Run Charts Research Articles

Adolescent Chlamydia Screening in Pediatric Primary Care: A Quality Improvement Project.

To increase Chlamydia trachomatis screening in adolescents 15-19 years of age from 7.8% to 15% following a 6-week implementation of universal chlamydia screening at three paediatric primary care (PPC) sites. Pre-implementation (1 January 2022-19 October 2022) and post-implementation (20 October 2022-1 June 2023) screening rates were tracked through run charts and compared via Chi-square testing. Universal opt-out chlamydia screening with universal urine collection for 15- to 19-year-old was implemented at well visits, along with patient and staff education, and sexually transmitted infection treatment protocols. Chlamydia trachomatis screening increased from 7.8% to 34.1% with implementation of universal opt-out chlamydia screening. Proportions of patients screened increased significantly among White individuals, males and privately insured individuals. A universal C. trachomatis screening project can be feasibly implemented in pediatric primary care and successfully increase adolescent chlamydia screening rates. Implementing a universal opt-out C. trachomatis screening project is feasible in PPC and can help achieve the public health goal of chlamydia identification and treatment. These findings will be impactful for both paediatric primary care and adolescent patients. The universal, opt-out C. trachomatis screening approach facilitated screening increases, improved equity in screening and led to increased case detection and treatment which has vast significance for those patients. This manuscript is submitted using the SQUIRE 2.0 guidelines for quality improvement reporting. Patient contribution included de-identified data collection of chlamydia screening rates of eligible adolescents 15-19 years old who attended routine well visits at the three PPC locations. The data were reviewed on a dashboard, then stratified by race, ethnicity, payor and sex assigned at birth.

How I Do It: Process Control in Medical Student Experiences of Surgery

ObjectiveExtreme variation exists in teaching and clinical exposure for medical students, both from specialty-to-specialty but also between universities. There is mounting literature highlighting the need to reform and standardise surgical education to allow for unified graduate competency. In line with the recommendations from the GMC2 and the Royal College of Surgeons England (RCSE) 3, Queens University Belfast (QUB) significantly revised their undergraduate medical programme. Within this new curriculum is the introduction of Specialty Focus week in Surgery. This report reviews the processes used in the introduction of this week. DesignThe initial curriculum was formulated with a weekly timetable consisting of tutorials, bedside teaching and students following a peri-operative case. Run charts were populated with an alert when feedback dropped below a certain standard, which then triggered an intervention. ParticipantsFeedback was collected via a QR code from the first 200 surgical student. SettingsBelfast City Hospital in association with Queens university Belfast (QUB) undergraduate surgical curriculum. ResultsRun charts resulted in an alert when feedback dropped below 8/10. Following this we implemented smaller group bedside teaching. There was a significant improvement in feedback post intervention (P=0.04) with no further alerts. Overall feedback had a non-significant feedback improvement post intervention (P=0.07) with once again, no further alerts. ConclusionThis review has shown how we have provided some standardisation of local surgical teaching, as well as having a process centred model of monitoring. This curriculum is easy to implement and could be reproduced elsewhere.

Prevent Acute Chest Syndrome checklist (PACScheck): A quality improvement initiative to reduce acute chest syndrome.

Acute chest syndrome (ACS) is a life-threatening complication of sickle cell disease (SCD). The Prevent Acute Chest Syndrome checklist (PACScheck) was created to drive appropriate ordering of opioids, incentive spirometry (IS), intravenous fluids (IVF), evaluation of oxygen desaturation, and bronchodilator use. Decrease the development of ACS by 5% in a hospitalized pediatric SCD population. A multidisciplinary team conducted a quality improvement (QI) project between April 2020 and August 2021 on an inpatient pediatric hematology unit. At-risk hospitalizations were patients with SCD who did not have ACS upon hospital admission. PACScheck was implemented and weekly run charts assessed documentation. Process control (p) charts, geometric control (g) charts, and chi-square tests assessed checklist process measures pre- and post-PACScheck. G chart assessed the number of encounters between ACS events. A total of 483 at-risk hospitalizations were identified in the 12 months prior and 363 during the study period. A g chart demonstrated that fewer encounters developed ACS during PACScheck. A p chart demonstrated that IS documentation increased during PACScheck. A run chart of PACScheck documentation demonstrated a median of 100% documentation at least once per hospitalization during the last six months of the intervention. Development of ACS can be reduced by implementing a best-practices checklist (PACScheck) on an inpatient pediatric hematology unit with a multidisciplinary team.

Navigating the path to equitable rheumatologic care for underserved children with quality improvement.

The aim of this quality improvement project is to identify children with rheumatologic conditions to prevent delayed or missed diagnosis in underserved pediatric populations. Our focus is on prompt and accurate identification and subsequent treatment of rheumatologic symptoms in pediatric patients referred from Atrium Health safety-net primary care clinics that deliver care to families without private insurance, including those lacking insurance entirely. We collaborated with providers at one safety-net clinic to improve the processes of identification and subspecialty referral, resulting in an increase in the number of identified pediatric patients and referrals for these patients with potential rheumatologic disease. We used the Model for Improvement framework with rapid Plan-Do-Study-Act cycles and evaluated improvement with run and statistical process control charts. We achieved improvement, with zero referrals in the previous 5 years for the targeted population increasing to 15 patient referrals within 1 year of project initiation. Despite this increase in referrals, the rheumatology clinic was able to see all priority patients within 20 business days from referral. An awareness of concerning rheumatologic symptoms in safety-net primary care clinics, combined with the use of both visual and decision aids, allows care teams to efficiently recognize and accurately refer patients needing specialty care.

7991 A Quality Improvement Initiative to Increase Documentation of Carbohydrate Ratios and Correction Factors on Insulin Sliding Scales

Abstract Disclosure: R.J. Vitale: None. C. Lu: None. A. Sonawalla: None. T.K. Maxwell: None. S. Nanavati: None. N.E. Renthal: None. E.T. Rhodes: None. C.E. Cherella: None. Background: In the management of insulin-dependent diabetes mellitus, sliding scale (SS) tables - which contain precalculated insulin doses for ranges of blood glucose and carbohydrate intake, usually based on a carbohydrate ratio (CR) and correction factor (CF) - provide a safer alternative for families with limited health literacy and numeracy. However, as insulin needs change, adjusting SS tables can be more difficult than adjusting CRs and CFs, which can cause less frequent or non-standard adjustments in SS tables, result in potential errors, and lead to disparities in the quality of care for these patients. We identified challenges to standardized SS documentation and adjustment at our institution and conducted a quality improvement (QI) initiative to address this problem. We aimed to increase the use of CR/CF to generate and adjust SS to improve the ease and accuracy of SS adjustments and ultimately improve care for this vulnerable patient population. Methods: Our goal was to increase the proportion of patients with diabetes mellitus discharged with CR/CF documented on the most recent SS in the medical record (the primary outcome measure) by 20% over 12 months. The process measure was clinician-reported utilization of CR/CF when generating or adjusting SS. To achieve our goal, we made two process improvements and used Plan-Do-Study-Act cycles to evaluate them. First, we standardized the template for documentation of the SS which also prompted inclusion of the CR/CF to preserve it for future adjustments. Second, we developed a Microsoft Excel SS generator based on clinician input of CR/CF. Clinicians were educated about the importance of CR/CF documentation and were taught to use the new process. SS documentation of CR/CF in the medical record was evaluated through monthly chart review and tracked on a run chart. Clinicians were periodically surveyed on the frequency of use of CR/CF in the creation of SS. Results: The median value of SS that included CR/CF documentation in medical records increased from 0% at baseline to 58% after the interventions. Reported use of CR/CF to make and adjust SS increased from 6/15 (40%) to 6/7 (86%). Provider qualitative feedback on the new process was positive. Conclusion: In this QI project, the implementation of a template that promoted documentation of CR/CF, and a standardized and automated SS calculator that generated SS based on CR/CF, led to both increased documentation of CR/CF for SS, and increased clinician-reported use of CR/CF to adjust SS. The latter may indicate a decrease in barriers to adjusting SS regimens. By facilitating adjustment, this low-cost, reproducible system could increase frequency of changes to SS and may help to improve the quality of care for children with diabetes mellitus using SS. Presentation: 6/2/2024

Enhancing screening for nutritional causes of anemia in hospitalized patients with cancer.

367 Background: Anemia in patients with cancer has been associated with lower quality of life, diminished performance status, and potentially even delays in chemotherapy. Multiple professional societies, including the NCCN and ESMO, recommend routine testing for iron deficiency and iron replacement if deficiency is identified. The aim of this quality improvement project was to increase testing for nutritional causes of anemia, especially iron deficiency, among patients admitted to the onco-hospitalist teaching service at MD Anderson Cancer Center. Methods: A process map was constructed to identify pitfalls with the current process for identifying and ordering testing for nutritional (iron, B12, and folate deficiency) causes of anemia. The primary intervention for our Plan-Do-Study-Act (PDSA) Cycle was creating and implementing an electronic medical record smart phrase to be included in each note prompting consideration of reversible causes of anemia and whether testing was ordered in the last 6 months or needs to be ordered. Education was also provided to residents regarding reversible causes of anemia and appropriate studies to order. Fliers describing the intervention and the recommended testing algorithm were placed in the resident workroom. A retrospective chart review of all patients admitted to the onco-hospitalist teaching service from August 2023 to February 2024 was employed to collect pre- and post-intervention data, and a run chart was created to plot rates of screening over time. Results: Of the pre-intervention cohort (n=263) from August to December 2023, 196 (74.5%) were identified as having anemia; of these patients, 109 (55.6%) underwent screening for nutritional causes of anemia during the admission. After our intervention was implemented, of all patients admitted to the service (n=186), a total of 156 (81.7%) were found to have anemia and 116 (74.3%) were screened for reversible causes of anemia. Almost all reversible causes of anemia were found to be secondary to iron deficiency. Conclusions: Our data shows that anemia is prevalent in our patient population yet inconsistently evaluated at baseline. At the same time, a combination of smart phrase utilization and education successfully increased rates of screening from 55.6% to 74.3% of patients admitted to the onco-hospitalist teaching service. One potential future endeavor is addition of a smartphrase to the admitting H&P templates to prompt teams to consider reversible causes of anemia, especially iron deficiency, during the admission.

Routine Infectious Diseases Consultations on a Pediatric Cardiac Unit to Improve Positive Blood Culture Management.

Bacteremia can be life-threatening, and highly medicalized patients, such as those with complex congenital heart disease, are at high risk. Infectious diseases (ID) consultation is associated with improved outcomes in bacteremia. We noted an opportunity for improvement in management of positive blood cultures in our cardiac care unit (CCU). We completed a quality improvement project that included a single plan-do-study-act cycle consisting of a policy of routine ID consultation for all positive blood cultures events in the CCU. Our outcome measure of interest was percentage of appropriately managed blood culture events, the process measure was percentage of blood culture events for which the ID service was formally consulted, and the balancing measure was number of individual patients for whom the ID service was formally consulted. Appropriate antimicrobial management was determined via chart review by an ID physician. Data were analyzed via run chart and simple statistics. Following the intervention, the rate of appropriately managed positive blood culture events increased from a baseline of 86% to 98%, and the rate of ID consultation for these events increased from 75% to 98%. A shift was noted in run charts for both the outcome and process measures. There was an increase in patients for whom the ID service was consulted throughout the entire study period. We successfully implemented mandatory ID consultations in a CCU to increase proportion of appropriately managed blood cultures. While this intervention cannot be universally applied, others may find it useful in selected scenarios.

Enhancing Soil Resilience and Sugar Beet (Beta vulgaris L.) Yield: Mid‐Term Effects of Compost and Glauconite Integration

ABSTRACTSugar beet (Beta vulgaris L.) is a globally significant crop, valued for its economic importance in sugar production. Saline‐sodic soil environments negatively impact sugar beet productivity. This study investigates the effects of using compost, glauconite enriched‐K and their combinations in mitigating the saline‐sodic soil environment, sugar beet productivity and extracted sugar quality. A two‐season field experiment in split‐plot design with the main plots is three doses of compost: control (C0), recommended (100%) dose (C1) and 150% recommended dose (C2). Each group divided into four subplots of glauconite treatments arranged according to the recommended dose of potassium (K) as follows: G0 (no glauconite), G1 (50% K), G2 (100% K, 480 Kg glauconite Fed−1) and G3 (150% K). The results showed that compost and glauconite mitigated adverse soil effects caused by salinity and sodicity. The C2G3 treatment reduced electrical conductivity (EC) and exchangeable sodium percentage (ESP), improved organic matter and enhanced soil bulk density, porosity and penetration resistance. This combination also increased soil nutrients (N, K, Fe, Mn, Zn and Cu). Regarding the sugar beet yield, C2G3 improved root yield, top yield, sugar yield and extracted sugar. The application of glauconite increased root diameter by 20% and root length by 23%, enhanced sugar quality with minimal sugar losses to molasses (2.43%), and reduced impurities of K, α‐amino N and Na. Principal component analysis showed positive correlations between root yield and soil potassium, organic matter, cation exchange capacity and soil porosity, with negative correlations to bulk density, EC, pH and ESP. Two‐way analysis of main (ANOM) illustrated significant effects of compost and glauconite on soil–plant interactions. Multivariate analysis indicated that higher glauconite doses significantly enhanced root yield. The Gag run charts confirmed that compost (100%) and G3 levels explored more homogeneity reducing the ESP%, increasing sugar beet root yield, sugar yield and quality.

Decreasing Patient Visit Length at a Student-Run Free Clinic via a Continuous Quality Improvement Project.

The University of Florida Equal Access Clinic Network (EACN) is the largest student-run free clinic(SRFC) network in Florida. This student-driven, continuous quality improvement (CQI) project is intended to decrease total patient visit length at Eastside clinic, one of EACN's primary care sites. The original median visit length of 126.25 minutes represented a significant time burden for patients, especially those with limited transportation or inflexible schedules. Over six months, four Plan-Do-Study-Act (PDSA) cycles were implemented. PDSA cycle 1 increased personnel and space for taking vitals. PDSA cycle 2 reduced redundancy in the intake process. PDSA cycle 3 triaged patients to match patient complexity with student experience level. PDSA cycle 4 introduced "nudge" interventions to reinforce clinic flow. Total patient visit length and time spent at each step of clinic flow were recorded anonymously for each patient visit. The median visit length per week was tracked on a run chart. From PDSA cycle 1 through PDSA cycle 4, the median visit length decreased from 126 minutes to 114 minutes. This shift was primarily driven by a decrease in the length of patient intake from a median of 19 minutes to 9 minutes. The run chart did not show clear trends until PDSA cycle 4, which demonstrated a strong downward trend. This study demonstrated the ability of a student-driven CQI model to decrease patient visit length in an SRFC setting. Similar models could be used to address this and other contributors to patient experience across SRFCs nationwide.

Reduced Time to Admit Emergency Department Patients to Inpatient Beds Using Outflow Barrier Analysis and Process Improvement.

Because admitted emergency department (ED) patients waiting for an inpatient bed contribute to dangerous ED crowding, we conducted a patient flow investigation to discover and solve outflow delays. After solution implementation, we measured whether the time admitted ED patients waited to leave the ED was reduced. In June 2022, a team using Lean Healthcare methodologies identified flow delays and underlying barriers in a Midwest, mid-sized hospital. We calculated barriers' magnitudes of burden by the frequency of involvement in delays. During October-December 2022, solutions targeting barriers were implemented. In October 2023, we tested whether waiting time, defined as daily median time in minutes from admission disposition to departure (ADtoD), declined by conducting independent sample, single-tailed t-test comparing pre- to post-intervention time periods, January 1-September 30, 2022 (273 days) to January 1-September 30, 2023 (273 days). Additionally, we regressed ADtoD onto pre-/post period while controlling for ED volume (total daily admissions and ED daily encounters) and hospital occupancy. A run chart analysis of monthly median ADtoD assessed improvement sustainability. Process mapping revealed that three departments (ED, environmental services [EVS], and transport services) co-produced the outflow of admitted ED patients wherein 18 delays were identified. The EVS-clinical care collaboration failures explained 61% (11/18) of delays. Technology contributed to 78% (14/18) of delays primarily because staff's technology did not display needed information, a condition we coined "digital blindness." Comparing pre- and post-intervention days (3,144 patients admitted pre-intervention and 3,256 patients post), the median minutes a patient waited (ADtoD) significantly decreased (96.4 to 87.1 minutes, P = 0.04), even while daily ED encounter volume significantly increased (110.7 to 117.3 encounters per day, P < 0.001). After controlling in regression for other factors associated with waiting, the intervention reduced ADtoD by 12.7 minutes per patient (standard error 5.10, P = 0.01; 95% confidence interval -22.7, -2.7). We estimate that the intervention translated to ED staff avoiding 689 hours of admitted patient boarding over nine months (ADtoD coefficient [-12.7 minutes] multiplied by post-intervention ED admissions [3,256] and divided by 60). Run chart analysis substantiated the intervention's sustainability over nine months. After systemwide patient flow investigation, solutions resolving digital blindness and environmental services-clinical care collaboration failures significantly reduced ED admitted patient boarding.

A quality improvement project on reducing antibiotic use duration in very low birth weight preterm infants in the neonatal intensive care unit

To develop effective measures to reduce antibiotic use duration in very low birth weight (VLBW) preterm infants in the neonatal intensive care unit through quality improvement methods. The study population consisted of hospitalized VLBW preterm infants, with the percentage of hospitalization time during which antibiotics were used from November 2020 to June 2021 serving as the baseline. The specific quality improvement goal was to reduce the duration of antibiotic use. Factors affecting antibiotic use duration in preterm infants were analyzed using Pareto charts. Key drivers were identified, and specific interventions were formulated based on the stages of antibiotic use. Changes in the percentage of antibiotic use duration were monitored with run charts until the quality improvement target was achieved. From November 2020 to June 2021, the baseline antibiotic use duration percentage was 49%, with a quality improvement target to reduce this by 10% within 12 months. The Pareto analysis indicated that major factors influencing antibiotic duration included non-standard antibiotic use; delayed cessation of antibiotics when no infection evidence was present; prolonged central venous catheter placement; insufficient application of kangaroo care; and delayed progress in enteral nutrition. The interventions implemented included: (1) establishing sepsis evaluation and management standards; (2) educating medical staff on the rational use of antibiotics for preterm infants; (3) supervising the enforcement of antibiotic use standards during ward rounds; (4) for those without clear signs of infection and with negative blood cultures, discontinued the use of antibiotics 36 hours after initiation; (5) reducing the duration of central venous catheterization and parenteral nutrition to lower the risk of infection in preterm infants. The control chart showed that with continuous implementation of interventions, the percentage of antibiotic use duration was reduced from 49% to 32%, a statistically significant decrease. The application of quality improvement tools based on statistical principles and process control may significantly reduce the antibiotic use duration in VLBW preterm infants. Citation:Chinese Journal of Contemporary Pediatrics, 2024, 26(7): 736-742.

Improving Interpreter Access in the Pediatric Emergency Department: A Quality Improvement Initiative.

An increasing proportion of the population in the United States have limited English proficiency (LEP). Hospitals that receive federal funding must offer interpreter services. However, access is often lacking for patients. Patients with LEP are at higher risk for adverse events, and the Emergency Department is a particularly high-risk environment for these events. This quality improvement initiative took place from April 2021 to August 2022 in an urban, tertiary care Pediatric Emergency Department. A driver diagram informed four Plan-Do-Study-Act cycles, and data were collected through medical record review, patient surveys, and staff surveys. We tracked outcomes using run and control chart data. During the study period, the proportion of patients with LEP reporting "always" having an interpreter was unchanged (no centerline shift-control chart rules). Documentation of interpreter use for encounters with patients with LEP improved. Preferred language documentation and documentation of the need for an interpreter in the electronic medical record showed no change. Process measure data for staff-reported use of professional interpreters significantly increased, and the use of ad hoc interpreters decreased significantly. Length of stay did not change for English or LEP patients. This quality improvement initiative improved appropriate documentation of LEP and decreased use of nonqualified interpreters, although no change occurred in the proportion of patients who reported always having an interpreter. Patient satisfaction was unaffected.

Optimizing Comprehensive Care for the Hospitalized Hip Fracture Patients: Time to Surgery and Bone Health at Discharge

Background: Approximately 300,000 older people ( 65 years and older) are hospitalized yearly for hip fractures, according to the CDC. Hip fracture is considered a life-altering event with increased morbidity and up to 30% mortality. The Clinical Practice Guidelines by the American Academy of Orthopedic Surgeons highlight the importance of an interdisciplinary team approach while caring for these patients and recommend surgery within 24 hours for improved outcomes. Most of these fractures are considered fragility fractures occurring from a simple ground-level fall and, thus, a manifestation of osteoporosis. Yet, only a few patients, 26%, receive osteoporosis treatment within 30 days of surgery, as per a recent study. ACP recommends replenishing Vitamin D and Calcium in all fragility fracture patients, followed by the initiation of bisphosphonates. At our institution, hip fracture patients used to be admitted to internal medicine or orthopedic services based on their complexity. There was a perceived feeling that those admitted to primarily internal medicine service received less comprehensive care and were likely delayed in getting to the OR given the competing priorities of a sick internal medicine service load. Vitamin D levels were not being checked or replaced despite having it be part of the admission order set used for hip fracture patients. Our project aimed at improving overall care for hospitalized hip fracture patients. Our goal was to increase the percentage of hospitalized hip fracture patients going to the operating room within 24 hours to 85% by the end of 2023. Additional goals were to improve the percentage of checking vitamin D levels and supplementing them at discharge by 25% by the end of 2023. Methods: Our intervention was to build a fragility fracture orthopedic and internal medicine co-management service where hip fracture patients were admitted. We collected outcome, process, and balancing measures, including time to surgery, unnecessary cardiac testing and consultation before surgery, percentage of ordering vitamin-D levels, and vitamin-D supplementation at discharge. Qualitative satisfaction with the process was also included. Data was collected biweekly from Jan 2023 to Dec 2023. Run chart analysis was utilized for statistical analysis. Results: Our results showed that the percentage of patients going to surgery within 24 hours did not differ (median of approximately 80%). Patients rarely got unnecessary cardiac testing or consultations, so we stopped following this measure. The median of vitamin-D level checking and supplementation at discharge had improved from 45% to 77% and 35% to 50%, respectively, sustaining a shift using run chart analysis rules. Conclusions: Our project shows that establishing a dedicated service for hospitalized fragility hip fractures has improved care for our patients. While time to surgery had not improved, it had been within the reported national average. Time to surgery is being delayed mostly when further medical optimization is required. However, having this service improved bone-focused care with vitamin-D testing and supplementation. The future PDSA cycle will focus on post-discharge osteoporosis management and treatment when appropriate.

Expediting Discharges on the Inpatient Medicine Teaching Services

Introduction: Delayed discharges can adversely affect patient flow throughout the hospital. Late afternoon discharges may lead to high hospital occupancy, admission bottlenecks, ER overcrowding, and disrupted ICU transfers. Discharge by noon (DBN) is key to enhancing hospital capacity, bed utilization, and patient satisfaction and outcomes. Last year, DBN for patients returning home with or without home care services (HHC) was chosen as one of three annual priorities for our hospital medicine division. This was implemented in October 2023 but did not gain momentum among the medical resident teaching services (MTS), paving the way for our QI project. Model for Improvement: Baseline data on the percentage of MTS DBN to home and HHC were available from November 2023 to January 2024. We surveyed our residents/faculty and conducted a root-cause analysis. The main barriers to DBN included a lack of planning and motivation, delayed communication with case management, and prolonged rounding. Aims Statement: Our goal was to increase the median percentage of MTS discharge orders placed by noon to home and HHC from 22% to 35% within 3 months. Measures: Our primary outcome measure was the percentage of MTS DBN to home and HHC. Weekly EMR-generated reports were collected. The outcome measure was then calculated and uploaded weekly on a run chart for analysis. Qualitative process measures included assessing if residents were planning discharges and documenting the number of discharges completed before noon. Changes: Our interventions targeted the lack of planning and motivation. These included introducing the expedited initiative and its importance to residents/faculty through conferences. In addition, a process was created where potential next-day discharges were discussed at afternoon sign-out and a tracking chart of DBN orders was designed for each team room. Tests of Change: Our pre-intervention median percentage of MTS DMB to home and HHC was 22% and improved to 40% post-intervention. While we observed a variation in discharge practice based on the rounding attending, we had notably sustained an upward shift in practice from our baseline when data was plotted on a run chart. We are currently continuing data collection to track sustainability and variability among rounding physicians. Conclusion: We attained an upward shift in the percentage of MTS DBN to home and HHC post-intervention. Although an upward shift has been achieved, we are looking to sustain and further improve it. In future PDSA cycles, we will look at individualizing feedback and optimizing interdisciplinary rounds. We plan on further investigating balancing measures such as bed availability, discharge timing for rehabilitation destinations, and patient and staff satisfaction.

Improving Obesity Outcomes in an Academic Clinic: A Quality Improvement Study

Introduction: Obesity is a chronic disease that affects more than 40% of the population in the United States. The prevalence of severe obesity doubled in the past two decades. Primary care providers are usually the first to screen patients for obesity. According to a 2018 study. Only 55% of adults with obesity were reported to have received the diagnosis of obesity and less than a third of the patients followed up for an obesity-specific visit. The management of obesity is multifactorial with lifestyle modifications and pharmacological and psychological therapies. In our academic clinic, there was a gap in comprehensive satisfactory obesity counseling, which addresses lifestyle modifications and adjunctive pharmacological therapies. Addressing this gap with an obesity-specific visit helps clinicians to discuss available options to manage obesity. Improvement in body weight is linked with improved control of hypertension, diabetes, and heart disease leading to improved health outcomes. Aim: To improve obesity counseling rates and usage of standardized obesity templates in an academic clinic by 25% in 3 months. Method: We used the IHI model of improvement using the plan-do-study-act framework to test changes on a small scale and guide the quality improvement study. To better address our aim, we divided our QI project into 2 cycles. For PDSA-1, a thorough chart search for the last 3 months was done to calculate a baseline obesity counseling rate. A root-cause analysis was completed with multi-disciplinary input from faculty, clinic staff, and residents, and several existing barriers that preclude satisfactory obesity counseling were identified. Proposed interventions corresponding to each root cause were plotted on an impact effort matrix. Interventions with the least effort and the most impact were selected as proposed solutions. These included creating a short education session on obesity management and creating an obesity counseling template. Post-intervention, the obesity counseling rates and use of the template were recorded on a run chart. For PDSA-2, we introduced an obesity assessment and plan (A/P) template, with the goal to incorporate all aspects of obesity management, i.e., lifestyle modification, diet, exercise, and screening for disease related co-morbidities. Results: Satisfactory obesity counseling prior to intervention was 32%. The first PDSA cycle post-intervention showed an improvement in the obesity counseling rates to 56%. About 20% of the clinic notes for the counseled patients used the proposed template. About 8% of the counseled patients agreed to a separate obesity-specific visit. The second PDSA cycle showed 20.1% usage of the standardized A/P plan template. In the group that the template was used, there was 63.6% reduction in BMI; compared to 39.4% BMI reduction in group without template usage. (OR= 2.34, p=0.034. Next steps: We noted an overall improvement in the obesity counseling rates after our interventions. However, we noticed that the A/P template usage did not meet our goal of 25% usage. We will conduct multidisciplinary team meetings to understand measures that can be undertaken to improve usage of A/P template. Patients will also be encouraged to have an obesity-specific visit.

Decreasing incidence of admission neonatal hypothermia in Gandhi Memorial Hospital, Addis Ababa, Ethiopia: quality improvement project

BackgroundWHO reported that neonatal hypothermia accounts for about 27% of newborn deaths worldwide. It is a serious concern in Ethiopia and other parts of sub-Saharan Africa; it poses a serious...

Improving Asthma Control Test completion rates across a multi-site pediatric pulmonary clinic network: a quality improvement initiative

Objective Assessing asthma control is an essential part of the outpatient management of children with asthma and can be performed through validated questionnaires such as the Asthma Control Test (ACT). Systematic approaches to incorporating the ACT in outpatient visits are often lacking, contributing to inconsistent completion rates. We conducted a quality improvement initiative to increase the proportion of visits where the ACT is completed for children with asthma in our multi-site pediatric pulmonary clinic network. Methods We developed an intervention of sending the ACT questionnaire to patients and caregivers through the electronic patient portal to complete prior to their visits. This strategy was first piloted at one clinic beginning in July 2020 and then expanded to 5 other clinics in the network in October 2020. Our outcome measure was average monthly proportion of visits with a completed ACT, tracked using statistical process control charts. The process measure was method of ACT completion tracked using run charts. Results At the pilot clinic, average monthly completion rate rose within 3 months of the intervention from 27% to 72% and was sustained more than 22 months. Completion across all clinics increased from 57% pre-intervention to 76% post-intervention. Importantly, the intervention did not rely on clinic staff to administer the questionnaire and did not interfere with existing clinic flow. Conclusion An intervention of delivering the ACT electronically to patients and caregivers for completion prior to visits led to a rapid and sustained improvement in ACT completion rates across a large, pediatric pulmonary clinic network.

Closer to Home: A Quality Improvement Initiative to Optimize Satellite Site Bed Capacity.

The coronavirus disease 2019 pandemic resulted in the underutilization of inpatient beds at our satellite location. A lack of clarity and standardized admission criteria for the satellite led to frequent transfers to the main campus, resulting in patients traveling larger distances to receive inpatient care. We sought to optimize inpatient resource use at the satellite campus and keep patients "closer to home" by admitting eligible patients to that inpatient unit (LA4). Our aim was to increase bed capacity use at the satellite from 45% to 70% within 10 months. Our process measure was to increase the proportion of patients needing hospitalization who presented to the satellite emergency department (ED) and were then admitted to LA4 from 76% to 85%. A multidisciplinary team used quality improvement methods to optimize bed capacity use. Interventions included (1) the revision and dissemination of satellite admission guidelines, (2)steps to create shared understanding of appropriate satellite admissions between ED and inpatient providers, (3) directed provider feedback on preventable main campus admissions, and (4) consistent patient and family messaging about the potential for transfer. Data were collected via chart review. Annotated run charts were used to assess the impact of interventions over time. Average LA4 bed capacity use increased from 45% to 69%, which was sustained for 1 year. The average percentage of patients admitted from the satellite ED to LA4 increased from 76% to 84%. We improved bed capacity use at our satellite campus through transparent admission criteria and shared mental models of patient care needs between ED and inpatient providers.

Improvement Science Increases Routine Lipid Screening in General Pediatric Cardiology

ObjectiveTo evaluate the effectiveness of patient education, physician counseling, and point-of-care (POC) testing on improving adherence to lipid screening national guidelines in a general pediatric cardiology practice (2017-2023). Study designRegional primary care providers were surveyed regarding lipid screening practices. Key drivers were categorized (physician, patient, system) with corresponding interventions. Pediatric cardiologists started offering lipid screening during regular visits by providing families with preventive cardiovascular education materials and lab phlebotomy testing. System re-design included educational posters, clinical intake protocol, physician counseling, electronic health record integration, and POC testing. Run charts and statistical process control charts measured screening rates and key processes. ResultsThe primary care survey response rate was 32% (95/294); 97% supported pediatric cardiologists conducting routine lipid screening. Pediatric cardiology mean baseline lipid screening rate was 0%, increased to 7% with patient education, and to 61% after system redesign including POC testing. Screening rates among 1,467 patients were similar across age groups (P = 0.98). More patients received lipid screening by POC (91.7%) compared with phlebotomy (8.3%). Lipid abnormalities detected did not differ by screening methodology (P = 0.49). ConclusionPatient education, counseling, and POC testing improved adherence to national lipid screening guidelines, providing a possible model for primary care implementation.

The Changing Prevalence of Pressure Injury among Ontarians with SCI/D at Rehabilitation Admission: Opportunities for Improvement.

Despite preventability, 20-50% of patients with acute spinal cord injury/disease (SCI/D) develop hospital-acquired pressure injuries (PIs). The Spinal Cord Injury Implementation and Evaluation Quality Care Consortium (SCI IEQCC) aimed to mitigate PI risk through patient-reported daily skin checks alongside usual care. This quality improvement initiative utilized an interrupted time series design, encompassing adults ≥ 18 years admitted for inpatient rehabilitation across five Ontario sites from 2020 to 2023. Patient demographics, etiology, and impairment data were obtained from a national registry, while participating sites gathered data on PI onset, location, and severity. Run charts depicted temporal trends, and statistical analyses, including chi-square and logistic regression, compared patients with and without PIs. Data from 1767 discharged SCI/D patients revealed that 26% had ≥1 PI, with 59% being prevalent and 41% incident. Most severe PIs (stages III and IV and unstageable) were acquired prior to admission. Process indicator fidelity was reasonable at 68%. Patients with PIs experienced longer hospital stays, lower Functional Independence Measure (FIM) changes, and FIM efficiency during rehabilitation. PI prevalence is increasing, particularly sacral injuries at admission, while incident cases have decreased since 2021 due to regular skin checks. This trend calls for proactive health system interventions to reduce costs and improve patient outcomes.