Run Charts Research Articles

A Quality Improvement Initiative To Improve Postdischarge Antimicrobial Adherence.

Bedside delivery of discharge medications improves caregiver understanding and experience. Less is known about its impact on medication adherence. We aimed to improve antimicrobial adherence by increasing on-time first home doses for patients discharged from the pediatric hospital medicine service from 33% to 80% over 1 year via creation of a discharge medication delivery and counseling "Meds to Beds" (M2B) program. Using sequential plan-do-study-act cycles, an interprofessional workgroup implemented M2B on select pediatric hospital medicine units at our quaternary children's hospital from October 2017 through December 2018. Scripted telephone surveys were conducted with caregivers of patients prescribed antimicrobial agents at discharge. The primary outcome measure was on-time administration of the first home antimicrobial dose, defined as a dose given within the time of the inpatient dose equivalent plus 25%. Process measures primarily assessed caregiver report of barriers to adherence. Run charts, statistical process control charts, and inferential statistics were used for data analysis. Caregiver survey response rate was 35% (207 of 585). Median on-time first home antimicrobial doses increased from 33% to 67% (P < .001). Forty percent of M2B prescriptions were adjusted before discharge because of financial or insurance barriers. M2B participants reported significantly less difficulty in obtaining medications compared with nonparticipants (1% vs 17%, P < .001). The M2B program successfully increased parental report of timely administration of first home antimicrobial doses, a component of overall adherence. The program enabled providers to identify and resolve prescription problems before discharge. Importantly, caregivers reported reduced barriers to medication adherence.

"Relax City Homecare team; protocols are ready for you" - A Quality Improvement Project Conducted on Behalf of the City Homecare Unit Team at the Trivandrum Institute of Palliative Sciences.

Context:The city homecare unit (CHU) of the Trivandrum Institute of Palliative Sciences was dissatisfied with the quality of care provided to their patient population.Aims:This study aims to improve the average satisfaction score of CHU during their daily homecare services.Settings and Design:The improvement project for the CHU activities was conducted with a prospective plan-do-study-act design, with stepwise application of improvement tools.Materials and Methods:The A3 quality improvement (QI) methodology, which uses tools for (i) analysing contributors (process mapping, cause-effect diagram); (ii) to derive key drivers (Pareto chart) and (iii) for measuring impact of interventions and sustainability (annotated run chart) was applied. The project was conducted as a mentored activity of the PC-PAICE program. The team’s weekly average satisfaction score was recorded prospectively as the outcome parameter, with 0 representing total dissatisfaction and 10 representing total satisfaction. Accuracy of triaging and appropriateness of registration process were the process parameters selected. These were recorded as run charts across the project period of 9 months.Analysis and Results:The cause-effect tool and the impact effort tool were used to analyse the mapped CHU processes. Even though we identified 22 contributors to the problem, eight of them were found to be significant. Key drivers were determined based on these eight and applied to the CHU processes. Over the project period, the satisfaction scores of the CHU improved significantly from 5.82 to 7.6 that is, satisfaction levels were high on most days. The triaging and registration goals were achieved. The team also built its own capacity for QI.Conclusion:The application of the A3 methodology simplified and streamlined efforts and achieved the quality goal for the CHU team.

Community-Based Interventions to Reduce Child Stunting in Rural Guatemala: A Quality Improvement Model.

Rural Guatemala has one of the highest rates of chronic child malnutrition (stunting) in the world, with little progress despite considerable efforts to scale up evidence-based nutrition interventions. Recent literature suggests that one factor limiting impact is inadequate supervisory support for frontline workers. Here we describe a community-based quality improvement intervention in a region with a high rate of stunting. The intervention provided audit and feedback support to frontline nutrition workers through electronic worklists, performance dashboards, and one-on-one feedback sessions. We visualized performance indicators and child nutrition outcomes during the improvement intervention using run charts and control charts. In this small community-based sample (125 households at program initiation), over the two-year improvement period, there were marked improvements in the delivery of program components, such as growth monitoring services and micronutrient supplements. The prevalence of child stunting fell from 42.4 to 30.6%, meeting criteria for special cause variation. The mean length/height-for-age Z-score rose from −1.77 to −1.47, also meeting criteria for special cause variation. In conclusion, the addition of structured performance visualization and audit and feedback components to an existing community-based nutrition program improved child health indicators significantly through improving the fidelity of an existing evidence-based nutrition package.

Propylene Yield from Olefin Plant Utilizing Box-Cox Transformation in Regression Analysis

Propylene yield is one of the key operating parameters that is monitored daily in the running olefin plant. This study was conducted in the actual world-scale olefin plant to measure the impact of identified controlled variables on the propylene yield. The Box-Cox data transformation was adopted in the Regression Analysis using Minitab Software Version 18 due to non-normal data were observed after normality and stability test were conducted using Box Plot, I-MR Chart, Run Chart, Graphical Summary, and Normality Plot tools. The model concluded that propylene yield in the studied plant was contributed by the factors of -0.000243 Hearth Burner Flow, 0.01332 Integral Burner Flow, and 0.08598 Naphtha Feed Flow. The Response Optimizer tool also suggested that the propylene yield from naphtha liquid feed can be maximized at 11.22% with the control setting at 10,993.86 kg/hr of Hearth Burner Flow, 604.61 kg/hr of Integral Burner Flow, and 63.50 t/hr of Naphtha Feed Flow.

Prevalence & spectrum of congenital anomalies at a tertiary care centre in north India over 20 years (1998-2017).

Background & objectives:Congenital anomalies lead to significant morbidity and mortality. Systematically published data on the prevalence and spectrum of congenital anomalies from India are scarce. This study was aimed to ascertain the prevalence, spectrum, trend, and outcome of congenital anomalies at a tertiary care centre in north India over two decades.Methods:Electronic records of all live births from January 1998 to December 2017 were retrieved, and the neonates with congenital anomaly were included in this retrospective analysis. International Statistical Classification of Diseases and Related Health Problems, tenth revision (ICD-10) was used for uniformity and international comparison. The further sub-categorization was done as per the WHO birth defects surveillance manual. The prevalence of individual as well as overall congenital anomalies was calculated. Run charts were used to analyze the trends.Results:In the two decades studied (1998-2017), there were 86850 live births, of which 1578 [1.82%, 95% confidence interval (CI): 1.73-1.91%] neonates had a major congenital anomaly. The overall prevalence of anomalies was 182 (95% CI: 173-191) per 10,000 live births. Malformation of the circulatory system was the most common (28.0%) followed by musculoskeletal (18.6%) and urinary system (14.3%). Congenital anomaly-related death rate was 6.78 per 1000 live births. No significant trend was observed in the annual prevalence, individual malformations or contribution of congenital anomalies to overall mortality over the two decades.Interpretation & conclusions:Our results showed a high prevalence of congenital anomalies which could be responsible for significant mortality, warranting the need for a national surveillance programme and birth defect services. It is important to have a national database to know the overall burden and spectrum of congenital anomalies in the country.

Implementation of a multicomponent intervention sign to reduce delirium in orthopaedic inpatients (MIND-ORIENT): a quality improvement project

Delirium is a serious and common condition that leads to significant adverse health outcomes for hospitalised older adults. It occurs in 30%–55% of patients with hip fractures and is one...

1353. Pediatric Urinary Tract Infections: A Choosing Wisely Initiative to Advance Antimicrobial Stewardship and Diagnostic Accuracy in the Emergency Department

BackgroundUrinary tract infection (UTI) is a common diagnosis in the pediatric emergency department (ED) that often results in empiric antibiotic treatment prior to culture results. A 2016 cohort study from our centre found that 47% of children diagnosed with a UTI and prescribed antibiotics had a negative urine culture. None of these patients were notified of the misdiagnosis or told to discontinue antibiotics.Figure 1: Choosing Wisely pediatric urinary tract infection diagnostic algorithm Figure 2: Patients included/excluded with exclusion criteria MethodsInstitutional approval was obtained for a quality improvement project in our quaternary pediatric ED. For uncomplicated pediatric UTIs, the aim was to reduce misdiagnosis by 50% and promote antimicrobial stewardship over a 24-month period. Using the Model for Improvement, two interventions were implemented using PDSA cycles: (1) a UTI diagnostic algorithm embedded in the electronic medical record, (2) a urine culture callback system. Outcome measures included the percentage of patients with UTI misdiagnosis (urine culture negative) and antibiotic-days saved. Process measures included adherence to the UTI algorithm and callback system as well as antibiotic duration standardization. As a balancing measure, patients developing positive urine cultures without UTI diagnosis were reviewed for potential harm.Figure 3: Run chart of urinary tract infection misdiagnosis rate Figure 4: Callback system - Percent patients contacted and antibiotics-days saved ResultsFrom June 2017-April 2020, 2,183 children (0.97% of all visits) were diagnosed with a UTI in the ED. 1,381 (63.3%) met inclusion criteria for analysis. Following UTI algorithm launch, median UTI misdiagnosis decreased by 20% (52.5% vs. 32.5%), median correct antibiotic duration increased by 30% (45.2% vs. 75.1%), and algorithm adherence was 78.9%. With implementation of the callback system, 1,678 antibiotic-days were saved as mean patients contacted to discontinue antibiotics increased from 0% to 76.8%. Of 106 patients with positive urine cultures with missed UTI diagnosis over a 29-month period, 8 patients returned to the ED within 72 hours and 2 patients required admission for intravenous antibiotics.ConclusionImplementation of a UTI diagnostic algorithm and urine culture callback system for uncomplicated pediatric UTIs reduced UTI misdiagnosis and promoted antimicrobial and resource stewardship in the ED. Future directions include improving UTI algorithm adherence through targeted clinician audit and feedback, plus sustainability planning.DisclosuresOlivia Ostrow, MD, Choosing Wisely Canada (Advisor or Review Panel member)

Implementing and Maintaining an Increased Frequency of Nighttime Education Sessions.

Conferences are an essential component to resident education. Work hour requirements have led to night rotations, causing residents to miss this important educational experience. To fill this void, many institutions have created night curricula, but few have studied how to implement and sustain it. Our aim was to increase formal nighttime teaching led by upper level residents from 0 to ≥3 times weekly by December of 2018. After a needs-assessment survey was completed by upper level residents, pediatric night education sessions were established. Upper level residents on wards were responsible for teaching and recording whether nighttime teaching occurred. Data were collected by using this form, and a run chart was used to analyze the data over time. A team of hospitalists, pediatric residency program leadership, and a second-year resident met throughout the project and used the model for improvement. Data were collected for 84 weeks. Introduction of the education sessions increased teaching occurrences from a baseline of 0 to a median of 1. After several plan, do, study, act cycles, most notably after implementing upper level feedback, special cause variation was achieved and median teaching occurrences increased to 3 times weekly. This was sustained for 32 weeks. Focused quality improvement methodologies can be used to improve new residency program education. These methods can inform other residency programs how to successfully weave a teaching expectation into their night shifts to provide more learning opportunities in the era of duty hour requirements.

Optimizing Disclosure of HIV Status to a Diverse Population of HIV-Positive Youth at an Urban Pediatric HIV Clinic

PurposeThe purpose of the study was to increase the proportion of youth living with HIV (YLWH) aged ≥11 years who undergo developmentally appropriate disclosure about their HIV status. MethodsA quality improvement project was initiated at an urban pediatric HIV clinic between July 2018 and March 2020. The primary outcome measure was the proportion of YLWH aged ≥11 years who were disclosed to about their HIV status. The proportion of undisclosed YLWH who had documented nondisclosure status was also assessed as a process measure. Plan-Do-Study-Act (PDSA) cycles for change included monthly clinic staff check-ins to discuss new disclosures, quarterly team meetings to discuss strategies to improve disclosure, and modifying a clinic note template to prompt providers to document disclosure status. Annotated run charts were used to analyze the data. ResultsBefore the first PDSA cycle, 26/46 (57%) of the target population of YLWH aged ≥11 years had their HIV status disclosed to them, and none of the undisclosed youth had disclosure status documented in their medical record. After 20 months and six PDSA cycles, the proportion of YLWH aged ≥11 years disclosed to about their HIV status increased to 80% and the proportion of undisclosed YLWH with documentation of their disclosure status increased to 100%. ConclusionsSeveral interventions integrated throughout the pediatric HIV care process were associated with an increase in the proportion of YLWH with developmentally appropriate HIV disclosure and documentation of disclosure status, an important psychosocial aspect of care in these individuals.

Reducing the waiting time to initiation of infertility treatment at a tertiary care centre in India

BackgroundIn a low-resource and high-volume setting, it is often felt that patient care cannot be improved within the limitations of existing infrastructure and resources. However, the use of a systematic...

Improving Equitable Access to Cervical Cancer Screening and Management.

Each year, 13,000 women in the United States are diagnosed with cervical cancer and 4,000 die from it. Moreover, 8 million women 21 to 65 years of age haven't had a Pap test in five years. Hispanic women have the highest incidence of cervical cancer and are less likely to be screened or return for care. Migrant women can face additional barriers to cervical cancer screening, including federal prohibitions against their participation in public health insurance exchanges and nonemergency Medicaid. Improving cervical cancer screening rates was identified as a priority in a federally qualified health center when only 40% of eligible women were properly screened in 2016. Forty-five percent of the population the clinic serves is uninsured and 60% are Hispanic. The aim of this quality improvement project was to have 75% of the women 21 to 65 years of age who sought care at this clinic during the 60-day project period receive Pap test eligibility screening, enrollment in a state and federal screening program, and case management. Four rapid plan-do-study-act cycles were used. Tests of change included team engagement, patient engagement, eligibility screening, and case log management. Data were analyzed using run charts to evaluate the impact of interventions on outcomes. The interventions consisted of team meetings, a patient engagement tool, an eligibility screening tool, and case log management. Among the women who completed care at the clinic during the 60-day project period, 80% were uninsured and 86% were Hispanic. A total of 87% of women received effective care, which consisted of same-day Well Woman Health Care Program enrollment and a same-day Pap test or an appointment to return for a well-woman visit. A multicomponent approach led to underserved women receiving equitable access to cervical cancer screening and timely enrollment in a cervical cancer screening program.

Improving Effective Preventative Care Within an Urban Working Population.

To assess whether standardized screening and service navigation improve access to primary care in low wage workers. Four rapid plan-do-study-act cycles were conducted over an 8-week period. Each cycle consisted of four core interventions. Data were collected every 2 to 3 days, then analyzed on run charts and aggregate data tables. Effective care was achieved by increasing the percentage of patients with a primary care provider from 52% to 79%. Patients' perception of health increased from 3.6 to 4.4 and team communication and support score increased from 3.9 to 4.2 on a 5-point Likert scale. Patient engagement and a standardized referral process aids in the establishment of routine, effective care. Application of "smart phrases" in electronic health records provides sustainability for use in other occupational medicine practices.

Increasing lung cancer screening rates in HIV clinics.

189 Background: Data at our institution shows lung cancer is more prevalent and aggressive in HIV patients. A study of lung cancer patients revealed a mean age of 55.8 years in those with HIV vs. 68.0 in those without. Additionally, 67% of HIV patients had metastasis at time of diagnosis, compared to 49% in the overall population. One study found an 18.9% reduction in lung cancer mortality among HIV patients who receive NLST-recommended screening. Despite this, data from 2018 estimated only 13% of eligible HIV patients had completed screening at our institution. We pursued a quality improvement initiative to increase lung cancer screening in our HIV clinics. Methods: Our multi-disciplinary team studied charts of the 628 HIV clinic patients seen in a four-month span to identify those who had not received lung cancer screening and potential reasons why referrals were not made. We also spoke with clinic providers to identify improvement areas. Our intervention encompassed HIV patients that met CMS screening criteria (i.e. age 55-77, 30 pack-year smoking). Our process measure was new referrals to our dedicated screening coordinator, who contacts patients to arrange for CT scans. We plotted trends in appointment referrals on a run chart. Results: Areas for improvement included EMR documentation to assess screening eligibility and an occasional lack of awareness regarding criteria. Providers also cited time constraints may limit referrals. Our team identified patients that met screening criteria and generated EMR reminders for providers to refer patients to radiology. We also held sessions with providers and nursing staff to increase awareness of our screening program. Of 628 patients, 128 (20.4%) had sufficient documented smoking history to assess for screening eligibility. 81 patients (63.3%) met our criteria. Of these patients, 58 (71.6%) had not been screened or referred for screening. Through our most recent interventions, 16 (31.3%) patients have been referred to our screening coordinator, and 7 (12.1%) have received screening CT scans. Our interventions ultimately led to an increase from 23 of 81 (28.4%) patients with completed screening to a projected 46 of 81 (56.8%). Conclusions: Providing education and EMR alerts to raise awareness regarding eligibility, we substantially increased the screening rate in our clinics. Our interventions will be broadened as we return from COVID stoppages. Future interventions include increasing smoking history documentation in the EMR to allow for automated identification of screening eligibility. PDSA and interventions are ongoing with continued follow-up of efficacy.

Transforming surgical morbidity and mortality into a systematic case review

Background/PurposeThe surgical morbidity and mortality (M&M) conferences at a regional children's hospital achieved the goals of case by case peer review and education for trainees but provided limited data for trending and analysis. In 2019, an institution-wide effort was initiated to create an electronic case review system with the goals of improving event capture and real-time practice performance feedback. Surgical M&M was migrated to this structured case review format to provide a platform for surgical performance improvement. MethodsAn online secure database was created with a 3-step classification system based on Clavien-Dindo severity score, peer review, and causality fishbone analysis. The data entered were available in an interactive dashboard. Retrospective tabulation of the 2018 M&M data was performed using the archived paper system used prior to 2019. ResultsFor the calendar year of 2019, the division of pediatric surgery captured and categorized 193 complications in the case review system. The capture rate was 50 per 1000 surgical procedures. For a similar time frame in 2018, the capture rate was 35 per 1000 surgical procedures. The dashboard provided run charts of the incidence and types of complications by procedure and by surgeon. Similar trend data were not available in 2018. The dashboard output has made possible the creation of (non- risk adjusted) individual surgeon performance reports. The output has been used to direct process improvement projects and educational content. ConclusionCreation of an online database with interactive dashboard has allowed surgical M&M to evolve into a systematic case review that greatly facilitates quality improvement efforts. This system increased the event capture rate and provided novel practice performance feedback, resulting in process improvement projects and educational objectives predicated on the trending data. These electronic reporting tools are now available to all surgical divisions and represent a transformative approach to surgical case review. Type of StudyRetrospective Historical control; Quality improvement. Level of EvidenceLevel III.

S0219 It Takes a Village to Bend the Curve for HO-CDI: A Quality Improvement Initiative

Introduction: In 2015, the Centers for Disease Control (CDC) reported that Clostridium difficile infections (CDI) had become the most common microbial cause of health care-associated infections in the US. There are three types of C Diff infection for surveillance purposes: Healthcare facility-onset HO-CDI; Community-onset, healthcare facility–associated (CO-HCFA) CDI Community-associated (CA) CDI The Memphis VAMC has high rates of HO-CDI at 8.5/10,000 patient days in June 2019, which was double as compared to the national and local rates at other hospitals in the Memphis area. Methods: To combat the high rates of HO-CDI, a quality improvement (QI) CDI Prevention team was formed in June 2019 to work on a QI project to decrease the rates of HO-CDI at the Memphis VAMC. Highlights of the QI Project: Problem Statement: High rates of HO- CDI at the Memphis VAMC @ 8.5/10000 patient days as compared to national and local standards. Aim Statement: Decrease the rates of HO-CDI by 50 percentage in 6 months by December 2019 Core Metrics to be followed: Monthly HO-CDI rates Monthly rates of C Diff PCR orders Gap Analysis and Interventions: As showed in the GAP analysis table attached with the submission Results: Rates of HO CDI: Decrease in HO-CDI rates from 8.5/10,000 patient days to 2.3/10,0000 patient days in December 2019 as shown by the U chart with the submission. Number of C diff PCR tests ordered per month: Average of 81.5 tests/month in the preintervention period Average of 43.8 tests/month, a decrease by 46% as shown by the run chart in the submission. Conclusion: It really took a village and a combined effort from all the different departments as depicted in the gap analysis table to obtain the results that we were able to achieve. Electronic algorithms and protocols can be bypassed very easily, hence compliance monitoring with the note template is necessary even after completion of the QI Project. We all understand the importance of antibiotic stewardship, but the concept of diagnostic stewardship is equally important when you have a test with high sensitivity like the PCR for C.diff toxin.Table 1.: Gap Analysis TableFigure 1.: U chart showing the monthly rates of HO-CDI with the control limits.Figure 2.: Run chart showing the monthly number of C. Diff PCR tests ordered.

S0306 A Team-Based Approach Is Effective in Improving Colorectal Cancer Screening Rates in a Community-Based Resident Clinic

INTRODUCTION: Colorectal cancer (CRC) is the second leading cause to cancer-related mortality. This has resulted in increased utilization of screening modalities including fecal immunochemical test (FIT), multi-target stool DNA test (MT-sDNA) and colonoscopy. In 2016, 67.2% of the US population who are 50–75 years old were up-to-date on their CRC screening. Comparatively, CRC screening rates at our academic Internal Medicine resident-based clinic were 42.5%. Therefore, we established a team-based approach to improve the CRC screening program at our community-based clinic. The aim was to achieve a 3% increase in screening rates over the year 2019 which aligns with our organization goal. METHODS: Institute of Healthcare model for improvement was used as a framework for this quality improvement project. Initially, a team was assembled, comprised of resident physicians, practice manager (PM) and patient navigators [nurses and medical assistants (MAs)]. Afterwards, a root-cause analysis was performed to identify contributing factors to our low CRC screening rates and explore areas for improvement (Figure 1). Interventions were implemented across three cycles of improvement (Figure 2). This comprised of providing appropriate CRC screening education to the providers and clinic staff. Personal dashboards were then distributed to residents with the list of patients due for screening from their own panel. This was followed by identification of patients due for CRC screening as part of pre-visit planning and during daily inter-professional staff huddles. Furthermore, an educational brochure comparing the different screening modalities was given to eligible patients by MAs prior to seeing the provider. Choice of a screening method was recommended by the provider based on the patient’s CRC risk. Screening tests results were closely tracked and updated by MAs. Patients with incomplete orders after 30 days were followed by a phone call conducted by a resident physician. CRC screening registry was updated on monthly basis by the PM. RESULTS: There was a steady increase in CRC screening rates from a pre-intervention median of 42.5% to 48.5% by the end of December, 2019. Using run chart rules, this change is significant for a positive shift (Figure 3). CONCLUSION: A team-based approach is an effective method to improve CRC screening rates in a resident-based clinic. We anticipate that our intervention will show more measurable outcomes in the future through continuous cycles of improvement.Figure 1.: Root-Cause Analysis for low CRC screening rates. Abbreviations: CRC-Colorectal Cancer, FIT-Fecal Immunochemical Test, MT-sDNA-Multitarget stool DNA, EMRs-Electronic Medical Records.Figure 2.: PDSA cycles of improvement. Abbreviations: PDSA- Plan-Do-Study-Act.Figure 3.: Run chart graph detailing the exact times for the interventions during the year 2019. A positive Shift can be seen by having six consecutive points above the pre-intervention median. Abbreviations: PDSA- Plan-Do-Study-Act **The red central line reflects the pre-intervention median for the values from June, 2018 to January, 2019.

Effect of Removing Contact Precautions for Multidrug-Resistant Organisms on Hospital Infections in a Pediatric Health System

Background: Discontinuation of contact precautions for methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococci (VRE) have failed to show an increase in associated transmission or infections in adult healthcare settings. Pediatric experience is limited. Objective: We evaluated the impact of discontinuing contact precautions for MRSA, VRE, and extended-spectrum β-lactamase–producing gram-negative bacilli (ESBLs) on device-associated healthcare-associated infections (HAIs). Methods: In October 2018, contact precautions were discontinued for children with MRSA, VRE, and ESBLs in a large, tertiary-care pediatric healthcare system comprising 2 hospitals and 620 beds. Coincident interventions that potentially reduced HAIs included blood culture diagnostic stewardship (June 2018), a hand hygiene education initiative (July 2018), a handshake antibiotic stewardship program (December 2018) and multidisciplinary infection prevention rounding in the intensive care units (November 2018). Compliance with hand hygiene and HAI prevention bundles were monitored. Device-associated HAIs were identified using standard definitions. Annotated run charts were used to track the impact of interventions on changes in device-associated HAIs over time. Results: Average hand hygiene compliance was 91%. Compliance with HAI prevention bundles was 81% for ventilator-associated pneumonias, 90% for catheter-associated urinary tract infections, and 97% for central-line–associated bloodstream infections. Overall, device-associated HAIs decreased from 6.04 per 10,000 patient days to 3.25 per 10,000 patient days after October 2018 (Fig. 1). Prior to October 2018, MRSA, VRE and ESBLs accounted for 10% of device-associated HAIs. This rate decreased to 5% after October 2018. The decrease in HAIs was likely related to interventions such as infection prevention rounds and handshake stewardship. Conclusions: Discontinuation of contact precautions for children with MRSA, VRE, and ESBLs were not associated with increased device-associated HAIs, and such discontinuation is likely safe in the setting of robust infection prevention and antibiotic stewardship programs.Funding: NoneDisclosures: None

S1267 Improving Vaccination Rates in Patients With Inflammatory Bowel Disease

INTRODUCTION: Recent data suggests that inflammatory bowel disease (IBD) patients do not receive preventative services at the same rates as general medical patients. IBD patients are often treated with long-term immunosuppressive therapies which cause them to be at increased risk for vaccine-preventable infections. By identifying current gaps in care and developing a system for vaccine delivery, we set out to assume responsibility for this aspect of health maintenance for our IBD patients. We aimed to increase the vaccination rates in IBD clinic as compared to data obtained from the prior calendar year. METHODS: We performed a retrospective chart review to determine the reasons for missed opportunities for vaccination. We determined the current barriers and deficiencies in our current process and ecosystem as outlined in our process map and fish bone diagram (Figures 1 and 2). We then formulated various interventions and sequentially implemented these changes following a “Plan, Do, Study, Act” (PDSA) cycle. We first embedded a vaccination template within our clinic notes which allowed us to easily reference vaccine criteria for each patient. Following this, we updated our vaccination order menu, which provided an easier means to order vaccines in clinic. We also created return to clinic orders for vaccines series and a nurse clinic to administer these vaccines. We then worked with key shareholders to obtain all the vaccines in IBD clinic. RESULTS: A total of 399 patients were included in the preintervention group, and 132 patients were included in the postintervention group. The percentage of missed opportunities in the baseline data for influenza, PCV13/PPSV23, HBV, TDAP, and Zoster were 80%, 60%, 71.43%, 17.14%, 100%, respectively. This decreased to 22%, 22.22%, 22.22%, 16.67%, and 37.50% respectively by March 2020. With each vaccine, all percentages of missed opportunities in the post-intervention data from March 2020 were below the median, each with an additive effect. (Figure 3). CONCLUSION: We were able to see incremental gains in our interventions over time throughout this process. Our project was undoubtedly a positive experience for our patients. Moving forward, we anticipate continuing to see positive impacts from our interventions. We plan to share what we have learned with other GI clinics at the Atlanta VA and to other VA hospitals through the National VA Field Advisory Committee.Figure 1.: Process Map Process map outlining baseline patient flow in a visit. Oval: beginnings and endings, boxes: steps or activities, Diamonds: decisions.Figure 2.: Fishbone diagram Process analysis of cause and effect outlining barriers to vaccination.Figure 3.: a Baseline median of missed opportunities for each vaccination before the start of interventions on October 2019. b Run charts depicting percentage of missed opportunities (blue line) in relation to each intervention (gray arrow) and median (orange line). The percentage of missed opportunities for influenza, and PCV12/PPSV23 has a decreasing trend present since October 2019, which continues with each subsequent intervention. A decreased trend was beginning to develop for TDAP and Shringrex after the vaccine template was embedded in the clinic note. Fig 4. a Reasons for missed opportunities pre-intervention. B Reasons for missed opportunities post- intervention. The most common reason for pre and post-intervention was vaccination not being offered. The value decreased almost 70-80% for each vaccination post intervention.

How do the M4 and M6 models perform in an Australian pregnancy of unknown location population?

The diagnosis of a pregnancy of unknown location (PUL) is made when there is an elevated serum β human chorionic gonadotropin (βhCG) and no pregnancy on transabdominal and transvaginal ultrasound. Most of these pregnancies end as intra-uterine pregnancies or unsuccessful pregnancies and can be safely managed expectantly. However, up to 20% of these women will have an ectopic pregnancy. Several mathematical models, including the M4 and M6 protocols, have been developed using biochemical markers to triage PUL presentations. This rationalises numbers of tests and visits made without compromising safety and allowing timely intervention. We aimed to externally validate the M4 and M6 models in an Australian tertiary early pregnancy assessment service (EPAS). We performed a retrospective single-centre cohort study across fiveyears. Our study population included all women attending our EPAS with a PUL who had at least two serum βhCG levels and one progesterone level measured. The M4 and M6 models were retrospectively applied. Of the 360 women in the study population, there were 26 confirmed ectopic pregnancies (7.2%) and six persisting PULs (2%). The M4 model had a sensitivity and specificity of 72%. The M6P model had a sensitivity of 91% and specificity of 63%. The M6P misclassified two ectopic pregnancies into the low-risk group, compared with seven in the M4 model. The M6P model has the highest sensitivity of the three models and a negative predictive value of 99%. These numbers are comparable to the original United Kingdom population. Further prospective validation is planned.

National Home Visiting Collaborative Improves Developmental Risk Detection and Service Linkage.

Fewer than 50% of children with developmental delay are identified before they start school, and only 10% of those identified receive services. Between May 2014 and August 2016, the Home Visiting Collaborative Improvement and Innovation Network (HV-CoIIN) aimed to improve early detection and linkage to services so that 80% of children with an identified developmental concern would receive timely, targeted developmental support. HV-CoIIN enrolled 13 home visiting programs in 8 states and 1 tribe in a Breakthrough Series Collaborative (BTS). These programs tested interventions aligned with 5 key drivers: early detection, referral and follow-up, home visitor capacity, families engaged in developmental promotion, and data systems. Run charts were used to study measures. The main outcome was the percent of children with an identified concern who were linked to developmental support. Process measures included the percent of visits where parents were asked if they had any concerns about their child's development and the percent of children screened every 6 months. The percent of children with an identified developmental concern who received support increased from 70% to 82%. Parents were asked about developmental concerns at 95% of visits (baseline = 75%), and 90% of children were screened every 6 months (baseline = 51%). Home visiting programs can reliably execute early detection and linkage to services for at-risk populations they serve. BTS holds promise for improving implementation of federal public health programs to improve population health outcomes.