Run Charts Research Articles

Projects evaluation in construction Industry

The economic activity support in the construction industry in numerous developed countries is a percentage of about 5-11 of their GDP consumed yearly on different kinds of construction projects and associated activities. This paper attempts to evaluate the construction project under different circumstances and different periods.This paper was divided into several stages to accomplish its aim, the first stage, the researchers have gathered information about 30 projects in a different period starting from 2001 to 2017. The second stage included a questionnaire survey to get an indication of the importance of these factors. The third stage comprised analyzing the project's evolution using an artificial intelligence technique, which is a K-nearest neighbor classifier. The fourth stage included using the run chart technique to show the change in the evaluation of the project. It can conclude that the project's evaluation is continuously fluctuated in different periods, the risks that occur have a direct relationship with cost and time overruns and indirect connection with project evaluation.

108. IMPROVING RESIDENT EDUCATION IN THE NEONATAL INTENSIVE CARE UNIT

Background At the Medical University of South Carolina, the neonatal ICU is known for its high volume of patients. With such high volume, education often is not prioritized. Resident evaluations of the NICU rotation were reviewed from the previous year. Residents perceived education in the NICU as one of the weaknesses of this rotation. Aim Statement Our primary aim was to improve the quality of education as measured by surveys on a Likert scale. Our goal was a one-point improvement (on a 5-point scale) over a six-month period. Our secondary aim was to increase the total number of educational sessions per month in the NICU. Interventions Our interventions were implemented over three PDSA cycles. In the first cycle, we provided neonatology textbooks to residents, set iPhone calendar reminders for residents and fellows to complete weekly educational sessions and provided a checklist to track education. We continued those improvements for cycle 2, with the addition of weekly bedside education. For cycle 3, we added an expectation that each off-service fellow would provide one additional lecture per month. Measures The primary outcome was quality of resident education in the NICU. Residents completed surveys at the end of their rotation to evaluate the education they received. Also, the number of educational sessions per month were documented and a run chart was created. Results Our results showed that there was no change in the quality or quantity of the resident educational experience in the NICU. Regarding the 3 PDSA cycles, 20/22 (91%), 11/30 (37%), and 12/42 (29%) of goal educational activities were completed. Conclusions and Next Steps We surmise that the high clinical volume combined with limited time was the reason this initiative failed to produce change. In addition, we approached potential solutions to the lack of education from a resident and fellow driven perspective. We believe that when the responsibility for education is placed on the residents and fellows, patient care and documentation take precedent over creating educational opportunities. In hindsight, the project may have been more successful with more faculty involvement. The next step will be presenting our data to the MUSC NICU faculty and discussing further changes.

15. WHO SPEAKS FIRST? PROMOTING SENIOR RESIDENT AUTONOMY ON FAMILY CENTERED ROUNDS: A QI INITIATIVE

Background Graduated resident autonomy is fundamental as a trainee begins to transition to independent practice. Family Centered Rounds (FCR), the leading model of inpatient rounding in pediatrics, is an opportunity for trainees to demonstrate their competence in leading a healthcare team, which is included as an entrustable professional activity for all pediatric residents by the American Board of Pediatrics. At our institution, senior residents (SR) at baseline performed at a novice level based on the SREA-21, a validated tool that assesses SR autonomy during FCR in 4 domains. Aim Statement Our aim was to increase the median percentage of SREA-21 domains where SR perform at a competent level from 38% to 75% within 6 months. Interventions We used the Model for Improvement to identify key drivers and test proposed interventions using serial PDSA cycles. Interventions included: creation of unified inpatient SR expectations agreed upon by the division of pediatric hospital medicine, introduction of a hospitalist-SR pre-FCR huddle, auditing of FCR interruptions, and direct feedback to the hospitalist-SR dyad by the observer after FCR. Run charts were used to track both SR and hospitalist scores based on the SREA-21 tool. Measures Researchers observed 4 FCR encounters weekly, and calculated SREA-21 domain scores based on actions promoting SR autonomy that were performed by the hospitalist-SR dyad. The primary outcome measure was the percentage of SREA-21 domains in which the SR achieved a competent score based on the tool. Results Prior to our interventions, the median percentage of SREA-21 domains in which the SR performed at a competent level was 38%. After multiple PDSA cycles, there was special cause improvement with a desirable shift upward in the median to 75%, which correlated with the project's interventions and met our goal. The creation of unified SR expectations and the addition of a daily hospitalist-SR huddle had the strongest impact on SR autonomy. Conclusions and Next Steps Using quality improvement methodology, we improved senior resident autonomy during FCR, as measured by the SREA-21 tool. Future interventions will be aimed at sustaining this improvement and evaluating the effect of this change on future independent practice, as well as resident well-being.

Performance Assessment of Sri Lankan Pre-Hospital Ambulance Service

Ischemic heart disease is the leading cause of mortality that raised the demand for pre-hospital emergency care in Sri Lanka. Understanding the performance of Sri Lanka's 1990 Suwa Seriya ambulance service is essential to improve its quality and to reduce morbidity and mortality associated with the disease. This study aims to describe socio-demographic characteristics and evaluate the clinical assessment and management process of patients presenting with acute chest pain of cardiac in origin. A descriptive study was conducted in Gampaha District of the Western Province of Sri Lanka. A total of 154 records of patients with acute chest pain who rang the 1990 call centre over a 3-month period were selected. Composite values for treatment and examinations as a percentage were plotted on run charts to assess the performance and its variations over the study period. About 47.4% of the study group were in 35–65 age group, 53.2% were males, and 81.8% had a typical presentation. The median for composite value for examination as a percentage was 89.5%, indicating substantial control and alignment with the reference package with normal cause variation. The median composite value for treatment as a percentage was 9.96%, a low value with normal cause variation. A good control of the processes of clinical examination and treatment is apparent. A higher median for composite value for examination as a percentage attributed to the formal training process of the ambulance staff. Although a low median was obtained for the composite value for treatment as a percentage, it was stable and pointed room for improvement.

Improving antimicrobial stewardship in an Acute Medical Unit (AMU) during patient discharge following introduction of an antimicrobial information card

Patients who initially present to the emergency department are often streamlined to an Acute Medical Unit (AMU). A quality improvement project was developed to introduce a new "Antibiotic Information Card" for patients discharged home from the AMU. Aims were to reduce 30-day readmission and reattendance rates due to the same infection after initial discharge by 75%, as well as improving patient education regarding their antibiotic prescription to 75%. Two Plan Do Study Act cycles were implemented in a busy AMU. Data were collected using electronic discharge software and patient records, as well as individual patient telephone questionnaires. Statistical analysis used run chart analysis. Baseline findings showed a variable level of patient knowledge on their antibiotic prescriptions (14%-70%) and fluctuations in 30-day reattendance rates (0%-50%). After the initial introduction of the Antibiotic Information Card, run chart analysis showed a shift in patient knowledge, significantly increasing to over 75%, and special cause variation which was not sustained. There were no significant changes in 30-day hospital reattendance and readmission rates throughout the intervention; however, there was a significant improvement in patient knowledge of their antibiotic prescription and management. Staff engagement is encouraged for sustainability of quality improvement changes to promote antimicrobial stewardship within the AMU.

Using the Model for Improvement and Plan-Do-Study-Act to effect SMART change and advance quality.

Using the Model for Improvement and Plan-Do-Study-Act to effect SMART change and advance quality.

Poof! Reduction of Immediate Use Steam Sterilization via Education and Transparency

<h3>Background</h3> Immediate use steam sterilization (IUSS) is used in Operating Room (OR) environments when an instrument is needed for surgery about to occur or currently occurring and there is not sufficient time to perform sterilization in Sterile Processing (SPD). The IUSS process is less effective than standard sterilization processes, which may increase the risk of surgical site infection (SSI). There is no benchmark frequency of IUSS, but trending use by procedure, instrument, and reason is useful. We sought to identify the current IUSS baseline and identify improvement strategies. <h3>Methods</h3> Baseline surveillance from 2016-2017 demonstrated an overall rate of 0.28% with a high of 0.9% in October 2017. Improvement strategies included the addition of IUSS rates at the Infection Prevention and Control Committee and the SSI Prevention Huddle, including run charts. The rationale for IUSS was defined for more targeted approaches to data collection. Based on data, targeted education of OR members included physicians and nurses to the appropriate use of IUSS instead of standard practices. SPD processes and expected turnaround time were discussed. The hospital policy on standard practices were reviewed with vendors. Inventory was assessed to insure proper par levels for surgical instruments. Finally, the surgeon must sign a document acknowledging the risks, that benefits outweigh those risks, and they wish to proceed when IUSS is required. <h3>Results</h3> IUSS rates dropped from 0.28% to 0.11% for 2018-October 2019 (p=0.0013). Between July 2018 and October 2019, IUSS was not used in 9 of 16 months, including four consecutive months in 2019. Additionally, there was a shift from "contaminated during procedure (30% to 19%)," towards "compromised packaging of unique item" and "vendor non-compliance," which rose to 50% and 38%, respectively. <h3>Conclusions</h3> Minimization of IUSS can be indicative of a highly reliable OR. With focused infrastructure and transparency, instances of IUSS can be minimized, even zero.

Reducing Central Line Associated Blood Stream Infections in a Major Academic Facility Using a Novel Comprehensive Tool

<h3>Background</h3> Central line-associated blood stream infections (CLABSIs) are a major source of morbidity, mortality, and increase in cost for healthcare facilities. At our facility, a multi-disciplinary team created a comprehensive tool to prevent higher than expected number of CLABSIs. <h3>Methods</h3> This quality improvement project was conducted at a 953 bed- Level 1 Trauma Teaching Facility, in the 105- bed adult intensive care units (ICUs). On August 2017, a novel comprehensive tool to reduce CLABSI was created by a multi-disciplinary team. The tool was implemented in January 2018. A multidisciplinary team (nurses, vascular access team, physicians, infection prevention), collaborated on CLABSI prevention. The first step was performing Apparent Cause Analysis (ACA) for CLABSI cases. The ACA identified the following improvement opportunities: Device indication, insertion bundle completion, device access, dressing best practices, daily audits, necessity for central lines in patients leaving ICUs, prompt removal of emergent lines (femoral), standardized line insertion and dressing kits, Chlorhexidine Gluconate (CHG) daily bathing, timely identification of CLABSI and posting unit specific CLABSI run charts, and patient education. ACA findings were remediated with staff education (flyers, just-in-time), and the Kamishibai CLABSI maintenance Audit Tool (K card). <h3>Results</h3> Statistically significant reduction in the number of CLABSIs was reported in 2019 (P-value 0.003). In 2016 and 2017, the ICUs reported a Standard Infection Ratio (SIR) of 2. In 2018 and 2019 up to September, the ICUs reported a SIR of 1 and 0.9 respectively. The observed CLABSI reduction was >50% with a decrease from 42 in 2016, to 34 in 2017, to22 in 2018 and 13 in 2019. <h3>Conclusions</h3> Utilizing ACA, involving front-line staff and leadership, providing just-in-time education to targeted staff, continuing education, and ensuring the appropriate audit tools (K card) are in place, enhances staff awareness, resulting in a significant reduction in CLABSI rates.

Improving timely sepsis care using the surviving sepsis campaign one-hour bundle in a rural emergency department.

Sepsis is deadly when not recognized and treated in a timely manner and leads to 270,000 deaths each year in America. Mortality increases eight percent for each hour treatment is delayed. Sepsis-related admission is the most expensive condition in the United States with a median cost per patient of $32,421. Baseline data for patients with sepsis revealed that only 30% were recognized in triage, only 20% received correct amounts of fluids, and only 45% received antibiotics within one hour. The aim of this project was to improve timely sepsis care to 75% for patients in a rural emergency department within 90 days. A rapid cycle quality improvement project was completed, consisting of four plan-do-study-act cycles over 90 days. Each cycle included tests of change related to team and patient engagement, screening, and the use of timely sepsis orders. Data were collected three times weekly and analyzed using run charts. Interventions included screening in triage with positively screened patients receiving participatory education, team handoff communication, a sepsis checklist for nurse-driven orders, and Power Hour for timely care. Team communication improved to 83%. Patient education exceeded goal, with 100% of patients taking an active role in care. Sepsis screening improved to 100%. The recommended One-Hour Bundle for timely sepsis treatment improved to 83%. The project was successful in improving patient and team engagement, screening, and sepsis care within 1 hour for emergency department patients.

A new distribution‐free adaptive sample size control chart for a finite production horizon and its application in monitoring fill volume of soft drink beverage bottles

AbstractNonparametric control charts have received increasing attention in process monitoring. In this article, a new nonparametric sign (SN) control chart with variable sample size (VSS) for a finite horizon process is developed. The novelty of this research lies in the incorporation of the VSS technique into the nonparametric SN chart for a finite horizon process, hence, resulting in the development of a more sensitive nonparametric short run chart. The statistical performance of the new nonparametric VSS SN control chart is evaluated and compared with the existing fixed sample size (FSS) SN chart for a finite horizon process. The charts' performances are compared using the truncated average run length (TARL) and truncated standard deviation of the run length (TSDRL) criteria. The results obtained show that the nonparametric VSS SN short run chart is always quicker than the FSS SN short run chart in detecting process shifts for various underlying process distributions, hence, reducing scrap and rework cost. Finally, an application of the proposed control charting scheme is shown through a real‐life example on the fill volume of soft drink beverage bottles.

The Effect of Ibuprofen Dosing Interval on Post-Tonsillectomy Outcomes in Children: A Quality Improvement Study.

In this Quality Improvement (QI project) it was hypothesized that an increase in dosing intervals for postoperative analgesia when alternating Ibuprofen and Acetaminophen would reduce post-tonsillectomy hemorrhage (PTH) rates for those undergoing tonsillectomies with or without adenoidectomy, while maintaining the standard of postoperative analgesia and reducing visits to the Emergency Room (ER) for reasons other than PTH. Data was collected from 353 children. Utilizing run chart analysis, it was determined that patients experiencing the 4-hour dosing interval had lower rates of PTH, fewer ER visits, and no increase in postoperative phone calls from caregivers. Patients were treated with standing Acetaminophen 15 mg/kg q6h and Ibuprofen 10 mg/kg q6h for postoperative analgesia from July of 2017 until January of 2018. Starting January of 2018 through November of 2018, the dosage interval was lengthened 1 hour. Data relating to PTH, ER visits for reasons other than bleeding, and phone calls from caregivers was collected. Run charts were used to assess outcomes regarding PTH, postoperative visits to the ER for reasons other than PTH, and phone calls from caregivers. Our results suggest that a standing protocol of alternating Acetaminophen and Ibuprofen given every 4 hours improves the post-tonsillectomy hemorrhage rate without increasing ER visits or calls about pain. This data shows promise in reducing PTH and ER visits with a longer dose interval when alternating Acetaminophen and Ibuprofen for postoperative analgesia in tonsillectomy patients. A randomized clinical trial should be carried out to further validate these claims.

Smooth operator: Modifying the Anhøj rules to improve runs analysis in statistical process control.

The run chart is one form of statistical process control chart that is particularly useful for detecting persistent shifts in data over time. The Anhøj rules test for shifts by looking for unusually long runs (L) of data points on the same side of the process centre (mean or median) and unusually few crossings (C) of the centre depending on the number of available data points (N). Critical values for C and L have mainly been studied in isolation. But what is really of interest is the joint distribution of C and L, which has so far only been studied using simulated data series. We recently released an R package, crossrun that calculates exact values for the joint probabilities of C and L that allowed us to study the diagnostic properties of the Anhøj rules in detail and to suggest minor adjustments to improve their diagnostic value. Based on the crossrun R package we calculated exact values for the joint distribution of C and L for N = 10-100. Furthermore, we developed two functions, bestbox() and cutbox() that automatically seek to adjust the critical values for C and L to balance between sensitivity and specificity requirements. Based on exact values for the joint distribution of C and L for N = 10-100 we present measures of the diagnostic value of the Anhøj rules. The best box and cut box procedures improved the diagnostic value of the Anhøj rules by keeping the specificity and sensitivity close to pre-specified target values. Based on exact values for the joint distribution of longest run and number of crossings in random data series this study demonstrates that it is possible to obtain better diagnostic properties of run charts by making minor adjustment to the critical values for C and L.

Supporting Breastfeeding in Infants Hospitalized for Jaundice.

Infants readmitted for neonatal hyperbilirubinemia requiring phototherapy are less likely to exclusively breastfeed than infants who are not readmitted for phototherapy. Our aim for this study was to increase breastfeeding exclusivity for infants admitted for neonatal hyperbilirubinemia. Using the Model for Improvement, we conducted 3 plan-do-study-act cycles to improve exclusive breastfeeding (EB). Our outcome measure was to increase the percentage of EB for infants hospitalized for phototherapy from 30% to 80% in 12 months. Our process measure was to increase lactation consultations from 60% to 80%. Balancing measures included the development of >10% weight loss, acute bilirubin encephalopathy, readmissions, and length of stay. Interventions involved staff breastfeeding education, automated orders for lactation consultations, and use of bilirubin blankets during breastfeeding. Data were analyzed by using run charts and statistical process control. A total of 92 infants with neonatal hyperbilirubinemia were admitted from December 2016 to August 2019, with 61 in the postintervention period. After implementation of an automated order for lactation consultation, EB improved from 30% to 60% and completed lactation consultations increased from 60% to 90%. Infants who received a lactation consultation within the first shift during their hospitalization were 4 times more likely to have EB during hospitalization than infants who did not (odds ratio 3.8; confidence interval: 1.17-12.39.) No infant experienced >10% weight loss, acute bilirubin encephalopathy, or a readmission, and length of stay did not significantly change. Early involvement of trained lactation consultants safely improves rates of EB for infants hospitalized with neonatal hyperbilirubinemia.

1156 Polysomnographic Total Sleep Time: A Novel Biomarker For Dementia

Abstract Introduction Neuroprotection, early diagnosis, and behavioral intervention are national priorities for dementia research. Sleep duration is emerging as an important potential remediable risk factor. In this study, we examined whether total sleep time (TST) derived from attended overnight polysomnography (PSG) studies is associated with an increased prevalence of dementia diagnosis and determined the optimal cut-point. Methods We identified 69,847 PSG sleep studies using CPT code 95810 from 2000-19 in the US Department of Veteran Affairs (VA) national database of patient care. We used natural language processing to verify PSG reports and extract TST values from the patient free-text notes. We examined a TST of 240-420 minutes in 10-minute increments using a run chart (time series) approach to determine the optimal cut-point for determining greater odds of dementia. Results Patients had a mean age of 55.4±13.8, 91.5% were male, and 64% were Caucasian. PSG studies revealed a mean TST of 310.6±79.5 minutes. The run chart time series analysis revealing &amp;lt; 360 minutes being the optimal cut-point for increased odds of dementia (OR: 1.64, 95% CI: 1.36-1.99, p&amp;lt;.05). Conclusion Lower TST predicted higher prevalence of dementia diagnosis. TST of 360 minutes may serve as the optimal cut-point to determine greater odds of dementia. This is an important study examining PSG sleep duration and the prevalence of dementia across 19 years in the largest integrated healthcare system in the US. TST may function as a potential biomarker for developing dementia. Support This material is based upon work supported in part by the Department of Veteran Affairs, Veterans Health Administration, Office of Research and Development, and the Center for Innovations in Quality, Effectiveness and Safety (CIN 13-413). Dr. Nowakowski is also supported by a National Institutes of Health (NIH) Grant (R01NR018342).

Improving compliance with diabetes care using a novel mnemonic: A quality improvement project in an urban primary care clinic

AimThe aim of this quality improvement project was to improve compliance with the delivery of multidimensional patient-centered diabetes care using a streamlined mnemonic based on established diabetes guidelines. MethodsUsing the Institute for Healthcare Improvement (IHI) model for improvement, four rapid plan-do-study-act cycles primarily implemented different tests of change over eight weeks using a streamlined mnemonic – the LLaVES (lifestyle, laboratory tests, vaccination, examination, social/psychosocial) bundle for screening and case management of patients with diabetes. Secondary to the LLaVES bundle, tests of change were also conducted for clinic team members and patients. Team member engagement utilized a best-practice toolkit for effective communication. Patient engagement implemented validated models to evaluate knowledge of diabetes and stage of change. Data were analyzed using run charts to evaluate the impact of interventions on outcomes. Overall compliance was measured as the diabetes management compliance rate (DMCR), composed of LLaVES implementation, team engagement, and patient engagement scores. ResultsThe diabetes management compliance rate increased by 72.2%, from a baseline of 49% to 84.4% in eight weeks. Team engagement increased from 76.6% to 92% while patient engagement increased from 70.4% to 87.4%. ConclusionsDiabetes management is complex and requires team and patient engagement to implement a structured and multidimensional process. Composed of established, high-level evidence interventions, the LLaVES bundle is one approach to systematize complex care while taking into account the specific and unique challenges of a health care organization.

Optimization of screening tools in patients eligible to receive immune-checkpoint inhibitors.

e14139 Background: The management of immune-related adverse events (irAEs) produced by immune-checkpoint inhibitors can be challenging, considering differences with the toxicity of classical chemotherapy. In this study, we explored the limitations in the preventions and diagnosis of irAEs at our institution and developed a strategic plan to solve them according to guidelines of the European Society for Medical Oncology and the American Society of Clinical Oncology. Methods: This is a two-phase, single center, exploratory study. In the first phase, we analyzed a random sample of 20 patients (pts) treated with nivolumab or pembrolizumab in the years 2017-2018. A Pareto chart was designed to identify issues in the baseline screening, as well as potential ways to improve the management of irAEs. After that, we implemented corrective measures based on educational lectures, early identification of patients eligible for immunotherapy, standardized protocols, and a profile of screening tests in the electronic medical records. We applied the new strategy on 15 pts treated from January-April 2019. To compare the impact of the implemented measures we used a run chart, frequencies/percentages for categorical variables, and medians/ranges for continuous variables. Adverse events were assessed according to CTCAEv5.0. Results: In the first phase, 38% of the required tests were done before the start of immunotherapy. We identified a deficit in the evaluation of cardiac and pulmonary function, chronic infections, and skin disorders. 45% of pts had some irAEs (15% G1, 15% G2 and 15% G3). Due to toxicity, 33% of pts had delays in the administration of treatment, and 11% required early interruption. After applying corrective measures, 81% of tests were requested before treatment initiation. However, screening for tuberculosis infection and echocardiogram continued to be deficient. We identified irAEs in 53% of pts (16% G1, 50% G2 and 25% G3), and 37% of them presented two or more different irAEs during the period of treatment. 37,5% and 12,5% of pts had delays or early interruption of immunotherapy, respectively. All of pts with irAEs had presented any basal alterations in screening tests. The most frequent basal alterations were found in pancreatic (66%) and thyroid activity (50%). Conclusions: Simple improvement strategies such as education programs, standardized protocols, and an electronic profile can improve the basal screening for potential irAEs. The basal alterations found in some pts can be related to the development of side effects or interactions with the immunotherapy.

Enhancing Collaborative Learning for Quality Improvement: Evidence from the Improving Clinical Flow Project, a Breakthrough Series Collaborative with Project ECHO

This project engaged teams from Federally Qualified Health Centers (FQHCs) in a quality improvement (QI) collaborative to improve clinical flow (increase quality and efficiency of operations), using a novel combination of Breakthrough Series Collaborative tools with Project ECHO's telementoring model. This mixed methods study describes the collaborative and evaluates its success in generating improvement and developing QI capacity at participating FQHCs. The 18-month collaborative used three in-person/virtual learning session workshops and weekly telementoring sessions with brief lectures and case-based learning. Participants engaged in QI work (for example, PDSAs [Plan-Do-Study-Act]) and tracked data for 10 care system measures to evaluate progress. These data were averaged across consistently reporting sites for standard run chart analysis. Semistructured interviews assessed the effectiveness and value of the approach for participants. Fifteen sites across the United States participated for one year (Cohort 1); 10 sites continued to 18 months (Cohort 2). Cohort 2 evidenced improvement for 6 measures: Patient/Family Experience, Patient Time Valued, Empanelment, Cycle Time, Colorectal Cancer Screening Rate, and Third Next Available Appointment. Progress varied across sites and measures. Participant interviews indicated value from both in-person and virtual activities, increased QI knowledge, and professional growth, as well as challenges when participants lacked time, engagement, leadership support, and consistent and committed staff. This novel collaborative structure is promising. Evidence indicates progress in building QI capacity and improving processes and patient experience across participating FQHCs. Future iterations should address barriers to improvement identified here. Additional work is needed to compare the efficacy of this approach to other collaborative modes.

LO36: Reducing emergency department bloodwork and eliminating waste

Background: Patients presenting to the Emergency Department (ED) may be subjected to unnecessary bloodwork. This leads to excessive work for front-line nurses, physicians and laboratory staff, contributing to increased ED length of stay (LOS), patient discomfort, and health care costs. Aim Statement: By January 1, 2020, we will reduce the number of targeted blood tests (AST, GGT, aPTT and CK) by 40% in the Mount Sinai ED, as measured by the percent per 1000 ED visits of AST to ALT, GGT to ALT, aPTT to INR and CK to troponin. Measures &amp; Design: This was a prospective time series quality improvement study. Using the Model for Improvement, we engaged front-line ED staff, as well as stakeholders from Consultant, Laboratory and Information Services. Data was analyzed using run chart rules. Intervention: a) Removed rarely used tests from electronic nursing order sets b) Uncoupled order panels c) Developed six presentation-based medical directives with appropriate blood testing. d) Staff education Family of measures Outcomes: percent of targeted uncoupled test per 1000 ED visits for each of AST to ALT, GGT to ALT, aPTT to INR, and CK to troponin; Total number of blood tests ordered per 1000 ED visits Process: number of “separate and hold” tubes; number of blood tubes used in the ED; proportion of staff attending education Balancing: volume of blood drawn; LOS Evaluation/Results: Outcome: Estimated relative reduction in proportion of all uncoupled tests per 1000 ED visits by: • 33% AST/ALT • 52% GGT/ALT • 50% CK/troponin •18% aPTT/INR Total number of lab tests per 1000 ED visits decreased by 7.7% (5742 to 5331). Evidence of special cause variation on all outcomes. Process measures: 1. 100% reduction in weekly “Separate and Hold” tubes (56 to 0). 2. Monthly total of blood tubes used in the ED decreased by 2.8% (11620 to 11300) 3. Attendance pending. Balancing measures: Monthly average volume of blood drawn decreased by 1.4L(2%) from 50.4L to 49.0L; LOS pending Discussion/Impact: A multi-pronged intervention resulted in a decrease in blood testing in the ED. We achieved the sub-aim of reducing targeted blood tests and are on track to achieve the overall aim of total lab reduction in the ED by April 2020. Final interventions to be implemented in the coming months include changes to the ED paper record and replacement of the paper add-on order process with an electronic ordering tool. Complete data will be available by April 2020. This intervention is scalable and has the potential to reduce costs and preventable harm to patients.

P139: The impact of a pancreatitis admission algorithm on emergency department length of stay in a tertiary care academic hospital

Background: Emergency department (ED) overcrowding is associated with a broad spectrum of poor medical outcomes, including medical errors, mortality, higher rates of leaving without being seen, and reduced patient and physician satisfaction. The largest contributor to overcrowding is access block – the inability of admitted patients to access in-patient beds from the ED. One component to addressing access block involves streamlining the decision process to rapidly determine which hospital service will admit the patient. Aim Statement: As of Sep 2011, admission algorithms at our institution were supported and formalised. The pancreatitis algorithm clarified whether general surgery or internal medicine would admit ED patients with pancreatitis. We hypothesize that this prior uncertainty delayed the admission decision and prolonged ED length of stay (LOS) for patients with pancreatitis. Our project evaluates whether implementing a pancreatitis admission algorithm at our institution reduced ED time to disposition (TTD) and LOS. Measures &amp; Design: A retrospective review was conducted in a tertiary care academic hospital in Montreal for all adult ED patients diagnosed with pancreatitis from Apr 2010 to Mar 2014. The data was used to plot separate run charts for ED TTD and LOS. Serial measurements of each outcome were used to monitor change and evaluate for special cause variation. The mean ED LOS and TTD before and after algorithm implementation were also compared using the Student's t test. Evaluation/Results: Over four years, a total of 365 ED patients were diagnosed with pancreatitis and 287 (79%) were admitted. The mean ED LOS for patients with pancreatitis decreased following the implementation of an admission algorithm (1616 vs. 1418 mins, p = 0.05). The mean ED TTD was also reduced (1171 vs. 899 mins, p = 0.0006). A non-random signal of change was suggested by a shift above the median prior to algorithm implementation and one below the median following. Discussion/Impact: This project demonstrates that in a busy tertiary care academic hospital, an admission algorithm helped reduce ED TTD and LOS for patients with pancreatitis. This proves especially valuable when considering the potential applicability of such algorithms to other disease processes, such as gastrointestinal bleeding and congestive heart failure, among others. Future studies demonstrating this external applicability, and the impact of such decision algorithms on physician decision fatigue and within non-academic institutions, proves warranted.

LO39: Using an ambulatory zone to improve physician initial assessment times in a tertiary care hospital emergency department

Background: Increasing Emergency Department (ED) stretcher occupancy with admitted patients at our tertiary care hospital has contributed to long Physician Initial Assessment (PIA) times. As of Oct 2019, median PIA was 2.3 hours and 90th percentile PIA was 5.3 hours, with a consequent 71/74 PIA ranking compared to all Ontario EDs. Ambulatory zone (AZ) models are more commonly used in community EDs compared to tertiary level EDs. An interdisciplinary team trialled an AZ model for five days in our ED to improve PIA times. Aim Statement: We sought to decrease the median PIA for patients in our ED during the AZ trial period as compared to days with similar occupancy and volume. Measures &amp; Design: The AZ was reserved for patients who could walk from a chair to stretcher. In this zone, ED rooms with stretchers were for patient assessment only; when waiting for results or receiving treatment, patients were moved into chairs. We removed nursing assignment ratios to increase patient flow. Our outcome measure was the median PIA for all patients in our ED. Our balancing measure was the 90th percentile PIA, which could increase if we negatively impacted patients who require stretchers. The median and 90th percentile PIA during the AZ trial were compared to similar occupancy and volume days without the AZ. Additional measures included ED Length of Stay (LOS) for non-admitted patients, and patients who leave without being seen (LWBS). Clinicians and patients provided qualitative feedback through surveys. Evaluation/Results: The median PIA during the AZ trial was 1.5 hours, compared to 2.1 hours during control days. Our balancing measure, the 90th percentile PIA was 3.7 hours, compared to 5.0 during control days. A run chart revealed both median and 90th percentile PIA during the trial were at their lowest points over the past 18 months. The number of LWBS patients decreased during the trial; EDLOS did not change. The majority of patients, nurses, and physicians felt the trial could be implemented permanently. Discussion/Impact: Although our highly specialized tertiary care hospital faces unique challenges and high occupancy pressures, a community-hospital style AZ model was successful in improving PIA. Shorter PIA times can improve other quality metrics, such as timeliness of analgesia and antibiotics. We are working to optimize the model based on feedback before we cycle another trial. Our findings suggest that other tertiary care EDs should consider similar AZ models.