevention, National Cancer Institute, supports and conducts trials assessing safety, tolerability, and cancer preventive potential of a variety of interventions. Accrual to cancer prevention trials includes the recruitment of unaffected populations, posing unique challenges related to minimizing participant burden and risk, given the less evident or measurable benefits to individual participants. The Accrual Quality Improvement Program was developed to address these challenges and better understand the multiple determinants of accrual activity throughout the life of the trial. Through continuous monitoring of accrual data, Accrual Quality Improvement Program identifies positive and negative factors in real-time to optimize enrollment rates for ongoing and future trials. The Accrual Quality Improvement Program provides a web-based centralized infrastructure for collecting, analyzing, visualizing, and storing qualitative and quantitative participant-, site-, and study-level data. The Accrual Quality Improvement Program approaches cancer prevention clinical trial accrual as multi-factorial, recognizing protocol design, potential participants' characteristics, and individual site as well as study-wide implementation issues. The Accrual Quality Improvement Program was used across 39 Consortia trials from 2014 to 2022 to collect comprehensive trial information. The Accrual Quality Improvement Program captures data at the participant level, including number of charts reviewed, potential participants contacted and reasons why participants were not eligible for contact or did not consent to the trial or start intervention. The Accrual Quality Improvement Program also captures site-level (e.g. staffing issues) and study-level (e.g. when protocol amendments are made) data at each step of the recruitment/enrollment process, from potential participant identification to contact, consent, intervention, and study completion using a Recruitment Journal. Accrual Quality Improvement Program's functionality also includes tracking and visualization of a trial's cumulative accrual rate compared to the projected accrual rate, including a zone-based performance rating with corresponding quality improvement intervention recommendations. The challenges associated with recruitment and timely completion of early phase cancer prevention clinical trials necessitate a data collection program capable of continuous collection and quality improvement. The Accrual Quality Improvement Program collects cumulative data across National Cancer Institute, Division of Cancer Prevention early phase clinical trials, providing the opportunity for real-time review of participant-, site-, and study-level data and thereby enables responsive recruitment strategy and protocol modifications for improved recruitment rates to ongoing trials. Of note, Accrual Quality Improvement Program data collected from ongoing trials will inform future trials to optimize protocol design and maximize accrual efficiency.

Caring for hearts and minds: a quality improvement approach to individualized developmental care in the cardiac intensive care unit.

Infants with congenital heart disease (CHD) are at high risk for developmental differences which can be explained by the cumulative effect of medical complications along with sequelae related to the hospital and environmental challenges. The intervention of individualized developmental care (IDC) minimizes the mismatch between the fragile newborn brain's expectations and the experiences of stress and pain inherent in the intensive care unit (ICU) environment. A multidisciplinary group of experts was assembled to implement quality improvement (QI) to increase the amount of IDC provided, using the Newborn Individualized Developmental Care and Assessment Program (NIDCAP), to newborn infants in the cardiac ICU. A Key Driver Diagram was created, PDSA cycles were implemented, baseline and ongoing measurements of IDC were collected, and interventions were provided. We collected 357 NIDCAP audits of bedside IDC. Improvement over time was noted in the amount of IDC including use of appropriate lighting, sound management, and developmentally supportive infant bedding and clothing, as well as in promoting self-regulation, therapeutic positioning, and caregiving facilitation. The area of family participation and holding of infants in the CICU was the hardest to support change over time, especially with the most ill infants. Infants with increased medical complexity were less likely to receive IDC. This multidisciplinary, evidence-based QI intervention demonstrated that the implementation of IDC in the NIDCAP model improved over time using bedside auditing of IDC.

Do medical specialists accept claims-based Audit and Feedback for quality improvement? A focus group study

ObjectivesAudit and Feedback (A&F) is a widely used quality improvement (QI) intervention in healthcare. However, not all feedback is accepted by professionals. While claims-based feedback has been previously used for...

Disparities in the Timeliness of Addressing Patient-Initiated Telephone Calls in a Primary Care Clinic: The Impact of Quality Improvement Interventions

ABSTRACT A timely response to patient-initiated telephone calls can affect many aspects of patient health, including quality of care and health equity. Historically, at a family medicine residency clinic, at least 1 out of 4 patient calls remained unresolved three days after the call was placed. We sought to explore whether there were differential delays in resolution of patient concerns for certain groups and how these were affected by quality improvement interventions to increase responsiveness to patient calls. A multidisciplinary team at a primary care residency clinic applied Lean education and tools to improve the timeliness of addressing telephone encounters. Telephone encounter data were obtained for one year before and nine months after the intervention. Data were stratified by race, ethnicity, preferred language, sex, online portal activation status, age category, zip code, patient risk category, and reason for call. Stratified data revealed consistently worse performance on telephone encounter closure by 72 hours for Black/African American patients compared to Hispanic and non-Hispanic White patients pre-intervention. Interventions resulted in statistically significant overall improvement, with an OR of 2.9 (95% CI: 2.62 to 3.21). Though interventions did not target a specific population, pre-intervention differences based on race and ethnicity resolved post-intervention. Telephone calls serve as an important means of patient communication with care teams. General interventions to improve the timeliness of addressing telephone encounters can lead to sustainable improvement in a primary care academic clinic and may also alleviate disparities.

Outcomes of a Multi-Site Mentored Implementation Approach to Promoting Goals of Care Conversations

ContextThe Preference-Aligned Communication and Treatment (PACT) Project is a multi-site quality improvement effort that has been shown to increase the frequency of goals of care (GOC) conversations in hospitalized patients with serious illness. ObjectivesTo evaluate the effect of PACT on goal-discordant care and resource utilization. MethodsHospitals enrolled in a multi-year mentored implementation quality improvement initiative to facilitate GOC conversations for seriously ill hospitalized patients. The primary outcome was the percentage of patients with care discordant with stated preferences, assessed by comparing documented wishes to Medicare claims data for patients who were admitted to intervention units and died over the study period. Secondary outcomes evaluated end-of-life resource utilization by comparing Medicare claims data for intervention patients with propensity score-matched controls. ResultsIn the 9 hospitals included in the study, 1347 intervention group patients were compared to 4019 in the control group. Rates of discordance between wishes and care were generally low in the intervention group. Compared to the control group, patients in the intervention group had lower costs (-976.05 dollars, p=0.010), were less likely to be admitted to the ICU (OR 0.9, p=0.005), less likely to be on a ventilator or undergo CPR or cardioversion, more likely to enroll in hospice (OR 1.81, p<0.001) and had a longer hospice stay (3.35 more days, p=0.041). ConclusionA multi-site mentored implementation quality improvement intervention for seriously ill hospitalized patients resulted in care aligned with goals and decreased resource utilization at the end of life.

Reducing Inequity in the Use of Automated Insulin Delivery Systems by Adults With Type 1 Diabetes: Key Learnings From a Safety Net Diabetes Clinic Program

BackgroundRecent advancements in diabetes technology have significantly improved Type 1 diabetes (T1D) management, but disparities persist, particularly in the adoption of automated insulin delivery (AID) systems within minoritized communities. We aimed to improve patient access to AID system training and overcome clinical inertia to referral. MethodsWe report on a transformative program implemented at Boston Medical Center, the largest safety-net hospital in New England, aimed at reducing disparities in AID system utilization. We employed a multidisciplinary team and quality improvement principles to identify barriers and develop solutions. Strategies included increasing access to diabetes educators, creating a referral system, and developing telemedicine education classes. We also made efforts to raise clinician awareness and confidence in recommending AID therapy. ResultsAt baseline, 13.5% of our clinic T1D population was using an insulin pump. The population referred included 97 people with T1D (49% female, mean A1c 8.7%, 68% public insurance beneficiaries, 25% Hispanic and 25% non-Hispanic Black). Results from the first year showed a 166% increase in AID system use rates, with 64% of referred patients starting on AID. Notably, 78% of patients with A1c >8.5% adopted AID systems, addressing a gap in representation observed in clinical efficacy trials. The initiative successfully narrowed disparities in AID use among minoritized populations. ConclusionsThe program's success among minoritized patients underscores the significance of tailored, collaborative, team-based care and targeted educational initiatives. Our experience provides a foundation for future efforts to ensure equitable access to diabetes technologies, emphasizing the potential of local quality improvement interventions.

Improving parental mental health in the perinatal period: A review and analysis of quality improvement initiatives

Parental mental health is an essential sixth vital sign that, when taken into consideration, allows clinicians to improve clinical outcomes for both parents and infants. Although standards exist for screening, referral, and treatment for perinatal mood and anxiety disorders (PMADs), they are not reliably done in practice, and even when addressed, interventions are often minimal in scope. Quality improvement methodology can accelerate the implementation of interventions to address PMADs, but hurdles exist, and systems are not well designed, particularly in pediatric inpatient facilities. In this article, we review the effect of PMADs on parents and their infants and identify quality improvement interventions that can increase screening and referral to treatment of parents experiencing PMADs.

Organizational Context and Facilitation Interactions on Delirium Risk in Long-Term Care: A Cross-Sectional Study

ObjectivesOrganizational context (eg, leadership) and facilitation (eg, coaching behaviors) are thought to interact and influence staff best practices in long-term care (LTC), including the management of delirium. Our objective was to assess if organizational context and facilitation—individually, and their interactions—were associated with delirium in LTC. DesignRetrospective cross-sectional analysis of secondary data. Setting and ParticipantsWe included 8755 residents from 281 care units in 86 LTC facilities in 3 Canadian provinces. MethodsDelirium (present/absent) was assessed using the Resident Assessment Instrument-Minimum Data Set 2.0 (RAI-MDS 2.0). The Alberta Context Tool (ACT) measured 10 modifiable features of care unit organizational context. We measured the care unit's total care hours per resident day and the proportion of care hours that care aides contributed (staffing mix). Facilitation included the facility manager's perception of RAI-MDS reports' adequacy and pharmacist availability. We included unit managers' change-oriented organizational citizenship behavior (OCB) and an item reflecting how often care aides recommended policy changes. Associations of organizational context, facilitation, and their interactions with delirium were analyzed using mixed-effects logistic regressions, controlling for covariates. ResultsDelirium symptoms were prevalent in 17.4% of residents (n = 1527). Manager-perceived adequacy of RAI-MDS reports was linked to reduced delirium symptoms (odds ratio [OR] = 0.63). Higher care hours per resident day (OR = 1.2) and an available pharmacist in the facility (OR = 1.5) were associated with increased delirium symptoms. ACT elements showed no direct association with delirium. However, on care units with low social capital scores (context), increased unit managers' OCB decreased delirium symptoms. On care units with high vs low evaluation scores (context), increased staffing mix reduces delirium symptoms more substantially. Conclusions and ImplicationsUnit-level interactions between organizational context and facilitation call for targeted quality improvement interventions based on specific contextual factors, as effectiveness may vary across contexts.

Improvement in rates of optimal cord management without an increase in admission hypothermia-results of two quality improvement projects

BackgroundImproving the rates of Optimal cord management (OCM), and maintaining admission normothermia remains a challenge. ObjectiveTo improve OCM rates and admission normothermia in a tertiary perinatal centre in the UK. MethodsTwo Quality Improvement (QI) projects were launched in 2021 to increase OCM rates to 70% and admission normothermia rates to 80% by December 2023. Our QI project involved multidisciplinary team engagement, development of guidelines, and education. ResultsFollowing the QI interventions, our rates of OCM improved from 15% to 62% and admission normothermia from 50% to 87%. The most common reason for not performing OCM was the perceived need for resuscitation (72%). There are no increased odds of preterm infants receiving OCM and admission hypothermia (OR 0.23), and admission temperature above 37.5 C (OR 0.47). ConclusionsThrough our QI initiatives we have significantly improved rates of OCM and admission normothermia rates in preterm infants.

Remote Follow-up in a Heart Failure Pragmatic Trial: Insights From the CONNECT-HF

Randomized controlled trials typically require study-specific visits, which can burden participants and sites. Remote follow-up, such as centralized call centers for participant-reported or site-reported, holds promise for reducing costs and enhancing the pragmatism of trials. In this secondary analysis of the CONNECT-HF (Care Optimization Through Patient and Hospital Engagement For HF) trial, we aimed to evaluate the completeness and validity of the remote follow-up process. The CONNECT-HF trial evaluated the effect of a post-discharge quality-improvement intervention for heart failure compared to usual care for up to 1 year. Suspected events were reported either by participants or by health care proxies through a centralized call center or by sites through medical-record queries. When potential hospitalization events were suspected, additional medical records were collected and adjudicated. Among 5942 potential hospitalizations, 18% were only participant-reported, 28% were reported by both participants and sites, and 50% were only site-reported. Concordance rates between the participant/site reports and adjudication for hospitalization were high: 87% participant-reported, 86% both, and 86% site-reported. Rates of adjudicated heart failure hospitalization events among adjudicated all-cause hospitalization were lower but also consistent: 45% participant-reported, 50% both, and 50% site-reported. Participant-only and site-only reports missed a substantial number of hospitalization events. We observed similar concordance between participant/site reports and adjudication for hospitalizations. Combining participant-reported and site-reported outcomes data is important to capture and validate hospitalizations effectively in pragmatic heart failure trials.

Cost-Effectiveness of Increased Use of Dual Antiplatelet Therapy After High-Risk Transient Ischemic Attack or Minor Stroke.

Rates of dual antiplatelet therapy (DAPT) after high-risk transient ischemic attack or minor ischemic stroke (TIAMIS) are suboptimal. We performed a cost-effectiveness analysis to characterize the parameters of a quality improvement (QI) intervention designed to increase DAPT use after TIAMIS. We constructed a decision tree model that compared current national rates of DAPT use after TIAMIS with rates after implementing a theoretical QI intervention designed to increase appropriate DAPT use. The base case assumed that a QI intervention increased the rate of DAPT use to 65% from 45%. Costs (payer and societal) and outcomes (stroke, myocardial infarction, major bleed, or death) were modeled using a lifetime horizon. An incremental cost-effectiveness ratio <$100 000 per quality-adjusted life year was considered cost-effective. Deterministic and probabilistic sensitivity analyses were performed. From the payer perspective, a QI intervention was associated with $9657 in lifetime cost savings and 0.18 more quality-adjusted life years compared with current national treatment rates. A QI intervention was cost-effective in 73% of probabilistic sensitivity analysis iterations. Results were similar from the societal perspective. The maximum acceptable, initial, 1-time payer cost of a QI intervention was $28 032 per patient. A QI intervention that increased DAPT use to at least 51% was cost-effective in the base case. Increasing DAPT use after TIAMIS with a QI intervention is cost-effective over a wide range of costs and proportion of patients with TIAMIS treated with DAPT after implementation of a QI intervention. Our results support the development of future interventions focused on increasing DAPT use after TIAMIS.

Reducing catheter-associated urinary tract infection in high dependency unit: an eighteen-month quality improvement intervention study period

Reducing catheter-associated urinary tract infection in high dependency unit: an eighteen-month quality improvement intervention study period

A Quality Improvement Initiative to Increase Skin-to-Skin Care Duration in Preterm Neonates.

Skin-to-skin (STS) care effectively improves neonatal outcomes, particularly for preterm neonates. However, utilization of STS remains suboptimal for the most vulnerable preterm neonates in the first 4 weeks of life. This quality improvement (QI) project aimed to increase STS duration for neonates under 35 weeks gestation. The QI initiative was conducted in a 35-bed level IV NICU within a teaching hospital in New York City from July 2021 to January 2023. Six months of baseline data and a staff survey determined interventions across "Plan, Do, Study, Act" cycles. Interim analyses guided interventions using run charts. Interventions included parental counseling and information leaflets, discussion during rounds on STS eligibility, STS education for residents, nurses' feedback, and visual reminders. The primary outcome measure was the mean duration of STS per eligible patient day. The process measures were the age at first STS and documentation of eligibility for STS care in the electronic medical records. Balancing measures included adverse events such as apnea, bradycardia, desaturation, hypothermia, and inadvertent dislodgement of central lines and endotracheal tube. The study included 185 infants with a mean gestational age of 29.1 weeks. The mean STS duration per eligible patient day increased from a baseline of 13.3 minutes to 32.4 minutes without significantly increasing adverse events. The QI interventions implemented have successfully increased the duration of STS in preterm infants. Our interventions combined into an STS bundle can be a potential model for other NICUs to improve STS practice.