Quality Improvement Report Research Articles

Practical MRI of Endometrial Neoplasms, Part 2: MRI and FIGO Staging

MRI is the method of choice for the evaluation of endometrial carcinomas (ECs), from detection to evaluation of recurrent disease. Although the staging of ECs is done surgically using the system of the International Federation of Gynecology and Obstetrics (FIGO), preoperative assessment based on MRI findings helps in risk stratification and decision-making. The main parameters evaluated include the degree and depth of myometrial invasion, parametrial extent, and cervical stromal infiltration. The combination of T2-weighted imaging, dynamic contrast-enhanced MRI, and diffusion-weighted imaging increases the accuracy of EC diagnosis and staging. A proposed step-by-step guide was developed to help the radiologist formulate hypotheses and guide clinical reasoning from the approach of the patient to the preparation of the final report. A structured report is also proposed with the objective of improving report quality and facilitating communication with the treating physicians.

Quality Improvement Report: Safety Program for Prevention of Central Line-associated Bloodstream Infections.

The increasing usage of peripherally inserted central catheters (PICCs) in medical imaging departments has led to a corresponding increase in cases of central line-associated bloodstream infection (CLABSI). However, this condition is preventable with proper monitoring and use of aseptic techniques. A Comprehensive Unit-based Safety Program (CUSP) is a quality improvement (QI) measure implemented by health care institutions to reduce the incidence of CLABSI. However, effective strategies have yet to be established. The authors describe a QI project that evaluated the implementation of CUSP at a teaching hospital to reduce PICC-associated bloodstream infection (BSI). The framework consists of a five-step process: understand and train staff on the science of safety, assemble a team, engage senior executives, identify defects through sensemaking, and implement teamwork and communication strategies in a series of related and sequential steps that use QI tools. Targets were identified for improvement from existing processes, and the workflow was reengineered. Nine months after the start of the CUSP intervention, PICC-associated BSI incidence in the hospital had been reduced from 3.4 to 2.7 per 1000 central lines days after intervention. The incidence of BSI was also reduced correspondingly from 8.8% to 5.9%. The QI processes in this study may be adopted by other hospitals, as they involve minimal cost with significant impact on patient safety and well-being. The QI sequential steps described capture the implementation processes that can be modified for use in other department settings where patient safety could be compromised. Online supplemental material is available for this article. ©RSNA, 2022.

Development, implementation and evaluation of high-quality virtual preoperative anaesthetic assessment during COVID-19 and beyond: a quality improvement report

BackgroundPreoperative risk factor identification and optimisation are widely accepted as the gold standard of care for elective surgery and are essential for reducing morbidity and mortality. COVID-19 public health restrictions...

Novel Shared Decision-Making Tool Improves Contraceptive Screening and Right Care during Pregnancy in a Military Hospital: A Quality Improvement Report.

Unintended pregnancy rates in the military remain high compared with rates outside of the military in the United States (54%-60% vs 45%-50%, respectively). Contraceptive counseling in conjunction with shared decision-making is recommended to improve military unintended pregnancy rates. Best counseling practices and decision aids for contraceptive counseling are unknown in military and nonmilitary populations. Pregnancy may be an opportune time to complete contraceptive counseling because of regularly scheduled prenatal visits, and counseling during pregnancy is associated with higher postpartum contraception use. A quality initiative was implemented to improve contraceptive screening and counseling during pregnancy for servicewomen and nonservicewomen in a clinic setting. The initiative included 4 patient-centered core interventions: a patient screening, a shared decision-making tool, a right care checklist, and a team engagement plan, across 4 rapid plan-do-study-act cycles. Contraceptive screening rates and delivery of right care improved from 37% to 79% in the pregnant patients over 90 days; 81% of patients screened positive for contraception needs; 89% of patients made a same-day decision about their contraception plan after completing the tool; and 92% of patients had a contraception plan documented in the electronic health record by the health care provider prior to birth. Results demonstrated that contraception screening rates and right care improved with initiative interventions for servicewomen and nonservicewomen. A novel shared decision-making tool presented 18 contraception methods, risks and benefits, and tiered effectiveness that aided the majority of patients in a same-day decision with high patient satisfaction. Provider counseling was also simplified without delay in clinic time. Contraceptive counseling completed with a shared decision-making tool may benefit military and civilian populations during pregnancy. Additional research is needed to examine the best time to conduct counseling during pregnancy and the long-term rates of contraceptive use or unplanned pregnancy following counseling events.

A scoping review of local quality improvement using data from UK perioperative National Clinical Audits

BackgroundSignificant resources are invested in the UK to collect data for National Clinical Audits (NCAs), but it is unclear whether and how they facilitate local quality improvement (QI). The perioperative setting is a unique context for QI due to its multidisciplinary nature and history of measurement. It is unclear which NCAs evaluate perioperative care, to what extent their data have been used for QI, and which factors influence this usage.MethodsNCAs were identified from the directories held by Healthcare Quality Improvement Partnership (HQIP), Scottish Healthcare Audits and the Welsh National Clinical Audit and Outcome Review Advisory Committee. QI reports were identified by the following: systematically searching MEDLINE, CINAHL Plus, Web of Science, Embase, Google Scholar and HMIC up to December 2019, hand-searching grey literature and consulting relevant stakeholders. We charted features describing both the NCAs and the QI reports and summarised quantitative data using descriptive statistics and qualitative themes using framework analysis.ResultsWe identified 36 perioperative NCAs in the UK and 209 reports of local QI which used data from 19 (73%) of these NCAs. Six (17%) NCAs contributed 185 (89%) of these reports. Only one NCA had a registry of local QI projects. The QI reports were mostly brief, unstructured, often published by NCAs themselves and likely subject to significant reporting bias. Factors reported to influence local QI included the following: perceived data validity, measurement of clinical processes as well as outcomes, timely feedback, financial incentives, sharing of best practice, local improvement capabilities and time constraints of clinicians.ConclusionsThere is limited public reporting of UK perioperative NCA data for local QI, despite evidence of improvement of most NCA metrics at the national level. It is therefore unclear how these improvements are being made, and it is likely that opportunities are being missed to share learning between local sites. We make recommendations for how NCAs could better support the conduct, evaluation and reporting of local QI and suggest topics which future research should investigate.Trial registrationThe review was registered with the International Prospective Register of Systematic Reviews (PROSPERO: CRD42018092993).

Performance of a deep learning tool to detect missed aortic dilatation in a large chest CT cohort.

PurposeThoracic aortic (TA) dilatation (TAD) is a risk factor for acute aortic syndrome and must therefore be reported in every CT report. However, the complex anatomy of the thoracic aorta impedes TAD detection. We investigated the performance of a deep learning (DL) prototype as a secondary reading tool built to measure TA diameters in a large-scale cohort.Material and methodsConsecutive contrast-enhanced (CE) and non-CE chest CT exams with “normal” TA diameters according to their radiology reports were included. The DL-prototype (AIRad, Siemens Healthineers, Germany) measured the TA at nine locations according to AHA guidelines. Dilatation was defined as >45 mm at aortic sinus, sinotubular junction (STJ), ascending aorta (AA) and proximal arch and >40 mm from mid arch to abdominal aorta. A cardiovascular radiologist reviewed all cases with TAD according to AIRad. Multivariable logistic regression (MLR) was used to identify factors (demographics and scan parameters) associated with TAD classification by AIRad.Results18,243 CT scans (45.7% female) were successfully analyzed by AIRad. Mean age was 62.3 ± 15.9 years and 12,092 (66.3%) were CE scans. AIRad confirmed normal diameters in 17,239 exams (94.5%) and reported TAD in 1,004/18,243 exams (5.5%). Review confirmed TAD classification in 452/1,004 exams (45.0%, 2.5% total), 552 cases were false-positive but identification was easily possible using visual outputs by AIRad. MLR revealed that the following factors were significantly associated with correct TAD classification by AIRad: TAD reported at AA [odds ratio (OR): 1.12, p < 0.001] and STJ (OR: 1.09, p = 0.002), TAD found at >1 location (OR: 1.42, p = 0.008), in CE exams (OR: 2.1–3.1, p < 0.05), men (OR: 2.4, p = 0.003) and patients presenting with higher BMI (OR: 1.05, p = 0.01). Overall, 17,691/18,243 (97.0%) exams were correctly classified.ConclusionsAIRad correctly assessed the presence or absence of TAD in 17,691 exams (97%), including 452 cases with previously missed TAD independent from contrast protocol. These findings suggest its usefulness as a secondary reading tool by improving report quality and efficiency.

Improving compliance with appropriateness of testing for heparin-induced thrombocytopaenia: a quality improvement report

Heparin-induced thrombocytopaenia (HIT) is a serious complication of heparin therapy. Evidence-based guidelines recommend the use of the 4Ts scoring system to calculate pretest probability of HIT. However, this scoring system...

역량중심 교양교육 실현을 위한 CQI 적용 및 성과 분석

Objectives The purpose of this study is to analyze the effect of the Continuous Quality Improvement report on competency education in universities. Methods This study was conducted by analyzing the contents of the CQI report prepared for each of the seven common liberal arts subjects opened at University D, and comparing the results of the student's competency diagnosis conducted before and after the application of the CQI report. Results As a result of the study, it was found that the level of awareness among professors about the CQI report has been steadily improving, and as a result, the narrative content of the report has been greatly improved. Also, it was found that the students' competency scores increased significantly after CQI application compared to before, and the number of competencies that showed an increase in scores also increased. Conclusions It turns out that the CQI report is an effective tool in promoting competency-based education in universities. The CQI report can be a tool to help improve the curriculum in major subjects as well as common liberal arts subjects, the subject of this study.

Video Relay Interpretation and Overcoming Barriers in Health Care for Deaf Users: Scoping Review.

BackgroundPersons who are deaf are more likely to avoid health care providers than those who can hear, partially because of the lack of means of communication with these providers and the dearth of available interpreters. The use of video remote interpretation, namely the video camera on an electronic device, to connect deaf patients and health providers has rapidly expanded owing to its flexibility and advantageous cost compared with in-person sign language interpretation. Thus, we need to learn more about how this technology could effectively engage with and respond to the priorities of its users.ObjectiveWe aimed to identify existing evidence regarding the use of video remote interpretation (VRI) in health care settings and to assess whether VRI technology can enable deaf users to overcome barriers to interpretation and improve communication outcomes between them and health care personnel.MethodsWe conducted a search in 7 medical research databases (including MEDLINE, Web of Science, Embase, and Google Scholar) from 2006 including bibliographies and citations of relevant papers. The searches included articles in English, Spanish, and French. The eligibility criteria for study selection included original articles on the use of VRI for deaf or hard of hearing (DHH) sign language users for, or within, health care.ResultsFrom the original 176 articles identified, 120 were eliminated after reading the article title and abstract, and 41 articles were excluded after they were fully read. In total, 15 articles were included in this study: 4 studies were literature reviews, 4 were surveys, 3 were qualitative studies, and 1 was a mixed methods study that combined qualitative and quantitative data, 1 brief communication, 1 quality improvement report, and 1 secondary analysis. In this scoping review, we identified a knowledge gap regarding the quality of interpretation and training in sign language interpretation for health care. It also shows that this area is underresearched, and evidence is scant. All evidence came from high-income countries, which is particularly problematic given that most DHH persons live in low- and middle-income countries.ConclusionsFurthering our understanding of the use of VRI technology is pertinent and relevant. The available literature shows that VRI may enable deaf users to overcome interpretation barriers and can potentially improve communication outcomes between them and health personnel within health care services. For VRI to be acceptable, sign language users require a VRI system supported by devices with large screens and a reliable internet connection, as well as qualified interpreters trained on medical interpretation.

An initiative to reduce medication errors in neonatal care unit of a tertiary care hospital, Kolkata, West Bengal: a quality improvement report

BackgroundMedication errors are an emerging problem in various hospital settings, especially in neonates. A study conducted in the neonatal care unit of a tertiary institute in Kolkata as baseline over...

Assessing Suicide Risk in a Pediatric Outpatient Behavioral Health System: A Quality Improvement Report.

Introduction:Standardized suicide risk assessment improves the detection of individuals at risk of suicide. We conducted a quality improvement initiative in a system of outpatient behavioral health practices affiliated with a free-standing children’s hospital to implement standardized suicide risk assessment for new patients.Methods:Clinicians received education in suicide risk assessment and were trained to use an evidence-based suicide risk assessment tool, the Columbia Suicide Severity Rating Scale (C-SSRS). We standardized workflow processes and integrated the C-SSRS in the electronic health record with a feature to communicate instances of elevated risk across care teams through a problem list. We analyzed C-SSRS responses and adherence to standardized processes and compared the percentage of patients with a suicide-related item on the problem list before and after implementation. We assessed clinician knowledge through a survey. All patients with identified suicide risk received treatment to reduce their risk of suicide in the context of usual care.Results:For 3,972 new patient visits occurring postimplementation (November 2016–December 2018), the average monthly adherence to the standardized process was 97.7%. The mean monthly incidence of nonspecific active suicidal thoughts was 16%, aborted suicide attempts were 2%, and actual suicide attempts were 3%. The mean monthly incidence of a suicide-related item documented on the problem list was 5.66% in the postimplementation period compared with 1.47% in the 1-year preimplementation. Clinicians demonstrated statistically significant increases in knowledge about suicide risk factors and assessment.Conclusions:Standardization of suicide risk assessment processes improved detection and documentation of suicide risk in a pediatric outpatient behavioral health setting.

Implementation of a Children's Safe Asthma Discharge Care Pathway Reduces the Risk of Future Asthma Attacks in Children-A Retrospective Quality Improvement Report.

BackgroundMany children attend Emergency Departments (ED) and Out of Hours (OoH) frequently for acute asthma. Follow up care is often suboptimal leaving these children at risk of a future attacks. We report on the development, implementation and evaluation of a safe asthma discharge care pathway (SADCP).MethodsThis is a retrospective report on the development, implementation and evaluation of outcomes of a SADCP. The pathway was based on the Teach-to-goal educational methodology that supported the mastery correct inhaler technique and ability to action the personalized asthma action plan (PAAP). Children with frequent asthma attacks were entered as they were discharged from the Emergency Department or ward. The first training session occurred within 1–3 weeks of the index asthma attack with 2 further sessions in the following 8 weeks. Children exiting the pathway were discharged either back to primary care or to a hospital clinic.Results81 children entered the pathway (median age 5 years) with 72 discharged from the ED and 9 from the medical wards of the Royal Belfast Hospital for Sick Children. At pathway entry 13% had correct inhaler technique, 10% had a Personalized Asthma Action Plan (PAAP), and 5% had >80% (45% >50%) repeat refill evidence of adherence to inhaled corticosteroid over the previous 12 months. On pathway exit all children demonstrated correct inhaler technique and were able to action their PAAP. One year later 51% and 95% had refill evidence of >80% and >50% adherence. Comparisons of the 12 months before and 12 months after exit from the pathway the median number of emergency ED or OoH asthma attendances and courses of oral corticosteroids reduced to zero with >75% having no attacks requiring this level of attention. Similar findings resulted when the SADCP was implemented in a district general hospital pediatric unit.ConclusionImplementing an asthma care pathway, using Teach-to-Goal skill training methods and frequent early reviews after an index asthma attack can reduce the future risk of asthma attacks in the next 6 to 12 months.

Incorporating Quality Improvement Projects Into Stroke Care and Research.

Incorporating Quality Improvement Projects Into Stroke Care and Research.

Introducing antimicrobial stewardship to the outpatient clinics of a suburban academic health system.

Objective:To establish an antimicrobial stewardship program in the outpatient setting.Design:Prescribers of antimicrobials were asked to complete a survey regarding antimicrobial stewardship. We also monitored their compliance with appropriate prescribing practices, which were shared in monthly quality improvement reports.Setting:The study was performed at Loyola University Health System, an academic teaching healthcare system in a metropolitan suburban environment.Participants:Prescribers of antimicrobials across 19 primary care and 3 immediate- and urgent-care clinics.Methods:The voluntary survey was developed using SurveyMonkeyand was distributed via e-mail. Data were collected anonymously. Rates of compliance with appropriate prescribing practices were abstracted from electronic health records and assessed by 3 metrics: (1) avoidance of antibiotics in adult acute bronchitis and appropriate antibiotic treatment in (2) patients tested for pharyngitis and (3) children with upper respiratory tract infections.Results:Prescribers were highly knowledgeable about what constitutes appropriate prescribing; verified compliance rates were highly concordant with self-reported rates. Nearly all prescribers were concerned about resistance, but fewer than half believed antibiotics were overprescribed in their office. Among respondents, 74% reported intense pressure from patients to prescribe antimicrobials inappropriately. Immediate- and urgent-care prescribers had higher rates of compliance than primary-care prescribers, and the latter group responded well to monthly reports and online educational resources.Conclusions:Intense pressure from patients to prescribe antimicrobials when they are not indicated leads to overprescribing, an effect compounded by the importance of patient satisfaction scores. Compliance reporting improved the number of appropriate antibiotics prescribed in the primary care setting.

Patients Lacking the Capacity to Consent to Hip Fracture Surgery May Be Undergoing Major Operations Without Their Next of Kin Being Involved in Best-Interests Decisions: A Quality Improvement Report.

BackgroundCognitively impaired patients with a hip fracture may be undergoing major operations without attempts being made to involve their next of kin (NoK) in best-interest decisions.MethodsWe used the Plan-Do-Study-Act (PDSA) methodology to guide our quality improvement (QI) project. Cognitively impaired hip fracture patients were identified retrospectively by searching the hip fracture database of a medium-sized district general hospital (DGH). Their medical notes were reviewed for documented attempts at contacting their NoK prior to surgery as well as on completion of the NoK section of the Consent Form Four.InterventionA simple feedback intervention was delivered in the form of a mixed verbal and visual presentation to the orthopaedic registrars responsible for obtaining consent from these patients.ResultsPost-intervention, there were documented attempts at contacting the NoK before surgery for all patients, a significant improvement from only 80%. There was also a significant increase in completion of the NoK section of the consent form, from 30% to 64.3%.ConclusionsSimple audit and feedback interventions can produce significant positive changes in communication between clinicians and the NoK of cognitively impaired patients with hip fractures. Further interventions have been implemented to sustain these improvements.

Supporting Employee Wellness Within a Large Health System During the COVID-19 Crisis

Objective: Due to COVID-19, medical providers faced stress, feelings of isolation and fear. To support employees' health, Cleveland Clinic created a Wellness and self-care during COVID-19 taskforce which developed and implemented new programs to address COVID-19 related anxiety. The objective of this quality improvement report is to describe the development and implementation of wellness services for medical providers and evaluate the program's effectiveness. Methods: The program was evaluated using a crosssectional survey. The survey included questions on circumstances related to COVID-19, wellness services used, fulfillment and burnout. We described our results using Pearson's chi-square and Student's t-tests. We grouped responders who reported change in none or some responsibilities together and responders with change in most or all responsibilities together. Results: The Taskforce implemented neighborhood support groups, mindfulness and anxiety resources for employees, and a free thirty-minute sessions of mental health counseling. The response rate was 45%. A quarter of responders (27%) needed child care or elder care;8% had been quarantined;42% reported that most or all of their work responsibilities changed in the prior month. The highest levels of burnout was reported by those who had most or all of their responsibility changed. Eightypercent of the respondents felt that leadership kept them informed. Daily information tips, online self-help resources, and virtual yoga and meditation classes were the most utilized offerings. Conclusion: Creating a task force to address employee's emotional wellbeing was an important part of our organizational response to COVID-19. The wellness assistance program appeared to be used and appreciated. Many of our interventions may have been impactful due to their ability to drive connection since social connectedness can drive health, reducing major depression, and suicide. We observed that employees whose responsibilities were mostly or all changed experienced higher levels of burnout compared to those whose responsibility was minimally or not changed.

Use of a standardized reporting template: can we improve report quality in pancreatic and peri-ampullary malignancy?

Accurate pancreatic and periampullary cancer staging with resectability assessment is vital to optimize surgical management and improve patient outcomes. The aim of this study is to assess the usefulness of a standardized reporting template. Retrospective review of all surgically managed patients with pancreatic or periampullary malignancy between January 2018 and June 2019. Pre-operative CT imaging report was anonymised and audited against a modified NCCN reporting template. The same imaging studies were re-reported by two experienced GI radiologists using the same template. Fifty-nine patients (37 male) with median age of 68 years (36-83) underwent surgery for suspected pancreatic/peri-ampullary malignancy. The median time between pre-operative CT scan and surgery was 56.5 days (14-225). The use of reporting template resulted in significant increase in number of reported key features (p <0.005), interobserver agreed features (p< 0.005) and overall k-value assessed interobserver agreement (p< 0.005). Template reports correlated closely with key intraoperative findings whilst primary free text reports did not (k-value 0.85-0.96 versus 0.20-0.46, p< 0.05). The use of a reporting template resulted in a more complete and accurate pancreatic/peri-ampullary tumour evaluation, improved inter-observer relatability and correlation with intraoperative findings.

Feedback on Feedback.

Contaminated blood cultures are a known cause of increased hospital cost, prolonged length of stay, and exposure to unnecessary antibiotics. In 2007, the Clinical and Laboratory Standards Institute adopted an acceptable benchmark of overall blood culture contamination rate of <3%.1 However, multiple research studies have revealed that rates vary between institutions and are frequently greater than this benchmark.2,3 In this issue of Hospital Pediatrics , Bram et al4 describe a multifaceted quality improvement (QI) initiative to reduce the percentage of contaminated blood cultures in a pediatric emergency department at a freestanding children’s hospital. The results were impressive. Rates of contaminated blood cultures decreased from 6.7% to 2.1% over a 16-month period. The authors also estimated significant cost savings due to the reduction of contaminated blood cultures and their sequelae. The tremendous reduction in contaminated blood cultures and the cost savings are compelling. The improvers are to be commended for performing a true patient-centered QI initiative, avoiding unnecessary venipunctures, antibiotics, emergency department visits, hospital admissions and prolonged length of stay, work-life disruption, and concern over a potentially severe infection in a child. Although recognition of this accomplishment is appropriate, the point of publishing QI reports is to describe the context and interventions with enough specificity to replicate successful projects (with adaptations in new contexts) or to avoid ineffective interventions on the basis of the learnings of previous improvers. This report provides several replicable strategies but also raises interesting questions about …

Novel two-tiered developmental screening programme for Singaporean toddlers: a quality improvement report

Early identification of developmental delays with timely intervention, especially before the age of 3 years, can improve child development. In Singapore, however, diagnosis and intervention for developmental delays occur at...

Staying Connected: Using Quality Improvement to Bridge the Communication Gap Between Pediatric Hospitalists and Primary Care Providers.

Staying Connected: Using Quality Improvement to Bridge the Communication Gap Between Pediatric Hospitalists and Primary Care Providers.