Quality Improvement Process Research Articles

Quality improvement in the era of boarding and burnout: A postpandemic blueprint.

The COVID-19 pandemic led to unprecedented challenges to healthcare quality in the emergency department, including directly impacting quality metrics and worsening barriers to the quality improvement process such as burnout, staff turnover, and boarding. We aimed to develop a blueprint for postpandemic quality improvement to address these specific barriers, focused on prioritizing frontline staff engagement from idea generation to implementation and assessment. Drawing from teamwork literature, we constructed a process that emphasized egalitarian conversations, psychological safety, and creating an environment where staff could feel heard at every step of the process. We applied this blueprint to improving rates of patients who leave without being seen and achieved a four percentage point reduction (9%vs. 5%, p<0.001), with high rates of staff satisfaction with the process. We conclude that while postpandemic quality improvement presents significant challenges, we can rise to meet those challenges by adapting existing quality improvement processes to increase frontline staff engagement.

The Production and Performance of Workplace Hierarchies in Australian Outside School Hours Care

Outside School Hours Care (OSHC) provides play, leisure, care and education for significant numbers of Australian children. As government has become increasingly involved in the regulation of OSHC, the sector has become increasingly professionalised. OSHC practitioners are active participants in quality improvement processes and increasingly likely to have qualifications. Despite its growing social importance, there is little research about the OSHC workforce. This article draws on a research project conducted with OSHC practitioners who participated in a professional development program that introduced a set of professional standards for practitioners. The research investigated how participants engaged with the standards after completion of the program and demonstrated that uptake of the professional standards was complicated by workplace and sector hierarchies. Participants were less likely to use the standards for service leaders and short-term, casualised workers. These hierarchies formed in complex ways around dominant discourses that underestimate care and leisure work and position OSHC as a secondary consideration for school management. The findings in this research have important implications for the sustainability of the OSHC workforce, how it is perceived and how it engages with professional development programs.

Improving healthcare transition for young people with cancer: factors fundamental to the quality improvement journey.

Young people receiving cancer treatment in the South Thames Children's, Teenagers' and Young Adults' Cancer Operational Delivery Network usually receive care across two or more NHS trusts, meaning transition into adult services can be challenging. To develop a planned, co-ordinated approach to transition across the network that meets National Institute for Health and Care Excellence guidance recommendations for transition and the cancer service specifications. A 2-year, nurse-led quality improvement (QI) project, using the principles of experience-based co-design. The QI project resulted in the development of six key principles of practice; refining and testing of a benchmarking tool; initiatives to facilitate first transition conversations; and the launch of an information hub. Robust QI processes, cross-network collaboration and wide stakeholder involvement required significant resource, but enabled deeper understanding of existing pathways and processes, facilitated the establishment of meaningful objectives, and enabled the testing of interventions to ensure the project outcomes met the needs of all stakeholders.

Integrating Patient-Reported Outcomes in the Evaluation of Breast Implant Satisfaction and Quality of Life

With a focus on aesthetic and reconstructive services, PROs have become even more important in assessing the success rate of procedures. More specifically, the current study looks into the use of PROs to gauge patient quality of life and satisfaction with breast implants. Accordingly, patients may not be content with their care because typical measures based on a proportion of fatalities, morbidity/mortality rates, or other consequences following treatment do not necessarily provide the complete picture. It is recognized that including PROs could assist healthcare practitioners with patient satisfaction insights that conventional measurements must precisely record. Among the frequently employed tools is the Breast-Q, which assesses many domains, such as satisfaction with the physical, psychological, and sexual aspects of the breast's appearance. Because of this, research has shown that incorporating these indicators is crucial for evaluating the perceived surgical outcomes, which show improved life quality and psychosocial elements and enhanced satisfaction with the appearance of the treated body area. However, physical discomfort and other adverse effects might sometimes be felt as tightness or pain that are difficult to quantify with traditional medical testing. When PROs are used in the clinic, a more thorough picture of the patient's functioning domains is provided, which enables the doctor to help the patient manage their post-operative pain or consult with a specialist about psychiatric issues. PROs can also strengthen the relationship between patients and clinicians by allowing patients to participate in creating their treatment plans, which guarantees that the plans are tailored to the patients' needs and preferences. Therefore, we must stress the significance of PROs, especially in assessing patient satisfaction with breast implants and their overall quality of life. Carotenemia SC identified areas of strength and need for improvement from the perspective of subjective constructs to enhance process quality improvement in breast implant surgery for the benefit of patients.

Removing Persistent Barriers to Systematic Searching.

This is the third article in a new series designed to provide readers with insight into educating nurses about evidence-based decision-making (EBDM). It builds on AJN's award-winning previous series-Evidence-Based Practice, Step by Step and EBP 2.0: Implementing and Sustaining Change (to access both series, go to http://links.lww.com/AJN/A133). This follow-up series on EBDM will address how to teach and facilitate learning about the evidence-based practice (EBP) and quality improvement (QI) processes and how they impact health care quality. This series is relevant for all nurses interested in EBP and QI, especially DNP faculty and students. The brief case scenario included in each article describes one DNP student's journey. To access previous articles in this EBDM series, go to http://links.lww.com/AJN/A256.

Роль принципів загального управління якістю в діяльності підприємства

The article examines the influence of the main principles of total quality management (TQM) on the activities of enterprises. The article analyzes critical aspects of TQM, including customer orientation, involvement of all employees, process approach, systems approach to management, continuous improvement, evidence-based decision-making, and mutually beneficial relationships with suppliers. Implementing these principles is considered a strategic step to achieve high-quality standards, increase competitiveness, and satisfy customer needs. The article begins with the justification of the need to implement TQM in modern conditions of market competition, where the quality of products and services is one of the critical success factors. The role of management in forming a quality culture, the importance of involving all employees in the quality improvement process, and the creation of appropriate conditions for their motivation and training are described. The process approach to quality management, which includes identification, optimization, and monitoring of the main processes of the enterprise, is considered in detail. The advantages of a system approach, which helps enterprises to coordinate their actions better and achieve strategic goals, are described. Special attention is paid to continuous improvement, which is critical to competitiveness in a rapidly changing environment. Methods and tools used for continuous process improvement are discussed, as well as the importance of data-driven decision-making to minimize risk and improve management efficiency. The importance of mutually beneficial relations with suppliers, which contribute to improving the quality of products and services and ensure supply stability, is also analyzed. It is shown how long-term partnerships with suppliers can contribute to the overall success of the enterprise. The article presents examples of successful implementation of TQM at various enterprises, demonstrating the practical benefits of applying these principles. Specific outcomes achieved through TQM implementation include increased efficiency, reduced costs, improved product quality, and increased customer satisfaction. The article ends with conclusions about the importance and benefits of implementing the principles of total quality management for enterprises of various industries. It is emphasized that TQM is not only a quality improvement tool but also a strategic approach that contributes to the enterprise’s long-term success and sustainable development. Keywords: total quality management (TQM), principles of TQM, product quality, customer orientation, process approach, a systematic approach to management, quality management, increasing efficiency.

REDUCE missed oral healthcare: The outcomes of and learnings from an implementation project in an acute geriatric unit.

Oral healthcare is one of the most missed aspects of fundamental care. Failure to provide reliable and effective daily oral healthcare for older patients can lead to hospital-acquired pneumonias, longer hospital stays, increased health costs, and poor patient experience. The objective of this study was to codesign, implement, and evaluate an oral healthcare intervention for older adults in a geriatric unit. This mixed methods implementation project combined the hospital's quality improvement processes with the i-PARIHS knowledge translation framework. Multilevel facilitation guided the development of multidisciplinary implementation strategies, which were co-designed, tailored, and implemented at the ward and organizational level, targeting: awareness/engagement; clinical guideline development; building workforce capacity; access to appropriate products; patient awareness and support; utilization of multidisciplinary/dental referral pathways; and systematizing oral healthcare documentation. Gaps between evidence-based and current oral healthcare practice were identified through audits of practice and interviews with patients. Interviews and surveys with staff evaluated the feasibility and acceptability of the oral healthcare intervention and the success of implementation strategies. At the conclusion of the project, awareness, attitudes, and capacity of staff had increased, however, we could not demonstrate change in multidisciplinary oral healthcare practices or improvements for individual patients. Despite mixed success, the project informed discussions about including oral healthcare as a national healthcare standard for the acute care sector in Australia. Attempts to address oral healthcare may have started locally, but its impact was through policy change, which will empower health practitioners and managers to support practice change more widely.

Phase-Based Care in Community Mental Health: A Cost-Effective Innovation Using Algorithms, Rating Scales and Treatment Teams for Depression Management.

This retrospective, observational report describes an innovative quality improvement process, Phase-based Care (PBC), that eliminated wait times and achieved positive clinical outcomes in a community mental health center's (CMHC) mood disorder clinic without adding staff. PBC accomplishes this by eliminating the ingrained cultural practice of routinely scheduling stable patients at rote intervals of 1-3months, regardless of clinical need or medical necessity. Based on four organizational transformations and using mathematical algorithms developed for this process, PBC re-allocates therapy and medical resources away from routinely scheduled appointments and front-loads those resources to patients in an acute phase of illness. To maintain wellness for patients in recovery, lower frequency and intensity approaches are used. This report describes the development of the PBC methodology focusing on the Rapid Recovery Clinic (RRC) comprised of 182 patients with a primary diagnosis of a mood disorder, the largest of the 14 PBC clinics created. Over an 18-month period, wait times were reduced from several months to less than one week and recovery rates, meaning no longer in an acute phase, were 63% and 78% at weeks 6 and 12, respectively for patients who engaged in the program.

Codesigning youth diversion programmes with community-led organisations: a case study

Background:We explore the feasibility of applying methods of participatory codesign to collaborative service development with community-led youth diversion programmes. Collaborative partnerships can support wealth redistribution and community mobilisation, a goal of governments aiming to implement equity-focused policy. There is little systematic exploration of methods aiming to structure the relationship between government and community-led programmes as part of youth criminal-legal diversion efforts. Methods:We use case study methodology to assess the feasibility and impact of a curriculum codesign approach between a university research team and two community-led organisations providing diversion services through a county juvenile court. The codesign method was informed by participatory design and use of research evidence frameworks. Findings:The analysis focuses on the feasibility of the approach from the perspective of the university research team and community organisations as well as how well the approach successfully navigated critical components of participatory process, including shared power, deference to community vision and values, and a valued end product. We conclude that the approach was generally feasible as a quality improvement strategy and well-received by the community-led organisations. Discussion and conclusions:Codesign is a promising strategy for reconciling public administration and health equity goals. The approach used in this case study adds to a small literature on methods of using codesign as a quality improvement process with applications for government contracting and monitoring, programme development and capacity-building.

Evaluation of the quality of platelet concentrates obtained in a Peruvian hospital.

Platelet concentrates are blood products obtained from donor's blood, and their conservation must be subject to a strict quality control process to guarantee a safe and high-performance product in treating diseases that require their use. We designed a cross-sectional study to determine the total compliance rate in platelet concentrates obtained in the blood bank of the Cayetano Heredia Hospital in Lima during November and December of 2019. The Buffy method Coat obtained the platelet concentrates, and parameters such as platelet count and residual leukocytes, pH, and swirling effect were evaluated according to the National Hemotherapy and Blood Bank Program criteria. The platelet count had a mean of 6.66 ± 3.94 x 10¹⁰/µL, the platelet concentrates had a mean of 56.30 ± 6.22 mL, and all, without exception, had the presence of the Swirling phenomenon. The pH had a mean of 7.64 ± 0.15, while the leukocyte count had a mean of 4.22 ± 3.51 x 10⁷/µL. Regarding compliance by the parameters evaluated, it was evident that the platelet and leukocyte count had moderate compliance rates of 43.6% and 24.1%, while the pH and swirling effect had rates of 100% in both cases. The total compliance rate was 54.9% (95% confidence interval: 46.0 to 63.5). The compliance rate of platelet concentrates is moderate, and it is necessary to implement a process of continuous quality improvement in the blood bank.

Atomistic insight on temperature-dependent laser induced ultrafast thermomechanical response in aluminum film

Laser-induced ultrafast thermomechanical responses significantly impact ablation behaviors. Previous studies have focused on experimental observations, offering limited insights into the atomic phase transition process. This study explores the thermomechanical response of aluminum film to temperature changes using Molecular Dynamics coupled Two-Temperature Model (MD-TTM) and pump-probe imaging. The experimental results align closely with the simulations. In the simulations, the higher initial temperature tends to confine the heat to surface layer, creating regions of high potential energy. This confinement effect leads to accelerated surface melting, as evidenced by the more rapid decrease in reflectivity captured through ultrafast imaging. As the initial temperature increases from 300 K to 500 K, the stress distribution calculations show more pronounced surface spallation and reduced interior fractures. This alteration may impede thermal conduction from the surface to the interior. Consequently, the surface's enhanced thermomechanical response lowers the ablation threshold of the aluminum film by approximately 10 % and results in a significantly flatter ablation crater. In our opinion, integrating full-size MD-TTM simulations with ultrafast imaging provides deeper atomistic insights into the dynamics of ultrafast heat and mass transfer, which is crucial for improving processing quality and expanding technological capabilities.

Delirium Screening in Critically Ill Children: Secondary Analysis of the Multicenter PICU Up! Pilot Trial Dataset, 2019-2020.

To determine the patient-level factors associated with performing daily delirium screening in PICUs with established delirium screening practices. A secondary analysis of 2019-2020 prospective data from the baseline phase of the PICU Up! pilot stepped-wedge multicenter trial (NCT03860168). Six PICUs in the United States. One thousand sixty-four patients who were admitted to a PICU for 3 or more days. None. Of 1064 patients, 74% (95% CI, 71-76%) underwent delirium screening at least once during their PICU stay. On 57% of the 8965 eligible patient days, screening was conducted. The overall prevalence of delirium was 46% across all screened days, and 64% of screened patients experienced delirium at some point during their PICU stay. Factors associated with greater adjusted odds ratio (aOR) of increased daily delirium screening included PICU stay longer than 15 days compared with 1-3 days (aOR 3.36 [95% CI, 2.62-4.30]), invasive mechanical ventilation as opposed to room air (aOR 1.67 [95% CI, 1.32-2.12]), dexmedetomidine infusions (aOR 1.23 [95% CI, 1.04-1.44]) and propofol infusions (aOR 1.55 [95% CI, 1.08-2.23]). Conversely, decreased aOR of daily delirium screening was associated with female gender (aOR 0.78 [95% CI, 0.63-0.96]), and the administration of continuous infusions of opioids (aOR 0.75 [95% CI, 0.63-0.90]) or ketamine (aOR 0.48 [95% CI, 0.29-0.79]). Neither patient age, the presence of family or physical restraints, or benzodiazepine infusions were associated with daily delirium screening rates. In the 2019-2020 PICU UP! cohort, across six PICUs, delirium screening occurred on only 57% of days, despite the presence of established practices. Female gender, patients in the early stages of their PICU stay, and patients not receiving mechanical ventilation were associated with lower odds of daily delirium screening. Our results highlight the need for structured quality improvement processes to both standardize and increase the frequency of delirium screening.

Did the students’ satisfaction rates at Avalon University School of Medicine correlate with the occurrence of accreditation site visits?

Introduction Accreditation of medical education programs can be observed from different perspectives. Regulatory/accreditation agencies consider it vital to assure a certain level of quality. Other stakeholders may perceive the accreditation process as a negative experience, draining resources, and efforts. Although accreditation may improve the program’s governance and administration, its direct or indirect impact on students must be further investigated. This study explores the relationship between the occurrence of accreditation site visits and student satisfaction rates at Avalon University School of Medicine. Methods A comparison study was conducted with retrospective satisfaction data from two accreditation cycles at AUSOM. We used the Caribbean Accreditation Authority for Education in Medicine and Other Health Professions (CAAM-HP) student surveys for data collection, and data from 2017, 2019, and 2022 were used. The response rate was 70% (n = 71), 72% (n = 47), and 60% (n = 56) for basic science students and 80% (n = 111), 82% (n = 115), and 70% (n = 76) for clinical students in 2017, 2019, and 2022, respectively. The survey for basic sciences students included 37 questions/items, and the survey for clinical students included 39 questions/items. The responses for the questionnaire were on the five-point Likert scale. The retrospective data were evaluated using the unpaired Wilcoxon-rank sum test. Results The ratings for the basic science students’ survey increased from 2017 to 2019 (first accreditation cycle) only for 11 items/questions and they were increased from 2019 to 2022 for all items/questions. The ratings for clinical science students’ surveys increased from 2017 to 2019 (the first accreditation cycle) for all items/questions with a statistically significant p-value. They increased for 28 questions/items from 2019 to 2022, and two items (availability and adequacy of career counseling) showed statistically significant p-values. Conclusions The pre-accreditation preparation and the self-evaluation process while correcting the program’s deficiencies are essential triggers for the quality improvement process associated with accreditation.

Quality and resilience of clinical laboratories in Rwanda: a need for sustainable strategies

ABSTRACT Background Quality healthcare is a global priority, reliant on robust health systems for evidence-based medicine. Clinical laboratories are the backbone of quality healthcare facilitating diagnostics, treatment, patient monitoring, and disease surveillance. Their effectiveness depends on sustainable delivery of accurate test results. Although the Strengthening Laboratory Management Towards Accreditation (SLMTA) programme has enhanced laboratory quality in low-income countries, the long-term sustainability of this improvement remains uncertain. Objective To explore the sustainability of quality performance in clinical laboratories in Rwanda following the conclusion of SLMTA. Methods A quasi-experimental design was adopted, involving 47 laboratories divided into three groups with distinct interventions. While one group received continuous mentorship and annual assessments (group two), interventions for the other groups (groups one and three) ceased following the conclusion of SLMTA. SLMTA experts collected data for 10 years through assessments using WHO’s StepwiseLaboratory Quality Improvement Process Towards Accreditation (SLIPTA) checklist. Descriptive and t-test analyses were conducted for statistical evaluation. Results Improvements in quality were noted between baseline and exit assessments across all laboratory groups (mean baseline: 35.3%, exit: 65.8%, p < 0.001). However, groups one and three experienced performance declines following SLMTA phase-out (mean group one: 64.6% in reference to 85.8%, p = 0.01; mean group three: 57.3% in reference to 64.7%, p < 0.001). In contrast, group two continued to enhance performance even years later (mean: 86.6%compared to 70.6%, p = 0.03). Conclusion A coordinated implementation of quality improvement plan that enables regular laboratory assessments to pinpoint and address the quality gaps is essential for sustaining quality services in clinical laboratories.

An Audit of the First Stage of Service Development Initiatives Undertaken as Part of a Quality Improvement Process to Improve the Screening and Management of Older Adults Presenting With Delirium in Queen's Hospital (NELFT)

An Audit of the First Stage of Service Development Initiatives Undertaken as Part of a Quality Improvement Process to Improve the Screening and Management of Older Adults Presenting With Delirium in Queen's Hospital (NELFT)

KANSURVIVE: Testing a telementoring model for improving cancer survivorship care in rural practice.

e13791 Background: Cancer survivors require long-term, coordinated care to address the physical, emotional, and psychosocial effects of cancer and its treatment. KanSurvive, a single arm feasibility trial, evaluated the effectiveness of the KanSurvive ECHO intervention combined with practice facilitation (PF) to promote better adoption of evidence-based practice (EBP) survivorship care guidelines for breast, colorectal, lung, and prostate cancer among rural survivors. Methods: Fifteen primary care clinics in Kansas (80% in RUCA codes 4-10), including 62 healthcare professionals, were invited to participate in four, 1-hour Project ECHO telementoring program held in 2021. Real-time videoconferencing sessions covered EBP survivorship guidelines for breast, colorectal, lung, and prostate cancer. Clinics used brief plan-do-study-act cycles with PF supporting implementation of the quality improvement process. Utilizing the National Quality Forum framework, a performance indicator booklet with established measures in preventive health and cancer survivorship was developed as a data collection and quality improvement resource. Performance indicators included EBP screening actions related to cancer surveillance, lifestyle factors, distress, evidence of a review of family history of cancer, and the patient’s cancer diagnosis documented in the EHR. Results: Three clinics (7 = healthcare professionals) withdrew from the project citing competing demands and a provider leaving the practice. The COVID-19 pandemic delayed project initiation and prevented clinic visits. Recruitment and study procedures were implemented remotely. Clinic staff identified 138 cancer survivors (M = 13, IQR [6-16] per practice) seen in the year pre-intervention, and 129 survivors in the year prior to post-intervention. Pre-intervention, overall tumor surveillance was 91%, but lung cancer surveillance was lower than other tumor types at 70%. Other than surveillance, measures of baseline performance were similar across tumor types: screening for distress 84%, assessment of BMI 97%, screening for tobacco use 83% and documentation of family history 70%. Post-intervention performance indicators were similar except for documentation of family history which increased to 89% (p &lt; 0.01). Conclusions: Standardized survivorship metrics can facilitate quality assessment as part of an ECHO-based cancer survivorship program. Although there are modest opportunities for improvement, PCPs in this study caring for rural patients perform reasonably well across a variety of cancer survivorship performance metrics comparable to national primary care quality measures. Documented assessment of family history of cancer lags other metrics and improved after participation in the KanSurvive telementoring program.

Enhancing Cancer Care Through Quality Initiatives: The Uganda Cancer Institute Experience With the Quality Oncology Practice Initiative.

Cancer care in low- and middle-income countries (LMICs) faces numerous challenges, such as limited resources, infrastructure constraints, and a shortage of specialized training. To address these challenges, innovative quality improvement (QI) approaches are required. The Quality Oncology Practice Initiative (QOPI) by the ASCO provides a framework for improving care quality through evidence-based standards. This article explores how QOPI has been adapted to the local context of the Uganda Cancer Institute (UCI) and highlights the importance of aligning international best practices with local health care realities to bridge disparities in care standards. The adaptation of the QOPI program at UCI commenced with a collaborative meeting with the ASCO-QOPI team in 2020. A tailored implementation plan was developed focusing on incorporating ASCO's QOPI measures and additional metrics relevant to the Ugandan context, engaging multidisciplinary teams, and optimizing resource use by leveraging existing resources for data collection and analysis. The execution of the plan relied heavily on staff training, participatory data collection, and continuous quality improvement processes that utilized data-driven methodologies. A retrospective analysis of QOPI data of UCI from 2020 to 2023 shows significant improvements in oncology care quality, highlighted by an upward trend in QOPI assessment scores across various metrics. These reflect the journey of UCI toward aligning its oncology care practices with international standards despite facing significant challenges. UCI's experience demonstrated the feasibility and impact of implementing international QI programs in LMICs. The success demonstrates that significant improvements in cancer care quality can be achieved in resource-constrained settings through adaptability, stakeholder engagement, and strategic resource optimization. UCI's journey is a model for other LMICs seeking to raise their cancer care standards, demonstrating that QI is necessary and attainable worldwide.

Accelerating cancer research trial startup in the community setting: A quality-improvement study.

11066 Background: There is a large variation in activation times for cancer clinical trials, delaying the opportunity for patients to benefit from cutting edge treatments. Academic medical centers typically take longer to activate a clinical trial as compared to community settings. Some academic medical centers have adopted quality improvement processes to reduce clinical trial start-up time. Our center, TriHealth Cancer &amp; Blood Institute (TCBI) in the SW Ohio community has also adopted quality improvement processes to further reduce startup time within our oncology research group. Methods: This study encompassed July 2022-June 2023, with baseline data drawn from January 2021 to December 2021 prior to the study period which revealed a mean clinical trial start-up time of 116 days. The research group used a swim-lane process to define the typical process &amp; stakeholders for clinical activation time at our institution prior to the study time. Our group identified three major areas with significant lag-time - contracts, budgets, &amp; IRB/ICF - with the overarching root cause for delays due to lack of organizational process &amp; expertise in these major areas. Using Plan-Do-Study-Act (PDSA), we instituted interventions, which included utilizing a central IRB, identifying a responsible member with extensive research budgeting to review research study budgets, &amp; identified a responsible member with extensive contracts review &amp; negotiations working with Central Legal throughout the contracts negotiation process with sponsor(s). Results: During this 12-month study time, our center demonstrated a 44% reduction in trial start up time (141 days to 79 days), while at the same time doubling the number of active trials. This process change resulted in sustainability that carried into 2023, further reducing start-up time to 70 days. In 2021, we opened 6 studies and after adoption of these process improvements (2022) we doubled the number of studies by 117%, while opening 67% more in 2023 than in 2021. The ability to open more studies has allowed us to shift patient enrollment to more investigational trials while increasing treatment enrollment from 2022 to 2023 by 24%. Through process improvement, more treatment studies are open &amp; available for our community. Conclusions: By implementing interventions to streamline clinical trial activation time, our center was able to significantly &amp; sustainably reduce the time required to start a clinical trial in our community health system in a 12-month period, resulting in our ability to initiate more clinical trials. As a result, more treatment trial patients were able to be enrolled in these clinical trials at TCBI, with the hope of improved outcomes. We anticipate that further adoption of just-in-time studies may help to decrease this activation time further. [Table: see text]

Creating a national model to build anti-cancer stewardship and quality improvement initiatives.

e23219 Background: The Department of Veterans Affairs (VA) Pharmacy Benefits Management (PBM) Services created a national stewardship with focus on anti-cancer therapeutics within a disease-specific cohort. Building a model to focus on Veterans with a common malignancy is a novel approach. A toolkit was built containing resources to support initiatives to promote standardization of practice and monitor outcomes as a continual quality improvement process. This model was piloted in Veteran patients with Chronic Myeloid Leukemia (CML) since Tyrosine Kinase Inhibitors (TKIs) account for the second highest utilization among outpatient oral anti-cancer therapies in VA . Methods: Business rules identified Veterans Integrated Service Network (VISN) CML cohorts by using data and diagnostic coding (ICD-10; SNOMED CT) from the VA Electronic Health Record (EHR): primary care and hematology/oncology visits, inpatient stays, and problem lists. Medication Use Evaluations (MUEs) were developed: MUE #1: Veterans who received a drug other than imatinib as their initial VA prescription If new initiation, documented reason(s) for drug selection If continuation, prior drug therapy history MUE #2: Veterans who switched from first to second-line TKI Documented reason(s) for switch to 2L Documentation of adverse drug reaction (ADR) in the EHR. Results: 16 VISNs participated in the MUEs. Patient counts are each ~25% of the total CML cohort; ~50% of patients received imatinib 1L and have not switched to 2L. Responses for MUE #1 (N = 559) 293 (52%) continued therapy originally started outside VA with 71% of these patients (n = 208) without documentation of prior imatinib 266 (48%) newly initiated therapy with top documented reasons Intermediate/high risk scoring: 109 (41%) Reason not documented: 80 (30%) Cited FDA indication for CML without clinical justification: 35 (13%) Responses for MUE #2 (N = 576) Top documented reasons for switch from 1L to 2L therapy ADR: 325 (56%) Resistance / inadequate response: 132 (23%) Disease progression: 117 (20%) Only 59 (18%) who experienced an ADR had it documented in the EHR allergies / adverse reactions section. Conclusions: Disease-focused oncology stewardship in a national healthcare system is feasible. Imatinib remains the preferred TKI and accounts for the highest utilization. Oncology Stewardship activities based on the results include education on disease coding, an educational document on why to use imatinib in the 1L setting, and a medication safety article to emphasize documentation of ADRs. In our 1L to 2L MUE, ADRs were the most common reason for patients to be switched to 2L. Future activities include an education sheet on managing TKI ADRs and criteria for a potential treatment-free remission. Further interventions in TKI prescribing may be instituted in select sites. Following initiatives for CML, Anti-Cancer Stewardship Program will be expanded to other oncologic diseases.

Impact of Continuous Renal Replacement Therapy Initiation Time, Kidney Injury, and Hypervolemia in Critically Ill Children.

The mortality rate of pediatric patients who require continuous renal replacement therapy is approximately 42%, and outcomes vary considerably depending on underlying disease, illness severity, and time of dialysis initiation. Delay in the initiation of such therapy may increase mortality risk, prolong intensive care unit stay, and worsen clinical outcomes. In the pediatric intensive care unit of an urban level I trauma children's hospital, continuous renal replacement therapy initiation times and factors associated with delays in therapy were unknown. This quality improvement process involved a retrospective review of data on patients who received continuous dialysis in the pediatric intensive care unit from January 1, 2017, to December 31, 2021. The objectives were to examine the characteristics of the children requiring continuous renal replacement therapy, therapy initiation times, and factors associated with initiation delays that might affect unit length of stay and mortality. During the study period, 175 patients received continuous renal replacement therapy, with an average initiation time of 11.9 hours. Statistically significant associations were found between the degree of fluid overload and mortality (P < .001) and between the presence of acute kidney injury and prolonged length of stay (P = .04). No significant association was found between therapy initiation time and unit length of stay or mortality, although the average initiation time of survivors was 5.9 hours shorter than that of nonsurvivors. Future studies are needed to assess real time delays and to evaluate if the implementation of a standardized initiation process decreases initiation time.