Run Charts Research Articles

LO90: The clock is ticking: using in situ simulation to improve time to blood delivery in bleeding trauma patients

Background: Massive transfusion protocols (MTP) are widely used to rapidly deliver blood products to bleeding trauma patients. Every minute delay in blood product administration in bleeding trauma patients is associated with a 5% increased odds of death. In-situ simulation (ISS) is simulation that takes place in the actual clinical work environment. We used ISS as a novel, prospective and iterative quality improvement (QI) approach to identify and improve MTP steps that impact time to blood delivery (TTBD) during actual trauma resuscitations. Aim Statement: To reduce the TTBD for bleeding trauma patients by 20% over a 12-month ISS-based QI initiative. Measures & Design: We conducted twelve high-fidelity, interprofessional ISS sessions at a Level-1 trauma center in Toronto, Canada. We used clinician video review as well as extensive stakeholder involvement, including with nurses, porters, blood bank and human factors experts, to develop Plan-Do-Study-Act (PDSA) cycles for MTP improvement. Our three major PDSA cycles revolved around: 1) decreasing MTP activation time; 2) reducing the unpredictable and inefficient transport times for the blood itself; and 3) improving the notification of blood product arrival in the trauma bay. Each PDSA cycle was iteratively tested with ISS prior to implementation into clinical care. Outcome measure was the mean TTBD for trauma patients requiring MTP (in minutes, standard deviation [SD]). Process measures included time to MTP activation and porter transport times. Balancing measures included stakeholder satisfaction. Evaluation/Results: Our baseline TTBD for MTP patients was 11.58min (n = 41, SD 6.8). There were 54 trauma patients that had MTP during the ISS-based QI initiative, and their mean TTBD was 10.44min (SD 6.1). The TTBD after the QI initiative was 9.12min, sustained over 1 year (n = 50, SD 5.3; 21.2% relative reduction, p < 0.05). A run chart did not show special cause variation chronologically related to our interventions. Patients in each group were similar in demographic data, trauma characteristics and injury severity score. Discussion/Impact: We achieved a 21.2% reduction in TTBD for trauma patients requiring MTP with an ISS-based QI initiative. ISS represents a novel approach to the identification and iterative testing of process improvements within trauma care. This methodology can and should be included in QI projects in order to safely test and improve processes of care before they impact real patients.

LO87: Impact of an evidence-based clinical pathway for suspected renal colic in low-risk patients with previous nephrolithiasis on CT utilization and emergency department throughput

Background: Choosing Wisely (CW) recommends patients under age 50 with uncomplicated, recurrent renal colic do not require CT scans. Despite this, CT use has risen dramatically in the past two decades, resulting in unnecessary radiation, cost and prolonged length of stay (LOS). Additionally, a common alternative – formal ultrasound (US) – is not always available. Returning for US can add 10 hours to LOS. We introduced a clinical management pathway (CMP) for low-risk patients with renal colic utilizing point-of-care ultrasound (POCUS) and evaluated its impact on emergency department (ED) CT rates and LOS. Aim Statement: By April 2019, we aim to reduce CT utilization by 50% and time from physician initial assessment (PIA) to discharge by 1 hour for patients under age 50 presenting to Sunnybrook ED with uncomplicated, recurrent renal colic. Measures & Design: The primary intervention was a CMP developed collaboratively with local urologists. The CMP uses POCUS to assess for hydronephrosis (HN) as a marker of nephrolithiasis. Patients with HN receive follow-up in urology clinic without confirmatory imaging. Patients without HN proceed to usual care. An Ishikawa diagram helped identify barriers to success. Subsequent PDSA cycles included the introduction of reference cards, POCUS workshops and online modules. Outcome measures were ED CT utilization and PIA to discharge times. Process measures were referrals to urology clinic and proportion of patients receiving XR, US and no imaging. Balancing measures were urology CT utilization, alternate diagnoses and return ED visits. Data was plotted on a run chart. Evaluation/Results: Data collection is ongoing and will conclude by April 2019. Interim data shows patients enrolled in the CMP have a reduction in mean PIA-to-discharge time of 173 minutes. Fidelity – specifically, the willingness of ED physicians to use POCUS compared to the ease of ordering CTs – is the biggest challenge to success. Discussion/Impact: This study addresses the feasibility of CW recommendations and utilizes POCUS as a tool for recurrent renal colic. Collaboration with Urology will provide insight into the CMP's sustainability and downstream impact. Reduction of unnecessary CTs will lead to improved patient safety and reduced costs. Decreased PIA-to-discharge times will reduce overcrowding, shorten wait times and improve access to imaging for other patients. Finally, this project may encourage use of POCUS for low-risk patients with renal colic.

LO93: Implementation of sepsis order sets to decrease the time to antibiotics in the emergency department: a quality improvement initiative

Background: Sepsis is a life-threatening syndrome, and delays to appropriate antibiotic therapy increases mortality. Order sets have shown decrease in time to antibiotics in pneumonia, and in sepsis, the implementation of order sets resulted in more intravenous fluids, appropriate initial antibiotics and lower mortality. Aim Statement: The goal was to create an order set for an approach to septic patients, to improve sepsis management. We sought to improve time from triage to first antibiotics, by 15 minutes, for Emergency Department (ED) patients with sepsis in three months after implementation compared to three months before. Measures & Design: We used a literature review, as well as comparison to existing order sets at other EDs to design our initial order set. We underwent multiple revisions based on stakeholder feedback. We educated physician and nursing teams about the order sets, although use was ultimately at physician discretion. We implemented the order set on April 9, 2017. After three months, an electronic retrospective chart review identified patients with a final sepsis diagnosis admitted to the critical care unit. For each patient, we captured triage time using the electronic record, and time to antibiotics from when the antibiotic was taken out of the medication cart. Finally, utilization of order sets was checked via manual chart audit. Evaluation/Results: A run chart did not demonstrate any shifts or trends suggesting a change after implementation. Median time to antibiotics in minutes, 3 months prior (n = 45) and post (n = 55) intervention, increased from 245 to 340 minutes, although the range was very large. Chart audits demonstrated clinicians were not using the order sets. There was 10% usage for 2 of the months and 0% usage the other month, post-intervention. Disucssion/Impact: There was insufficient uptake of the Sepsis Order Set by the Sunnybrook ED to result in any impact on time to antibiotics. Order sets require more than just implementation to be effective. Difficulties in implementation were due to the document not being readily available to physicians. To mediate, we have organized nursing staff to attach the order set onto charts based on triage assessment and will re-assess with another PDSA cycle after this intervention.

MP25: Implementation of pain order sets to decrease the time to analgesics in the emergency department: a quality improvement initiative in progress

Background: Acute pain is a common presentation in the Emergency Department (ED) and inadequacy in its treatment can lengthen stay. Earlier analgesia use and discharge has been associated with positive patient experiences and improved pain management. Validated ‘fast-track pathways’ to aid physician decision making in analgesic administration is associated with decreased waiting times in renal colic diagnoses. Aim Statement: Our aim was to create an order set, for an approach to patients with acute pain, to reduce median time from point of triage to analgesia. We sought to reduce median time by 15 minutes, for ED patients with renal colic in the three months after implementation as compared to three months before. Measures & Design: We used a literature review and comparison to existing order sets at other EDs to design our draft. We focused our evaluation on patients with renal colic. We underwent multiple revisions based on stakeholder feedback and educated both physician and nursing teams about the order set. The utilization, however, was at physician discretion. We implemented the order set on March 30, 2017. After three months, an electronic retrospective chart review identified patients with a final renal colic diagnosis. For each patient, we captured triage time using electronic records and time to analgesia with the medication cart. Utilization of order sets was confirmed via manual chart audit. Evaluation/Results: A run chart showed worsening times after the intervention. Median time to analgesia in minutes, 3 months prior (n = 90) and post (n = 93) intervention, increased from 228 to 310 minutes, although the range was very large. Chart audits demonstrated a considerably low uptake of the order set with a small gradual increase from 0% to 20% over the 3-month period. Discussion/Impact: There was insufficient uptake of the Acute Pain order set preventing impact on time to analgesia. Changes in occupancy likely contributed to the worsening times. There was an increase in utilization over the 3-month period and could be due to increased awareness. This demonstrates that interventions require more than implementation to be effective. Difficulties in implementation were due to the document not being readily available. We have organized the nursing staff to attach order sets onto charts based on triage assessment and will re-assess with another PDSA cycle after this intervention.

LO89: A multi-disciplinary quality improvement project to improve adherence to best practice guidelines for emergency department patients with transient ischemic attack

Background: Canadian Stroke Guidelines recommend that Transient Ischemic Attack (TIA) patients at highest risk of stroke recurrence should undergo immediate vascular imaging. Computed tomography angiography (CTA) of the head and neck is recommended over carotid doppler because it allows for enhanced visualization of the intracranial and posterior circulation vasculature. Imaging while patients are in the emergency department (ED) is optimal for high-risk patients because the risk of stroke recurrence is highest in the first 48 hours. Aim Statement: At our hospital, a designated stroke centre, less than 5% of TIA patients meet national recommendations by undergoing CTA in the ED. We sought to increase the rate of CTA in high risk ED TIA patients from less than 5% to at least 80% in 10 months. Measures & Design: We used a multi-faceted approach to improve our adherence to guidelines including: 1) education for staff ED physicians; 2) agreements between ED and radiology to facilitate rapid access to CTA; 3) agreements between ED and neurology for consultations regarding patients with abnormal CTA; and 4) the creation of an electronic decision support tool to guide ED physicians as to which patients require CTA. We measured the rate of CTA in high risk patients biweekly using retrospective chart review of patients referred to the TIA clinic from the ED on a biweekly basis. As a balancing measure, we also measured the rate of CTA in non-high risk patients. Evaluation/Results: Data collection is ongoing. An interim run chart at 19 weeks shows a complete shift above the median after implementation, with CTA rates between 70 and 100%. At the time of submission, we had no downward trends below 80%, showing sustained improvement. The CTA rate in non-high risk patients did also increase. Disucssion/Impact: After 19 weeks of our intervention, 112 (78.9%) of high risk TIA patients had a CTA, compared to 10 (9.8%) in the 19 weeks prior to our intervention. On average, 10-15% of high risk patients will have an identifiable lesion on CTA, leading to immediate change in management (at minimum, an inpatient consultation with neurology). Our multi-faceted approach could be replicated in any ED with the engagement and availability of the same multi-disciplinary team (ED, radiology, and neurology), access to CTA, and electronic orders.

Quality Improvement in Rehabilitation: A Primer for Physical Medicine and Rehabilitation Specialists.

Physiatrists in all practice settings can improve the care of rehabilitation patients through the rigorous application of quality improvement (QI) methodology. This primer provides a step-by-step guide to QI in rehabilitation settings for academic and community physiatrists, using the Model for Improvement. Key concepts discussed include Plan-Do-Study-Act cycles, setting optimal aim statements and measures, involving the rehabilitation team, diagnostic tools to understand root causes of quality problems, selection of change concepts and ideas, and utilizing run charts for data analysis. A QI project focused on the secondary prevention of vascular complications in amputees with diabetes admitted to inpatient rehabilitation is used as an illustrative example throughout the primer.

Abstract 201: Evaluating Time from Electrocardiogram (ECG) Acquisition to ST-Elevation Myocardial Infarction (STEMI) Activation for Inpatients: Deployment of a Preliminary Automated ECG Reading System

Background: Inpatients with STEMI experience lengthier symptom-to-intervention times, decreased likelihood of invasive management, and an estimated 3-10-fold increased mortality risk compared to outpatients. Launched in October 2018, the Chest Pain - MI Registry™ now includes inpatient STEMIs, further motivating improvement of care for this vulnerable population. We investigated whether deployment of an automated ECG reading system across the inpatient enterprise at a large academic hospital is associated with improvement in time from ECG acquisition to STEMI activation. Methodology: From May 2018-December 2018, a pre-existing automatic ECG interpretation software on all inpatient ECG machines (Philips PageWriter TC70) was activated at our institution. The interpretation level on the software was changed from “none” to “measurements and interpretations.” This change affected all inpatient ECGs. A protocol for response to acute STEMI auto-interpretations was developed, which instructed all ECG technicians to hand ECGs ordered “stat” directly to a member of the patient’s clinical team within 5 minutes of acquisition. A run chart ( Figure ) was analyzed per the IHI “Four Rules for Interpreting Run Charts.” Baseline and intervention samples were assessed by Wilcoxon rank-sum test. Results: From May 2016-May 2018, median time from ECG acquisition to STEMI activation for inpatients at our institution was 23 minutes (N=14) [range 5, 90] with mean time of 35 minutes (+/- 30 per SD). During the subsequent seven-month study period, median time from ECG acquisition to STEMI activation was 21 minutes (N=5) [range 11, 64] with mean time of 34 minutes (+/- 26 per SD, p = 0.36). Of note, there was no reported increased workload or consultation to cardiology due to erroneous preliminary automated ECG reading. Conclusions: Following deployment of an automated inpatient ECG reading system for seven months, there was no significant decrease in the time from ECG acquisition to STEMI activation. Due to the relative infrequency of inpatient STEMIs and the resulting small number of cases during the study period, our results may be under-powered (power of 6.4%) to detect an improvement in STEMI activation times. This data suggests more aggressive and efficient strategies are required for timely diagnosis of acute inpatient STEMI.

Continuity Clinic Practice Feedback Curriculum for Residents: A Model for Ambulatory Education.

There is an unmet need for formal curricula to deliver practice feedback training to residents. We developed a curriculum to help residents receive and interpret individual practice feedback data and to engage them in quality improvement efforts. We created a framework based on resident attribution, effective metric selection, faculty coaching, peer and site comparisons, and resident-driven goals. The curriculum used electronic health record-generated resident-level data and disease-specific ambulatory didactics to help motivate quality improvement efforts. It was rolled out to 144 internal medicine residents practicing at 1 of 4 primary care clinic sites from July 2016 to June 2017. Resident attitudes and behaviors were tracked with presurveys and postsurveys, completed by 126 (88%) and 85 (59%) residents, respectively. Data log-ins and completion of educational activities were monitored. Group-level performance data were tracked using run charts. Survey results demonstrated significant improvements on a 5-point Likert scale in residents' self-reported ability to receive (from a mean of 2.0 to 3.3, P < .001) and to interpret and understand (mean of 2.4 to 3.2, P < .001) their practice performance data. There was also an increased likelihood they would report that their practice had seen improvements in patient care (13% versus 35%, P < .001). Run charts demonstrated no change in patient outcome metrics. A learner-centered longitudinal curriculum on ambulatory patient panels can help residents develop competency in receiving, interpreting, and effectively applying individualized practice performance data.

Procedure-specific Training for Robot-assisted Distal Pancreatectomy.

To train practicing surgeons in robot-assisted distal pancreatectomy (RADP) and assess the impact on 5 domains of healthcare quality. RADP may reduce the treatment burden compared with open distal pancreatectomy (ODP), but studies on institutional training and implementation programs are scarce. A retrospective, single-center, cohort study evaluating surgical performance during a procedure-specific training program for RADP (January 2006 to September 2017). Baseline and unadjusted outcomes were compared "before training" (ODP only; <June 2012) and "after training" (RADP and ODP; >June 2012). Exclusion criteria were neoadjuvant therapy, vascular- and unrelated organ resection. Run charts evaluated index length of stay (LOS) and 90-day comprehensive complication index. Cumulative sum charts of operating time (OT) assessed institutional learning. Adjusted outcomes after RADP versus ODP were compared using a secondary propensity-score-matched (1:1) analysis to determine clinical efficacy. After screening, 237 patients were included in the before-training (133 ODP) and after-training (24 ODP, 80 RADP) groups. After initiation of training, mean perioperative blood loss decreased (-255 mL, P<0.001), OT increased (+65 min, P < 0.001), and median LOS decreased (-1 day, P < 0.001). All other outcomes remained similar (P>0.05). Over time, there were nonrandom (P < 0.05) downward shifts in LOS, while comprehensive complication index was unaffected. We observed 3 learning curve phases in OT: accumulation (<31 cases), optimization (case 31-65), and a steady-state (>65 cases). Propensity-score-matching confirmed reductions in index and 90-day LOS and blood loss with similar morbidity between RADP and ODP. Supervised procedure-specific training enabled successful implementation of RADP by practicing surgeons with immediate improvements in length of stay, without adverse effects on safety.

Improving Access to Diagnostic Assessments for Autism Spectrum Disorder Using an Arena Model.

To improve access to diagnostic evaluations for children younger than 3 years with concerns for possible autism spectrum disorder. A multidisciplinary "arena model" for children younger than 3 years was developed, tested, and implemented over an approximately 2-year period. Arena assessment teams comprised a developmental behavioral pediatrician (DBP), psychologist, and speech language pathologist (SLP). Quality improvement methods were used during the design phase, conducting Plan-Do-Study-Act (PDSA) cycles and collecting feedback from key stakeholders, and during implementation, plotting data on run charts to measure outcomes of the time to initial visit and time to diagnosis. Over the 9-month implementation period, 6 arena assessment teams were formed to provide 60 evaluation slots per month for children younger than 3 years. The time to first visit was reduced from a median of 122 days to 19 days, and the time to final diagnosis was reduced from 139 days to 14 days, maintaining these outcomes at <35 and <18 days, respectively, over a 2-year period. Total visits required decreased from 4 to 5 visits to just 2 visits, and the average assessment cost was reduced by $992 per patient. Feedback from both providers and families participating in this model was overwhelmingly positive. Access for young children referred for developmental assessments can be improved through an understanding of supply and demand and the development of creative and flexible care delivery models.

Improving Anemia in Inflammatory Bowel Disease: Impact of the Anemia Care Pathway.

Anemia is a common complication of inflammatory bowel disease (IBD). Despite existing guidelines for anemia in IBD, it is frequently under-treated and the prevalence of anemia has remained high. To address this gap, the Crohn's and Colitis Foundation developed the Anemia Care Pathway (ACP). To implement the ACP in a managed care setting and identify where it improves practice habits and where barriers remain. The ACP was implemented from July 2016 through June 2017 and retrospectively studied. Run charts were used to identify shifts in iron deficiency screening and treatment as well as anemia prevalence. Results were compared to those of other providers in the same center not using the ACP. 640 IBD encounters were studied. In the ACP clinic (n = 213), anemics received iron therapy in only 30% of encounters at baseline but improved to 80%. Concurrently, anemia prevalence decreased from 48 to 25%. Screening for iron deficiency, however, did not improve. No shifts were seen in the non-ACP clinics (n = 427) across the same period despite awareness of the ACP and other guidelines. Across 1year, we observed gaps in the screening and treatment of anemia in IBD. Although screening rates did not improve, the ACP appeared to reduce missed opportunities for iron therapy by about half. Most importantly, this was associated with an overall decrease in anemia prevalence. Future refinements to the ACP should be focused on enhanced screening and follow-up.

QIM19-128: Improving Oral Chemotherapy Safety in Adult Neuro-Oncology Clinics

Background: The development of oral chemotherapies (OC) have transformed cancer care for millions of patients. Most patients with brain tumors have temozolomide (TMZ) delivered to their home. While this has improved the patient experience, it presents significant challenges to safety of prescription, administration, and side effect monitoring. While there are guidelines for documentation, there is not a best practices system for managing OC. This project identified areas of latent errors and implemented a standardized process for OC management. Methods: After review of the literature, we developed a process map for our institution’s practice and performed hazard analysis. We then evaluated the process at 3 other neuro-oncology practices. Based on these evaluations, changes were implemented at several stages (Table 1). Objective binary measures that could be recorded for every TMZ prescription were collected by chart review of the 6 months prior to process change. These measures were monitored every 2 weeks after process change implementation using run charts. A baseline process mean was calculated for each measure from the 6 months before program implementation. Successful change implementation was defined as 7 consecutive 2-week averages that were continually on one side of the process mean. Results: At the time of this abstract submission, we had successfully reduced refills for OC and increased documentation of dose calculation and dose ordered. There is improvement in independent dose calculation by 2 providers and dedicated chemotherapy teaching visits; however, these have not yet reached criteria for process change. Additionally, oral chemotherapy order sets were created in the electronic medical records system and an on-site specialty pharmacy was added as another safety measure in OC management. Conclusions: This project used published studies and multi-institutional process mapping and hazard analysis to implement a standardized ordering of TMZ for patients with brain tumors. This process can be implemented for OC management in other oncology practices.

Quality Improvement Project to Improve Screening for Tobacco Use in Adolescent Inpatients at a Children's Hospital.

Tobacco use begins in adolescence for the majority of smokers. The purpose of this study was to increase screening and reporting of tobacco use in hospitalized adolescents at a tertiary care children’s hospital. We completed a nursing focus group to understand challenges and completed four iterative Plan-Do-Study-Act cycles, which included: (1) in-person nursing education regarding tobacco use screening, (2) addition of an e-cigarette-specific screening question, (3) the creation and dissemination of an educational video for nursing, and (4) adding the video as a mandatory component of nursing orientation. Run charts of the percentage of patients screened who reported tobacco use were created. Absolute counts of tobacco products used were also captured. From January 2016 to September 2018, 12,999 patients ≥13 years of age were admitted to the hospital. At baseline, 90.1% of patients were screened and 4.8% reported tobacco use. While the absolute number of adolescents reporting e-cigarette use increased from zero patients per month at baseline to five, the percentage of patients screened and reporting tobacco use was unchanged; the majority of e-cigarette users reported use of other tobacco products. This study demonstrates that adding e-cigarettes to screening increases reporting and suggests systems level changes are needed to improve tobacco use reporting.

Implementing Change Ideas, Interpreting Data and Sustaining Change in a Quality Improvement Project.

This article is the third and final installment in our diabetes quality improvement primer series. It summarizes how to interpret real-time data with run charts and highlights 4 key rules that can be applied to understand whether improvement is statistically significant. We also review the importance of outlining a family of measures, including outcome, process and balancing measures. Finally, we discuss strategies for sustaining change.

A qualitative study exploring how routinely collected Medication Safety Thermometer data have been used for quality improvement purposes using case studies from three UK hospitals

ObjectivesThe Medication Safety Thermometer (MedsST) is a medication safety data collection tool, which has been used by over 100 UK healthcare organisations to enable measurement of medication safety for improvement...

Decreasing Telephone Calls for Tympanostomy Tube Otorrhea: A Pilot Study.

The "Clinical Practice Guideline: Tympanostomy Tubes in Children" published in 2013 by the American Academy of Otolaryngology-Head and Neck Surgery Foundation encourages that an "educational video, or other teaching aid, should be developed to illustrate how parents/caregivers" may manage postoperative complications such as tube otorrhea; however, the current literature is devoid of such patient safety and quality improvement measures. Our objective was to develop an effective educational model to assist parents and caregivers in understanding the signs and symptoms of tympanostomy tube (TT) otorrhea and how to independently institute the appropriate otologic treatment. A 3.5 × 2-inch instructional card was designed to illustrate TT otorrhea and describe the subsequent steps necessary to obtain and institute the appropriate medical therapy. This was distributed to caregivers of all patients undergoing TT placement in September 2016; patients undergoing TT placement in May 2016 served as the preintervention control cohort. Group comparisons were made before and after implementation of the educational model by number of telephone calls our clinic triaged regarding untreated TT otorrhea, as documented within the electronic medical record. A total of 30 sets of TT were placed in September 2016, compared to 27 sets of TT in May 2016. Postoperatively, a run chart revealed a significant shift (ie, 7 consecutive points) in the number of telephone calls received (16-5 calls) after establishment of the proposed educational model. This clinical experience demonstrates the utility of patient-driven management of TT otorrhea through ancillary educational material. Given the superiority of topical otic therapy, continued translation efforts are needed for continued focus on practice implementation and dissemination.

A Quality Improvement Project to Increase Mother's Milk Use in an Inner-City NICU.

We conducted a quality improvement project from January 2015 to December 2017 focused on prenatal education, first milk expression ≤6 hours after birth, and skin-to-skin care in the first month. We tracked process measures and main outcomes with run and control charts among 202 infants younger than 34 weeks' gestation eligible to receive mother's milk born at our hospital; We tracked results according to maternal race/ethnicity subgroups. Forty-seven percent of mothers were non-Hispanic black, 28% were Hispanic, and 13% were non-Hispanic white. We improved the rate of first milk expression ≤6 hours after birth and skin-to-skin care in the first month but did not improve rates of any/exclusive mother's milk use at discharge/transfer. Eight-five percent of infants had mothers that initiated milk production, but only 55% received any mother's milk at discharge/transfer. Our single-center quality improvement effort focused on infants younger than 34 weeks' gestation whose mothers were predominately Hispanic and non-Hispanic blacks. We successfully increased first milk expression ≤6 hours after birth and skin-to-skin care but did not increase mother's milk use at discharge/transfer.

Lessons learned from introducing huddle boards to involve nursing staff in targeted observation and reporting of medication effect in a nursing home.

BackgroundMedication administration and management in nursing homes can occur during all phases of the medication process. The aim of this study was to investigate if an introduction of a systematic use of huddle board led to an increased amount of documentation in the patient record of observations of effects and side effects following a change in medication.MethodsA three-layer intervention approach combining huddle boards, educating the entire staff in medication observation and documentation, and frequent feedback to the staff about the outcome was applied. A standard was set for the expected reporting. Correlation between expected and actual reporting as an average was calculated and the staff received weekly updates on their observation–reporting results.ResultsThe huddle board became a hub in providing an overview of the expectations of observations. To visualize the impact of the intervention, use of a run chart gave comprehensive information about the extent to which the expected goal of documentation was reached. Four different organizational steps and one individual action in the last step were taken to improve the observation–reporting. The identifying of the nonreporting nurses and individual staff guidance to these nurses resulted in a significant improvement in observation–reporting. The expected goal of 100% average reporting was achieved 6 months after all wards were included in the improvement project.ConclusionThe combination of huddle boards, educating the entire staff in observation and documentation, and frequent feedback to the staff about the outcome proved to be a useful approach in medication safety work in nursing homes.

Implementation and Evaluation of a Standard Operating Procedure for Pediatric Infliximab Infusions.

Background:The purpose of this quality improvement project was to decrease care variation regarding infliximab delivery at a pediatric inflammatory bowel disease (IBD) center. This variation was driven by differences in provider and nurse practices within 2 distinct infliximab administration units in our center. Following the development of an infusion protocol, the primary project goal was to assess improvement in the submission and completion of a protocol-specific preinfusion safety checklist.Methods:The infusion protocol was developed based on the standard of care and expert physician opinion. A safety checklist was created to screen for active IBD symptoms and infection. We utilized continuous quality improvement to evaluate and guide the implementation of this preinfusion checklist. Checklist completion was assessed monthly over 15 months. We also conducted focus group interviews with infusion nurses and physicians to solicit qualitative protocol feedback.Results:We used standard run chart rules and identified a shift in the median completion rate for both units, with no trends or astronomical points. The baseline period was defined as the 6-month post-checklist implementation. The median baseline completion rate for 1 unit was 46%, and during the subsequent 9 months, the rate increased to 81%. In the other unit, the median baseline completion rate was 91%, and during the succeeding 9 months, the rate was 95%. Focus group feedback included themes of quality, communication, safety, and efficiency and helped improve the protocol.Conclusions:Feasibility was established for a standardized protocol to improve completion of a preinfusion safety checklist in children with IBD who receive infliximab. Nurse and physician focus group feedback was important for guiding protocol refinements.

Improving the Evaluation and Management of Abnormal Uterine Bleeding in Female Adolescents Presenting for Emergency Care.

We sought to improve emergency care for adolescents with abnormal uterine bleeding (AUB) by developing a clinical effectiveness guideline (CEG) and assessing its effect on quality of care. A stakeholder engagement group designed a CEG algorithm for emergency AUB management. Pediatric residents received CEG training and their knowledge and attitudes were assessed using pre- and post intervention surveys. International Classification of Diseases ninth and 10th revision codes identified electronic health record data for patients who presented to the pediatric emergency department for AUB 6months before and after CEG implementation. A weighted, 20-point scoring system consisting of prioritized aspects of history, laboratory studies, and management was developed to quantify the quality of care provided. Descriptive statistics, χ2 test, Wilcoxon rank sum test, and a run chart were used for analysis. Pediatric residents reported higher confidence and knowledge scores post CEG implementation. Of the 91 patients identified, 62 met inclusion criteria. Median score was 14±7 before CEG implementation and 15.5±6 after. The Wilcoxon rank sum test showed a difference in AUB evaluation and management scores (P=.09) after implementation of the CEG. Run chart data showed no shifts or trends (overall median score, 14 points). Pre- and post implementation, points were deducted most frequently for not assessing personal/family clotting disorder history. The largest improvements in care were with appropriate medication dosing and disposition. We designed a CEG and educational intervention for AUB management in a pediatric emergency department. These findings suggest our CEG might be an effective tool to improve emergency AUB care for adolescents and could increase trainees' confidence in managing this condition, although additional cycles are needed.