Rapid-cycle Quality Improvement Research Articles

Using the Expertise of a Clinical Nurse Specialist to Lead a Neonatal Peripherally Inserted Central Catheter Team to Central Line-Associated Bloodstream Infection Reduction and Cost-Efficiency Through Quality Improvement.

This quality improvement project aimed to reduce central line bacteremias (central line-associated bloodstream infections [CLABSIs]) in a neonatal ICU (NICU) to a CLABSI rate of zero using a clinical nurse specialist (CNS)-led neonatal peripherally inserted central catheter (PICC) team. The NICU at the study site was experiencing more than twice the National Healthcare Safety Network average CLABSI rate at 2.2 per 1000 line-days with an estimated cost of $2 072 806 to the organization. In early 2009, the CNS guided the unit from on-demand PICC placement to a dedicated team of PICC certified nurses who assumed total care of PICC line insertion and maintenance. The project used a continual, rapid cycle quality improvement model to incorporate the current evidence-based practices. The CNS-led PICC team has maintained a zero CLABSI rate for 9 years with only 1 CLABSI since June 2022. The adoption of a CNS-led PICC team was instrumental in achieving a zero CLABSI rate over a prolonged period.

Improving Equitable Postpartum Care in an Urban Private Clinic with Predominantly Black Patients.

Maternal health disparities based on race, ethnicity, and socioeconomic factors exist in the United States, with Black women experiencing significantly worse outcomes. With much of perinatal morbidity and mortality attributed to the postpartum period, attention to equitable postpartum care is necessary for addressing this disparity. A rapid-cycle quality improvement initiative was implemented in an urban clinic serving predominantly Black, Medicaid-insured clients. Although baseline data indicated 95% of clients experienced comorbidities, only 65% attended a comprehensive postpartum visit (PPV). The project's goal was to improve equitable postpartum care by increasing PPV attendance and quality of postpartum care to 90% in 8 weeks. The clinical team was engaged throughout to promote organizational change within the clinic. A provider checklist was implemented to improve PPV care metrics, and shared decision-making was initiated surrounding contraception and mood disorders. A care log tracked clinical practice guideline adherence with regular feedback informing the change process. Postpartum care improved across a variety of factors studied over 8 weeks. The provider checklist prompted a 78% documentation rate of PPV care metrics, and care log tracking reflected an ending PPV attendance rate of 93%. Client satisfaction with postpartum care education was measured using a Likert scale of 1 to 5 (1 = dissatisfied and 5 = satisfied) with a noted improvement from a baseline score of 4.3 to an overall mean of 4.8. This quality initiative addressed a key factor in health equity for a predominantly Black, Medicaid-insured population in an urban clinic by raising PPV attendance rates above national standards of 90% and improving client satisfaction and the quality of care received during these visits. The project was low cost and created sustainable systems for maintaining evidence-based equitable care. Limitations included the coronavirus disease 19 pandemic, clinic staff turnover, and staff and client biases. Continued innovative research targeted at improving health equity is needed.

A pilot resiliency course for Doctor of Nursing Practice (DNP) students: Lessons learned

Graduate nursing students can face varied and significant stressors during their programs of study. The need for interventions to promote nursing student resiliency has been reported in the literature, by accrediting bodies, and in previous research conducted with students at the same university. Thus, the purpose of this project was to pilot a resilience course for Doctor of Nursing Practice (DNP) students. The theoretical frameworks guiding the design and implementation of the resiliency pilot program were andragogy (the science of adult learning) and rapid cycle quality improvement. The course included eleven monthly modules addressing resiliency content with written material, original videos, and online discussions and meetings. The first module overviewed the resiliency skills (Belief, Persistence, Trust, Strength, and Adaptability), five modules were dedicated to a specific resiliency skill, two modules addressed recent and anticipated challenges, two modules concentrated on the application (clinical and academic) of the resiliency skills, and the last module focused on reflection. Results of this pilot program indicate that DNP students can benefit from receiving resiliency content during their studies, especially from faculty involvement and increased peer support; however, future resiliency content may be more accepted and effective if embedded into nursing program curriculum and activities.

Catalyzing System Change: 100 Quality Improvement Projects in 1000 Days.

Health system change requires quality improvement (QI) infrastructure that supports frontline staff implementing sustainable innovations. We created an 8-week rapid-cycle QI training program, Stanford Primary Care-Project Engagement Platform (PC-PEP), open to patient-facing primary care clinicians and staff. Examine the feasibility and outcomes of a scalable QI program for busy practicing providers and staff in an academic medical center. Program evaluation. A total of 172 PCPH team members: providers (n = 55), staff (n = 99), and medical learners (n = 18) in the Stanford Division of Primary Care and Population Health (PCPH) clinics, 2018-2021. We categorized projects by the Institute for Healthcare Improvement's (IHI) Quintuple Aim (QA): better health, better patient experience, lower cost of care, better care team experience, and improved equity/inclusion. We assessed project progress with a modified version of The Ottawa Hospital Innovation Framework: step 1 (identified root causes), step 2 (designed/tested interventions), step 3 (assessed project outcome), step 4 (met project goal with target group), step 5A (intervention(s) spread within clinic), step 5B (intervention(s) spread to different setting). Participants rated post-participation QI self-efficacy. Within 1000days, 172 unique participants completed 104 PC-PEP projects. Most projects aimed to improve patient health (55%) or care team experience (23%). Among projects, 9% reached step 1, 8% step 2, 16% step 3, 26% step 4, 21% step 5A, and 20% step 5B. Learner involvement increased likelihood of scholarly products (47% vs 10%). Forty-six of 47 (98%) survey respondents reported improved QI self-efficacy. Medical assistants, more so than physicians, reported feeling acknowledged by the health system for their QI efforts (100% vs 61%). With appropriate QI infrastructure, scalable QI training models like Stanford PC-PEP can empower frontline workers to create meaningful changes across the IHI QA.

Linking current dental education to gerontological education to meet the oral health needs of growing aging populations.

This study aimed to recognize the gaps in dental education by studying the current level of geriatric oral health training of recent graduated dentists who have been admitted into an Advanced Education in General Dentistry (AEGD) program. The AEGD program was developed along with the Age-Friendly 4Ms model to enhance current dental education. We adopted the Rapid Cycle Quality Improvement model to test the effectiveness of the training for AEGD residents from 2019 to 2022. A total of 18 residents participated (6 residents each year). A 5-question survey was administered before and after the rotation and Wilcoxon signed-rank with Fisher Exact tests were conducted to compare pre- and post- rotation results. All 18 residents have completed pre- and post-program surveys. They self-reported minimal to no training in preparation to provide care to older adults with multiple chronic conditions. After the rotation, residents' confidence in treating older adults was significantly increased (p = 0.011). Meanwhile, residents gained knowledge to apply the 4Ms framework (what matters, medication, mentation, and mobility) to their practices (p = 0.015) and provide age-friendly care for older adults. The study identified and addressed the missing link in dental education to gerontological and geriatrics education. More clinical rotations and didactic training to equip residents with competences of providing geriatric oral health are strongly recommended.

Wellness in Nursing Education to Promote Resilience and Reduce Burnout: Protocol for a Holistic Multidimensional Wellness Intervention and Longitudinal Research Study Design in Nursing Education.

The United States faces a nursing shortage driven by a burnout epidemic among nurses and nursing students. Nursing students are an integral population to fuel the nursing workforce at high risk of burnout and increased rates of perceived stress. The aim of this paper is to describe WellNurse, a holistic, interdisciplinary, multidimensional longitudinal research study that examines evidence-based interventions intended to reduce burnout and increase resilience among graduate and undergraduate nursing students. Graduate and undergraduate nursing students matriculated at a large public university in the northeastern United States are eligible to enroll in this ongoing, longitudinal cohort study beginning in March 2021. Participants complete a battery of health measurements twice each semester during the fourth week and the week before final examinations. The measures include the Perceived Stress Scale, the Satisfaction with Life Scale, the Oldenburg Burnout Inventory, the Brief Resilience Scale, and the Pittsburgh Sleep Quality Index. Participants are eligible to enroll in a variety of interventions, including mindfulness-based stress reduction, mindful eating, fitness training, and massage therapy. Those who enroll in specific, targeted interventions complete additional measures designed to target the aim of the intervention. All participants receive a free Fitbit device. Additional environmental changes are being implemented to further promote a culture that supports academic well-being, including recruiting a diverse student population through evidence-based holistic admissions, inclusive teaching design, targeted resilience and stress reduction workshops, and cultural shifts within classrooms and curricula. The study design protocol is registered at Open Science Framework (DOI 10.17605/OSF.IO/NCBPE). The project was funded on January 1, 2022. Data collection started in March 2022. A total of 267 participants have been recruited. Results will be published after each semester starting in December 2023. WellNurse evaluation follows the Rapid Cycle Quality Improvement framework to continuously monitor ongoing project processes, activity outcomes, and progress toward reducing burnout and increasing resilience. Rapid Cycle Quality Improvement promotes the ability to alter WellNurse interventions, examine multiple interventions, and test their effectiveness among the nursing education population to identify the most effective interventions. Academic nursing organizations must address student burnout risk and increase resilience to produce a future workforce that provides high-quality patient care to a diverse population. Findings from WellNurse will support evidence-based implementations for public baccalaureate and master's nursing programs in the United States. DERR1-10.2196/49020.

Pediatric Rheumatology Care and Outcomes Improvement Network's Quality Measure Set to Improve Care of Children With Juvenile Idiopathic Arthritis.

To describe the selection, development, and implementation of quality measures (QMs) for juvenile idiopathic arthritis (JIA) by the Pediatric Rheumatology Care and Outcomes Improvement Network (PR-COIN), a multihospital learning health network using quality improvement methods and leveraging QMs to drive improved outcomes across a JIA population since 2011. An American College of Rheumatology-endorsed multistakeholder process previously selected initial process QMs. Clinicians in PR-COIN and parents of children with JIA collaboratively selected outcome QMs. A committee of rheumatologists and data analysts developed operational definitions. QMs were programmed and validated using patient data. Measures are populated by registry data, and performance is displayed on automated statistical process control charts. PR-COIN centers use rapid-cycle quality improvement approaches to improve performance metrics. The QMs are revised for usefulness, to reflect best practices, and to support network initiatives. The initial QM set included 13 process measures concerning standardized measurement of disease activity, collection of patient-reported outcome assessments, and clinical performance measures. Initial outcome measures were clinical inactive disease, low pain score, and optimal physical functioning. The revised QM set has 20 measures and includes additional measures of disease activity, data quality, and a balancing measure. PR-COIN has developed and tested JIA QMs to assess clinical performance and patient outcomes. The implementation of robust QMs is important to improve quality of care. PR-COIN's set of JIA QMs is the first comprehensive set of QMs used at the point-of-care for a large cohort of JIA patients in a variety of pediatric rheumatology practice settings.

Enhancing diversity to transform the future geriatric nursing workforce

Objective: The growing number of older adults has placed unprecedented demands on the healthcare system while the number of geriatric nurses has not kept pace, and the gap is expected to widen. Simultaneously the older adult population is becoming more racially and ethnically diverse while the nursing workforce lacks diversity. Given the urgent need to increase and expand the number of diverse geriatric trained nurses, an innovative sustainable nursing program, Enhancing Diversity in Geriatric Nursing (EDGE) was implemented to train diverse nursing students in geriatrics thereby expanding the workforce and meeting the needs of underserved older adult populations.Methods: An Integrated Geriatric Training Program was implemented to provide didactic education through established online geriatric training modules, experiential learning through geriatric clinical placements, and telehealth training. EDGE supported students with stipends. Retention was enhanced via workshops and a combined mentorship program with peer tutoring to achieve a synergistic approach. Strategies were implemented to connect EDGE scholars to employment opportunities with underserved populations. Program impact was examined with a mixed-methods approach utilizing both quantitative and qualitative data to evaluate satisfaction and inform program refinement. Data were analyzed and Rapid Cycle Quality Improvement was utilized for monitoring and quality improvement.Results: EDGE resulted in the recruitment, enrollment, and geriatric training of 40 nursing students. EDGE scholars indicated program satisfaction.Conclusions: Disadvantaged nursing students benefitted from the EDGE Program. Longer term, the impact of the EDGE program has a strong likelihood for improving the care of underserved older adults by a diverse geriatric-trained nursing workforce.

Preventing measles transmission in ambulatory pediatric settings during peak respiratory viral season

Background: Measles is a highly transmissible respiratory virus that presents with nonspecific prodromal symptoms followed by a characteristic cephalocaudal rash. In the prodromal phase, children with measles can be challenging to differentiate from children with other circulating respiratory viral infections. A measles outbreak in Central Ohio starting in October 2022 coincided with a national surge in children with viral respiratory infections which presented unique challenges in preventing healthcare transmission in the pediatric ambulatory setting. Methods: Following initial identification of presumed community transmission of measles in Central Ohio in November 2022, a multidisciplinary measles response team was convened at Nationwide Children’s Hospital (NCH) to prevent secondary healthcare transmission via rapid-cycle quality improvement. Prevention efforts were focused broadly across NCH ambulatory locations in Central Ohio, including the main campus and offsite emergency departments, regional urgent cares, and primary care network. Preliminary risk factors were identified via chart review of initial cases, which included vaccine status, ZIP code of residence, and known daycare or household exposure. These risk factors were used to guide an intervention bundle comprising enhanced screening at registration and triage, creation of electronic medical record alerts to identify at-risk patients, increased clinician education, and expanded community messaging. As the outbreak evolved, risk factors were updated, and interventions were adjusted to adapt response. Outcome metrics included total patient exposures as well as the relative exposure score. The exposure score was an internal metric derived using the vaccine status of exposed patients and ventilation at the site of exposure to assess likelihood of secondary cases occurring from an exposure. Results: In total, 65 patients with measles were seen at NCH facilities between October 29 and December 8, 2022. The outbreak response was divided into 4 periods: (1) cases identified retrospectively prior to first diagnosis (October 29–November 7, 2022), (2) initial case discovery (November 8–14, 2022), (3) implementation of prevention bundle (November 15–28, 2022), and (4) updates to the response (November 29–December 8, 2022). Ambulatory healthcare exposures and incidence of secondary cases decreased over the outbreak periods in response to implementation of the prevention bundle (Fig. and Table). Conclusions: An outbreak of measles occurring simultaneously with peak respiratory viral season presented challenges in early identification of suspected cases and mitigation of healthcare exposure. Transmission was effectively prevented following rapid deployment of a prevention bundle adjusted in real-time through rapid-cycle quality improvement. Ongoing longitudinal vaccination efforts are needed to sufficiently mitigate transmission risk in communities with under-vaccinated populations.Disclosures: None

S1481 Impact of Time-Motion Patient Flow Analysis on the Productivity of an Endoscopy Unit in a Large Safety-Net Health Center

Introduction: The COVID-19 pandemic disrupted health care delivery, particularly for high-volume procedural areas. To improve productivity in the Los Angeles County + University of Southern California Medical Center (LAC + USC) Endoscopy Unit, we initiated an iterative rapid cycle quality improvement process to identify inefficiencies and implement changes to our workflow. Methods: A time-motion analysis of patient flow through the LAC + USC Endoscopy Unit was used to construct a time-tracked flow sheet to track individual patients as they moved through the Unit. Data were collected weekly over 3 9-10 week phases, and intervening plan-do-study-act (PDSA) cycles were conducted to direct interventions for subsequent phases. Following phase 1 (9/1/21 to 11/9/21) we implemented targeted interventions at the start of phase 2 (12/1/21 to 2/1/22) and phase 3 (3/15/22 to 5/31/22). Phase 2 was focused on our anesthesia supported endoscopy room which requires greater resource coordination. Metrics were compared to published benchmarks. Linear regression was used to compare outcome parameters for the lean process flow improvement project. Results: Our phase 1 analysis showed operational delays in room turnover time for all procedures and pre-operative assessment and first-case on time start percentage for procedures supported by anesthesia, when compared to published benchmarks (Table 1). In phase 2 we implemented an intervention of combining pre-anesthesia visits with endoscopy teaching visits for patients designated to have anesthesia support. This significantly improved both turnover time and throughput for the anesthesia room (Table 1). In phase 3 we initiated a policy of preparing the first patient of the day in the procedure room which dramatically increased first-case on time start percentage. We further streamlined inter-procedure processes by simultaneously consenting, placing monitoring equipment and documenting in the time between procedures, leading to a greater than 20% increase in total procedure volume (Table 1). Procedure throughput for the anesthesia supported procedure room increased from 4.5 to 7 to 9 procedures per room per day for phases 1, 2, and 3 respectively (Table 1). Endoscopy Unit staffing remained unchanged throughout the study period. Conclusion: Time-motion analysis of patient flow may be used to perform targeted interventions with significant improvements in Endoscopy Unit efficiency. This may be achieved without costly interventions such as hiring additional support staff or faculty. Table 1. - Core Productivity and Efficiency Parameters of LAC+USC Endoscopy Unit Phase 1 FIRST INTERVENTION 12/1/2021: pre-anesthesia visit Phase 2 SECOND INTERVENTION 3/15/2022:First patient prepared in-room and streamlined inter-procedure processes Phase 3 Sep-2021 Oct-2021 Nov-2021 Dec-2021 Jan-2022 Feb-2022 Mar-2022 Apr-2022 May-2022 Total Procedures 539 556 450 511 467 501 504 647 612 Moderate Sedation 515 539 426 488 432 468 465 608 573 Anesthesia Supported 24 17 24 23 35 33 39 39 39 Mean Room Turnover Time (minutes - for anesthesia room) 45 (±40) 31 (±40) 30 (±24) First-Case On Time Start % (moderate sedation) 75.7% 78.3% 87.5% First-Case On Time Start % (anesthesia supported) 0% 0% 92.5% Anesthesia Room Throughput (mean # of procedures per day) 4.5 7.0 9.0

Enhancing MSW Field Education Using Rapid Cycle Quality Improvement: Feasibility and Acceptability of an Online Weekly Feedback Tool and Process

ABSTRACT Rapid Cycle Quality Improvement (RCQI) is often required for behavioral health work force training and evaluation projects supported by the U.S. Health Resources and Services Administration (HRSA). The RCQI process is well established within healthcare but under-utilized in academia to improve teaching and learning. We created and piloted the Friday Feedback (FF) survey tool as part of a HRSA funded training program for weekly completion by MSW interns. Across two semesters of full-time field education, a cohort of 15 MSW students completed 281 weekly FF surveys. Students reported activities such as number of patients seen, observations about integration of behavioral and physical health, patient successes and challenges, and time spent working on interdisciplinary teams. Cumulatively, students reported working with 2,425 patients/clients and in frequent close collaboration with other health professions. A review team comprised of faculty and staff met weekly to discuss students’ FF data and create response plans to promote student learning. The RCQI process was feasible and acceptable to students and the team. It created a feedback loop to improve students’ field experiences, enhanced the curriculum, and enabled effective monitoring and rapid response from team to students. Benefits and challenges of this RCQI approach to enhance field education along with lessons learned for wider adoption are discussed.

Improving acute pain management of trauma patients on medication-assisted therapy.

Approximately 9,500,000 people in the United States misused opioids in 2020. Many people manage their opioid use disorder (OUD) with medication-assisted treatment (MAT). Using MAT to address OUD adds to the complexities and challenges of adequate acute pain control. Chart review indicated only 20% of trauma patients on MAT achieved adequate pain control on the trauma service at the University of Louisville Hospital. This quality initiative aimed to increase patient pain control to 50% in 90 days. A rapid cycle quality improvement project with four plan-do-study-act (PDSA) cycles was conducted over 8 weeks. Four core interventions were implemented concurrently, with tests of change biweekly. Qualitative and qualitative data analyses were completed at each cycle. The core interventions included a risk assessment tool, shared decision-making (SDM) tool, provider checklist, and a team engagement plan. The number of patients with a pain score of ≤5 (scale 0-10) increased to 78% from 20%. The mean pain score decreased from 8 to 4.6. The fourth PDSA cycle results showed a 92% patient engagement with SDM and 100% utilization of the provider checklist. Team engagement scores greater than 4 on a 5-point Likert scale were 86%. Effective patient-centered acute pain control for trauma patients on MAT is achievable. The combined use of an SDM tool and a provider checklist was an efficient way to provide effective and patient-centered care and positively affected patient outcomes.

Feasibility of a Nursing Home Antibiotic Stewardship Intervention.

To evaluate a bundled electronic intervention to improve antibiotic prescribing practices in US nursing homes. Prospective mixed-methods quality improvement intervention. Nursing staff and residents in 13 nursing homes, and residents in 8 matched-control facilities (n= 21 facilities total, from 2 corporations). This study involved a 2-month design period (n= 5 facilities) focused on the acceptability and feasibility of a bundled electronic intervention consisting of 3 tools, followed by a 15-month implementation period (n= 8 facilities) during which we used rapid-cycle quality improvement methods to refine and add to the bundle. We used mixed-methods data from providers, intervention tools, and health records to assess feasibility and conduct a difference-in-difference analysis among the 8 intervention sites and 8 pair-matched controls. Nurses at 5 pilot sites reported that initial versions of the electronic tools were acceptable and feasible, but barriers emerged when 8 different facilities began implementing the tools, prompting iterative revisions to the training and bundle. The final bundle consisted of 3 electronic tools and training that standardized digital documentation to document and track a change in resident condition, infections, antibiotic prescribing, and antibiotic follow-up. By the end of the implementation phase, all 8 facilities were using at least 1 of the 3 tools. Early antibiotic discontinuation increased 10.5% among intervention sites, but decreased 10.8% among control sites. The 3 tools in our bundled electronic intervention capture clinical and prescribing data necessary to assess changes in antibiotic use and were feasible for nurses to adopt. Achieving this required modifying the tools and training before the intervention reached its final form. Comparisons of rates of antibiotic use at intervention and control facilities showed promising improvement in antibiotic discontinuation, demonstrating that the intervention could be evaluated using secondary electronic health record data.

Overuse, underuse, and misuse: Improving effective primary care at a Federally Qualified Health Center.

U.S. healthcare costs have increased exponentially to almost $4 trillion. Despite increased costs, patient outcomes remain suboptimal. It is imperative that primary care providers are intentional with testing and medical technology to improve effective care. Preintervention chart audits showed average overspending of $79.41 per provider per day. Despite overspending, outcomes are not optimal. Only 48% of persons with hypertension and 38% of persons with diabetes at Orange Blossom Family Health (OBFH) are controlled. The aim of this 8-week quality improvement (QI) project was to decrease lab spending by 20% for adult primary care patients at OBFH. A rapid cycle QI initiative of four Plan-Do-Study-Act cycles, 2 weeks each, was completed to implement four interventions concurrently. The data was assessed every 2 weeks with iterative tests of change as indicated. The primary care quality metrics chart audit and preclinical care coordination tools were developed, and the My Life, My Healthcare tool and medical assistant (MA)-provider huddles were initiated with the focus on effective patient care. A savings of $3406.43 on overordering of labs by one provider in 8 weeks was identified. The average provider compliance to national guidelines was found to be 54.1%. There was a 19.3% increase in referrals. MA-provider huddles were balanced for this initiative. The initiative addressed effective care through awareness of resource allocation, patient engagement, and team communication. Continued application of these core interventions will ensure consistent and quality healthcare.

Improving equitable access to inclusive sexual healthcare in a small urban college health setting.

Sexual and gender minorities (SGM) experience many disparities in sexual health. College health centers must address early inequities for this population. Significant access disparity was noted for SGM students at a small urban college health center. The aim of this quality initiative was to increase equitable access by 20% over 90 days. A rapid-cycle quality improvement project was initiated using a Plan-Do-Study-Act model. Templated nurse-led visits, a discussion starter tool, and an inclusive care checklist were introduced, with assurance of equity for each metric, and a focus on team collaboration. Access to sexual health services increased by 22.6% over 8 weeks with SGM utilization increasing 2.7-fold. Guideline-concordant care improved by 94% for all students. Student comfort scores (Likert range 1-5) also improved, from a baseline of 3.53 to a project mean of 4.62. This project addressed equity in a college health setting through improved student engagement, targeted workflow innovation, and enhanced team collaboration. Application of key findings to other health topics will continue to mitigate disparities in college health centers. Tools may also be applied to adolescent and adult primary care settings to improve patient comfort and SGM-inclusive sexual health service delivery.

Development and Implementation of a Neonatal Pain Management Guideline for Minor Surgeries.

Although opioids are effective for neonatal postoperative pain management, cumulative opioid exposure may be detrimental. Pain management practices vary among providers, but practice guidelines may promote consistency and decrease opioid use. To develop a pain management guideline (PMG) for neonates undergoing minor surgical procedures with the overarching goal of reducing opioid use without compromising the pain experience. The specific aim was for neonatal intensive care unit providers to adhere to the PMG at least 50% of the time. An interdisciplinary pain and sedation work group in a large level IV neonatal intensive care unit developed an evidence-based PMG for minor surgical procedures. Nurses and providers were educated on the new guideline, and rapid cycle quality improvement methodology provided an opportunity to adjust interventions over 3 months. The PMG was used for 32 neonates following minor surgical procedures: 18 (56%) of the neonates received only acetaminophen and no opioids, 32% required 0.15 mg/kg dose equivalent of morphine or less, and only 9% required more than 0.15 mg/kg dose equivalent of morphine. Overall, opioid use decreased by 88% compared with rates before implementation of the PMG. Providers adhered to the PMG approximately 83.3% of time. A PMG is a systematic approach to direct nurses and providers to appropriately assess, prevent, and treat neonatal pain following minor surgery while alleviating opioid overuse. Future research should focus on determining and mitigating barriers to nurse/provider use of the PMG and developing and implementing a PMG for major surgical procedures.

Geriatric Interprofessional Simulation Education Results and Rapid Cycle Quality Improvement

Following a geriatric interprofessional education event, we measured learner progression in interprofessional collaborative competencies using the Interprofessional Socialization and Valuing Scale (ISVS). We also measured student satisfaction with an investigator generated assessment tool. Through Rapid Cycle Quality Improvement (RCQI) processes, we implemented a number of variations of both the in-person and the virtual events. Variations included differences in case studies, pre work requirements, geriatric didactic topics, poster topics and presentation format, facilitator training, standardized patient or patient presence, huddle format, and demonstration of how to effectively perform teamwork. Results showed gains in interprofessional collaborative competencies between pre- and post-education using this geriatric simulation model. Learner satisfaction was high for all simulation variations. Results of education variations and comparisons of the delivery methods will be presented.

A Simulation Model for Geriatric Education: Theory, Virtual Transformation and Quality Improvement

Delivery of effective healthcare for the geriatric population is often complex due to the interplay between physical, social, and emotional variables. It is well established that it is the interplay between chronic medical conditions, social determinants of health, function and geriatric syndromes that drives outcomes. This complexity makes it especially important for the healthcare team to take an interprofessional team approach to avoid fragmented care which can lead to patient dissatisfaction, an ineffective plan of care, and low-quality outcomes. However, effective teamwork is not innate to healthcare; it must be learned and developed over time through purposeful education. The literature on team training supports active learning pedagogies such as simulation-based education that has emerged as an effective way to translate teamwork education into practice. Participation in active learning such as simulation, provides learners with authentic experiences that become cognitive frames that can transition into real practice. Education of adult learners should be a scaffolding of experiences that build on one another. This approach can lead the learner from the acquisition of basic knowledge, skills, and attitudes, to higher levels of competency and clinical judgement. Simulation simultaneously engages cognitive, perceptual-motor, and affective learning, and when combined with effective debriefing can lead to higher levels of learning. Effective models with scaffolding of experiences using simulations for geriatric team training are lacking in the literature. We describe here the theoretical framework for such training, adaptions of in-person and virtual training models due to COVID-19 restrictions through rapid cycle quality improvement.

Increasing Access to Forensic Nursing Services in Rural and Underserved Areas of Texas.

Sexual assault is prevalent in the Unites States. Many areas of the country lack access to sexual assault nurse examiners (SANEs), especially in rural areas. The U.S. Health Resources and Services Administration Advanced Nursing Education-Sexual Assault Nurse Examiner educational grant provided an opportunity to improve equity and reduce disparity in rural and underserved communities by offering education and simulation experiences in the care of sexual assault patients. Through the Texas A&M Health Center of Excellence in Forensic Nursing, Texas A&M University College of Nursing developed an innovative program using simulated medical forensic examinations and mock testimony education. Rapid cycle quality improvement was utilized to adapt quickly to feedback and meet overarching goals. This article describes development and adaptation of the program using rapid cycle quality improvement processes and progress in recruitment, retention, and certification of nurses to provide sexual assault care in rural and underserved areas of Texas.

Beyond "Red Man Syndrome": A Case for American Indian Health Equity.

Sitting in the lecture hall, the first-year medical student, an American Indian first-generation college graduate, was shocked and dismayed when learning about antimicrobial agents and their side effects as the professor described “red man syndrome” (RMS). The student was relieved when other students in the course discussed the racial insensitivity of this term and cited recent articles calling for the removal of this language. However, this feeling of isolation and damage was already inflicted. Unfortunately, this experience is not rare. Minority medical trainees experience microaggressions and bias daily.1 As a medical community, we must do better. Konold et al present a strong example of using rapid-cycle quality improvement methodology to purge the antiquated, racially insensitive term RMS from the medical record.2 They describe how the documentation of 274 pediatric patients who had been diagnosed with RMS within their hospital was successfully removed from charts.2 In addition, the success of this intervention is supported by the reduction of the use of this language 3 months after the intervention, with only 29 of 65 charts with vancomycin allergies listed citing RMS. Importantly, the rate of use revealed a statistically significant difference preintervention and postintervention ( P < .001).2 This approach is used to substitute more medically descriptive and correct terminology, “vancomycin flushing reaction” or “vancomycin infusion reaction”, as recently recommended by the Infectious Diseases Society of America and Pediatric Infectious Diseases Society.3–5 The quality improvement project by Konold et al serves as a simple and disseminatable action that other hospitals can emulate.2 They describe how others can use electronic medical records to address the racial injustice of terminology with further education to continue to make positive changes toward equality in the …