Run Charts Research Articles

P065: Development and implementation of a postpartum hypertension recognition and management protocol for use in the emergency department

Introduction: Hypertensive disorders of pregnancy (HDP), including preeclampsia, can develop or worsen in the early postpartum period, often following discharge from hospital, resulting in severe preventable maternal morbidity and mortality. Due to a lack of routine early out-patient follow-up, many women with postpartum HDP present to the emergency department (ED) with severe hypertension or symptoms of preeclampsia (e.g., headache). In the ED, postpartum HDP can be difficult for clinicians to recognize (due to vague presenting symptom) and manage (due to lower blood pressure targets and concern of medication safety). ED clinicians recognized a need for timely recognition and effective treatments for postpartum HDP in the ED to improve maternal outcomes. As such, as part of a multi-step quality improvement initiative, an interdisciplinary team developed and implemented a postpartum HDP management protocol (consisting of nursing and physician protocols and an electronic order set embedded in the electronic medical record). The aims of this specific project were to assess: 1) the use of this clinical management protocol in the ED; and 2) its impacts on clinical care. Methods: This quality improvement project used electronic medical records to identify: 1) ED visits for postpartum HDP for postpartum women ages 20-50; 2) utilization of the postpartum HDP order set; and 3) clinical care outcomes (consultation and admission). Patient population characteristics and clinical care measures were summarized with descriptive statistics and compared using a before and after design. Changes in the utilization of the protocol were assessed using run charts. Results: 540 women with postpartum HDP were seen in the four Calgary EDs in the 16-month period following protocol implementation compared with 335 women in the preceding 12 months. The protocol was used in 46% of these 540 women, and increased over the 16 month follow-up period. We found an increase in the frequency of consultation of specialists (47% to 52%) and admissions (26% to 29%) amongst these women after protocol implementation. Conclusion: This initial assessment demonstrated good uptake of a postpartum HDP management protocol including referral for consultation and admission to hospital for blood pressure management. Future steps include evaluation of the impacts of this management protocol on important patient outcomes.

MP22: Improving treatment of children’s presenting and procedural pain for emergency department visits: a province-wide quality improvement collaborative

Introduction: Pediatric pain is often under-treated in emergency departments (EDs), which is known to cause short and long-term harm. A recent quality improvement collaborative (QIC) was successful in improving treatment of children’s pain across 4 EDs in our city. A new QIC was then formed among EDs across our province to improve treatment of presenting and procedural pain. Aims were to improve the proportion of children <12 years of age who receive topical anesthetic before needle procedures from 13% to 50%; and for children <17 years of age with fractures: to 1) improve the proportion who receive analgesic medication from 35% to 50%; 2) improve the proportion who have a documented pain score from 23% to 50%, and 3) reduce median time to analgesia from 59 minutes to 30 minutes, within 1 year. Methods: Invitations to participate in the QIC were sent to all 113 EDs in the province that treat children and had not participated in the previous QIC. Each site was asked to form a project team, participate in monthly webinars, develop key driver diagrams and project aims, undertake PDSA tests of change, and audit charts to assess performance. Sites are given a list of 20 randomly selected charts per month for audit. Audit data was entered into REDCap and uploaded to a provincial run chart dashboard. All participating sites received a “comfort kit” consisting of distraction items for children as well as educational materials. Measures of presenting pain included proportion of children <17 years with a diagnosis of fracture who have a documented pain score, proportion who receive an analgesic medication, and minutes to analgesia. The measure for procedural pain was the proportion of children <12 years who receive topical anesthetic prior to a needle procedure for a laboratory test. Length of stay for pediatric patients and all patients were balancing measures. Run charts were used to detect special cause. Difference in proportions were compared using 2. Final analysis will include interrupted time series. Results: 34 of 113 invited sites (30%) agreed to participate, including rural and regional representation from all geographic zones; 4222 visits since June 2016 were analyzed. Implementation began June 2017. Comparing the first 4 months following implementation to the preceding year, the proportion of children receiving topical anesthetic prior to needles increased from 13% to 25% (p<0.001). For children with fractures, the proportion with pain scores increased from 23% to 35% (p<0.001), proportion receiving analgesic medication increased from 35% to 42% (p<0.001), and median minutes to analgesia decreased from 59 to 43. Insufficient time points at this stage preclude identification of special cause. Conclusion: This province-wide QIC has already resulted in significant progress toward aims during the first 4 months of implementation. The QIC approach shows promise for improving pain outcomes in children visiting diverse EDs across a province.

LO24: The checklist for head injury management evaluation study (CHIMES): a cQI initiative to reduce imaging utilization for head injuries in the emergency department

Introduction: Over 1 million patients with head injuries (HIs) are seen every year at emergency departments (EDs) in North America, with over 90% being minor HIs. Over-utilization of computed tomography (CT) scans in these patients results in unnecessary exposure to radiation and increases health-care resource utilization. Using recommendations from the Choosing Wisely Campaign (CWC) and quality improvement (QI) methodology, we developed a local initiative targeting this issue. Our aim was to reduce the CT scan rate for patients presenting with HIs by 10% over a 6-month period at two academic EDs. This was considered both achievable and meaningful by our stakeholders. Methods: Baseline CT scan rates for patients with HIs were determined through a 10-month retrospective cohort review. We used stakeholder engagement and provider surveys to develop our driver diagram and PDSA cycles, which included: 1) Assessing and improving provider knowledge about the CWC recommendations; 2) Testing, refining and implementing a modified Canadian CT Head Rule checklist in the ED; 3) Developing and giving patients CWC-themed handouts pertaining to HI best practice; 4) Bimonthly reporting of CT scan rates to providers. Our primary outcome measure was the number of CT scans performed for patients with HIs. Process measures included the number of checklists completed and ED length of stay (LOS). Our balance measure was return ED visits within 72 hours. Results: Baseline rate of CT scans prior to our interventions was 47.9%. Our QI initiative resulted in a significant shift in the run chart of the weekly CT scan rates, associated with the second PDSA cycle cluster. We observed a 16% relative decrease in CT scans at 3 months (47.9% to 40.5%, P=0.005) and 10.4% at 8 months (47.9% to 43.1%, P=0.02). Non-sustained trends and shifts were seen in the run chart of median ED LOS for HI patients, but overall before-and-after median times were not significantly different (237min to 225min, P=0.18). 33% of total checklists were completed. 72-hr return visits did not change during the 8-month study period (4.0% to 4.16%, P=0.85). Conclusion: Our local QI initiative was successful in decreasing CT rates for patients presenting with a HI. The decrease in effect at 8 months suggests the need for continued feedback and reminders to ensure long-term sustainability. Other centres could use similar QI methods, as well as the materials we developed, to achieve similar results of improved evidence-based utilization of diagnostic tests.

Trauma Quality Improvement: Reducing Triage Errors by Automating the Level Assignment Process

Trauma patients are triaged by the severity of their injury or need for intervention while en route to the trauma center according to trauma activation protocols that are institution specific. Significant research has been aimed at improving these protocols in order to optimize patient outcomes while striving for efficiency in care. However, it is known that patients are often undertriaged or overtriaged because protocol adherence remains imperfect. The goal of this quality improvement (QI) project was to improve this adherence, and thereby reduce the triage error. It was conducted as part of the formal undergraduate medical education curriculum at this institution. A QI team was assembled and baseline data were collected, then 2 Plan-Do-Study-Act (PDSA) cycles were implemented sequentially. During the first cycle, a novel web tool was developed and implemented in order to automate the level assignment process (it takes EMS-provided data and automatically determines the level); the tool was based on the existing trauma activation protocol. The second PDSA cycle focused on improving triage accuracy in isolated, less than 10% total body surface area burns, which we identified to be a point of common error. Traumas were reviewed and tabulated at the end of each PDSA cycle, and triage accuracy was followed with a run chart. This study was performed at Vanderbilt University Medical Center and Medical School, which has a large level 1 trauma center covering over 75,000 square miles, and which sees urban, suburban, and rural trauma. The baseline assessment period and each PDSA cycle lasted 2 weeks. During this time, all activated, adult, direct traumas were reviewed. There were 180 patients during the baseline period, 189 after the first test of change, and 150 after the second test of change. All were included in analysis. Of 180 patients, 30 were inappropriately triaged during baseline analysis (3 undertriaged and 27 overtriaged) versus 16 of 189 (3 undertriaged and 13 overtriaged) following implementation of the web tool (p = 0.017 for combined errors). Overtriage dropped further from baseline to 10/150 after the second test of change (p = 0.005). The total number of triaged patients dropped from 92.3/week to 75.5/week after the second test of change. There was no statistically significant change in the undertriage rate. The combination of web tool implementation and protocol refinement decreased the combined triage error rate by over 50% (from 16.7%-7.9%). We developed and tested a web tool that improved triage accuracy, and provided a sustainable method to enact future quality improvement. This web tool and QI framework would be easily expandable to other hospitals.

Patient Complaints in Image-Guided Interventions: Evaluation of Multifactorial Issues Using a Coding Taxonomy.

The purpose of this article is to classify complaints from patients undergoing image-guided interventions using a coding taxonomy and to test whether single-coded complaints were resolved satisfactorily compared with multifactorial (multiple codes) complaints. In this retrospective study, patients' complaint narratives between April 1999 and December 2012 were reviewed and categorized according to a three-level taxonomy into domains and codes. Resolutions were categorized as satisfactory or unsatisfactory to the patient and were classified as follows: clarification, apology, manager notification, change of provider, reimbursement, and quality review. Complaints were classified as single coded (only one code identified in the patients' description) and multifactorial (multiple codes identified). Statistical analysis was performed with the Fisher test, with the significance level set at 0.05. A run chart with the distribution of complaints by domains (relationships, management, and clinical) by year was performed. A total of 146 codes were extracted from 71 narratives (2.06 codes/complaint) and were classified into the following domains: clinical (52%; n = 76), management (24%; n = 35), and relationships (24%; n = 35). The most common codes included quality of care, safety, and communication breakdown issues. A run chart found a decline in absolute numbers of complaints over the years in the domains studied. The frequency of satisfactory resolution was 86% for multifactorial versus 81% for single-coded complaints with no statistically significant differences observed (p = 0.72). Over 50% of complaints were resolved by providing clarification to patients (n = 36). There were no statistically significant differences between multifactorial and single-coded complaints. Clinical codes and communication breakdown were the most common reasons for patient-reported complaint, with most complaints successfully resolved with clarification.

Building the Child Safety Collaborative Innovation and Improvement Network: How does it work and what is it achieving?

ObjectiveThis study investigated whether the Child Safety Collaborative Innovation and Improvement Network (CS CoIIN) framework could be applied in the field of injury and violence prevention to reduce fatalities, hospitalizations...

Evolution of bias and sample size in postoperative pain management trials after hip and knee arthroplasty.

Bias (systematic error) and small trial sample size (random error) may induce imprecise and exaggerated treatment effects in randomised controlled trials (RCTs). To avoid this, SPIRIT- and CONSORT-guidelines, and Cochrane Collaboration bias recommendations were developed. We investigated risk of bias and trial sample size development over time in postoperative pain trials. This study was based on data from two systematic reviews regarding pain management after total hip arthroplasty (THA) or total knee arthroplasty (TKA). RCTs of analgesic interventions with a comparator control group were included. Primary outcomes were risk of bias and trial sample size developments over time. We calculated cumulated bias scores ranging from 0 to 14 based on Cochrane's seven bias domains (0 = low; 1 = unclear, 2 = high). Developments were evaluated with run and control charts. Further, we compared data from trials published between 1990-1999 and 2010-2016. We included 171 trials published between 1989 and 2016. Overall, the summarised risk of bias decreased, mainly due to better randomization and allocation concealment. Visual inspection suggested an on-going improvement that started around 2007. Trial sample size did not change significantly. For trials published between 1990-1999 and 2010-2016 adequate reporting increased from 36% to 75% for random sequence generation, from 9% to 38% for allocation concealment and from 27% to 52% for blinding of participants/personnel. Risk of bias for RCTs regarding postoperative pain management after THA and TKA has decreased from 2007 to 2016, mainly due to better randomization and allocation concealment. Deficiencies remain. Thus, reporting according to validated guidelines is essential. Sample sizes did not change significantly.

P161 SUSTAINABLE IMPROVEMENTS IN URGENT CARE ACCESS AND OUTCOMES FOR PATIENTS WITH INFLAMMATORY BOWEL DISEASE THROUGH IMPLEMENTATION OF AN URGENT ACCESS TOOLKIT

Patients with inflammatory bowel disease (IBD) without adequate access to urgent medical care for exacerbation of symptoms tend to obtain care from emergency departments (ED), which is associated with an increased use of opiates, steroids, and poor patient satisfaction. We previously described the development of an urgent access toolkit using a Breakthrough Series (BTS) Collaborative as part of IBD Qorus. The aim of this study was to demonstrate the sustainability and clinical impact of implementation of the urgent access toolkit after 1 year. The urgent access toolkit consisted of an urgent care hotline for direct patient access to a nurse, and patient educational processes. Data were collected from July 2015 through February 2017 from patients at the Baylor College of Medicine IBD clinic. The urgent access toolkit was implemented in December 2015. The baseline period was considered prior to December 2015 and the post-implementation period was after December 2015. Outcomes were assessed using run charts. A total of 1663 patient encounters were included in the study period, including 438 encounters in the baseline time period and 1225 encounters in the post-implementation period. In the baseline period, a median of 22% of patients reported ED visits, 24% with CT scans, 18% with IBD-related hospitalizations, 17% of patients on prednisone, and 11% on narcotics. Run charts after implementation of the toolkit demonstrated shifts in reduction in ED visits (Fig1), CT scans(Fig2), prednisone use, and an increase in patient satisfaction related to IBD urgent care. Implementation of the urgent access toolkit reduces IBD-associated ED visits, CT scans, and prednisone use, as well as increases patient satisfaction related to urgent care access. These improvements can be sustained for 1 year. Participation in a learning health system facilitates sustainable improvements in access to urgent IBD care and related outcomes.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Reducing Interdisciplinary Communication Failures Through Secure Text Messaging: A Quality Improvement Project.

Interdisciplinary communication failures contribute to medical mistakes and adverse events. At our institution, provider communication previously occurred through unidirectional pager systems. We utilized quality improvement methodology to (1) implement a secure text messaging system for providers on a pediatric ward and (2) evaluate its impact on communication failures. We aimed to reduce potential communication failures between providers by > 25% within 1 month. Implementation of secure text messaging occurred via Plan-Do-Study-Act cycles focused on education, feedback, and electronic health record interventions. We collected pager data before implementation and both pager and secure text messaging data after intervention. Potential communication failures were identified a priori through manual review of the messaging data to capture lack of closed-loop communication. A run chart was used to track daily potential communication failures and total communication volumes. Before implementation of secure text messaging, the median daily potential communication failure rate was 5.5%. Usage of secure text messaging increased after implementation, representing 3.5 of 7.2 communications per patient-day. Paging communications decreased from 4.2 to 3.7 per patient-day. Potential communication failures decreased to a median daily rate of 2.2%, representing a 59% reduction in communication failures. Implementation of secure text messaging using quality improvement methods resulted in a significant reduction in potential communication failures between residents and nurses. Future interventions will be aimed at maintaining and augmenting providers' use of secure text messaging to ensure the potential for communication failure remains low.

Quality Improvement (QI): A Splendid Driver for Achieving the Third 90 in Addis Ababa, Ethiopia

Background: Routine HIV viral load tests improve treatment quality and individual health outcomes for people living with HIV. Quality improvement (QI) consists of systematic and continuous actions that lead to measurable improvement in health care services. Thus, the aim of this study was to assess the effect of Quality Improvement (QI) on achieving routine HIV viral load implementation in Addis Ababa, Ethiopia. Methods: Facility based prospective follow up study design approach was used from January 2016 to December 2016. Data was entered, cleaned using EPI-Data 3.1 and exported to SPSS version 20 software for further processing and analysis. The effect of QI was measured and monitored by test change using run chart. Results: At the end of the quality improvement, the monthly routine viral load performance samples using one analyzer were 3255 from less than 676 at baseline. The routine viral load feedback arrival within agreed turnaround time and regularly archival availability increase from 6 health facilities (7.2%) to 65% at 54 health facilities by December 2016, from the 83 ART monitoring health facilities sent their HIV viral load sample. Implementation of continuous quality improvement is a game changer in transforming laboratory quality and positively impact on meeting the third 90 in Addis Ababa, Ethiopia. Conclusion: The QI model which have implemented at Addis Ababa health research HIV viral load laboratory achieve and worth good experiences with a range of benefits. We strongly believe that healthcare has much to gain by successfully implementing Quality improvement principles within their routine programs.

Improving STI and HIV Passive Partner Notification using the Model for Improvement: A Quality Improvement Study in Lilongwe Malawi.

Background:In Malawi, passive partner notification is the mainstay method of partner notification (PN). Despite its wide use, the proportion of sexual partners referred for care through this method is very low. We aimed to increase the proportion of sexual partner referral through passive PN.Methods:We implemented a quality improvement (QI) project at Bwaila STI unit in Lilongwe, Malawi between January and June 2017 using a pre- and post- intervention quasi-experimental study design. Pre-intervention, we conducted key-informant interviews and clinic observations and used the findings to design a QI project using expert opinion. The intervention included three change ideas: early start time of the clinic, shortening of the group health talk and expedited clinic flow for sexual partners. Each change idea was tested twice through 1-week long Plan-Do-Study-Act cycles using the model for improvement (MFI) and then combined and tested twice. Process data were collected and monitored using run charts. Post-intervention, we evaluated the proportion of sexual partners who presented to the clinic, to detect a 10% increase at 95% power and α=0.05, between pre- and post-intervention periods.Results:The average duration of the group health talk dropped from 56 minutes to 38 minutes and the duration of clinic stay for sexual partners reduced by 45 minutes (from 1hour 36 minutes to 51 minutes). The average clinic start time improved from 09:02 hours to 08:17 hours. The proportion of sexual partner referral increased by 37% (P=0.04) - from 15.6% to 21.4%. We observed an upward trend in the proportion of sexual partners referred in the post-intervention period.Conclusion:The yield of sexual partners through passive PN was improved using a simple QI intervention implemented using the MFI. However, the proportion of sexual partner referral remains suboptimal. More effort is required to increase the proportion of sexual partner referral in Malawi.

Assessment of efficacy of aseptic intravenous line insertion and maintenance bundle on reduction of incidence of phlebitis and infiltration in children: A quality improvement study

Background : To assess the efficacy of aseptic Intravenous line insertion and maintenance bundle on minimizing the incidence of phlebitis and infiltration by 50% over a period of 2 months Methods : Aquality improvement study was undertaken in the pediatric emergencyAPC, PGIMER, Chandigarh. Ethical approval was taken from the Institute’s Ethics Committee to conduct the study. A total of 185 children of age more than 28 days and 46 health care personnelwere enrolled in the study. The study selected the PDSA(Plan, Do, Study, and Act) model to do the quality improvement. Pre-assessment phase was conducted from 24th June 2017 to 15th July 2017 to find out current practices including facilitators and barriers related to aseptic IV line insertion and maintenance. Permission from Head of Department and Assistant Nursing Superintendent of Advanced Pediatric Centre was taken to assess practices by covert participation. A total of 105 peripheral IV line were inserted during observation time. Out of that checklist was filled for35 IV cannulation and drug administration and it was found that the score ranged between 21.7%-39.1% and 20%-54.2% respectively. Focused group discussions were conducted with the health care personnel to know the facilitators and barriers related to “Aseptic Intravenous line insertion and maintenance bundle”.On the basis of pre-assessment run chart of findings was made and root-cause analysis was done. With the use of action priority matrix 4 sets of interventions of PDSA were selected based on low efforts and high impact. In PDSA 1 sensitization of health care personnel was done on aseptic IV line insertion and maintenance bundle. Supply of articles like injection trays, sterile gauzes, tourniquets, tagaderm and increase supply of hand rubs, clean gloves was ensured. Whatsapp group of health care personnel of pediatric emergency was also made. Regular reminders were sent in the form of text and videos on techniques to be followed during bundle. HCP’s were also encouraged to function as a QI team; they are also informed about their function and responsibilities in team. In PDSA 2 Infection control nurse was introduced to regularly monitor the practices and suggest remedial measures. Positive reinforcement was given and HCPs were encouraged to follow the bundle. In PDSA 3 Health care personnel were again motivated with the findings of PDSA 1 and PDSA 2 and by giving emotional examples. In PDSA 4Reinforcement of team members and other health care personnel to take over of the responsibilities independently without direct role of investigator. After running all the four PDSA cycles health care personnel were also interviewed for their experiences on use of bundle. The process measures that are checklist for IV line insertion/ maintenance” and “administration of drugs through IV revealed increase in scores and in return the primary outcome measure that is incidence of phlebitis and infiltration was reduced. Though 50% reduction can’t be achieved for primary outcome the improvement revealed that the consistent regular efforts can bring improvement. Conclusion : Sensitization of health care personnel, introduction of infection control nurse, repeated motivation of health care personnel, framing the responsibilities of health care team were successful in achieving efficacy of the”aseptic Intravenous line insertion and maintenance bundle” and reducing the rate of infiltration and phlebitis.

46 Testing of the ‘always events’ approach to improve the patient experience in the emergency department

AimsThis project aimed to identify issues patients would like to see improved when interacting with the Minor Injuries Unit (MIU) and as a result generate measurable and feasible Always Events...

Improving the Quality of Pediatric Healthcare through Quality Improvement Collaboratives

Purpose of review This review summarizes the current need for Quality Improvement Collaboratives (QICs) and includes considerations specific to pediatric healthcare, such as low-frequency of outcomes and unique funding barriers. This review will consider nuances within measure formation and data collection within QICs, available models for structured formation of a QIC, components that are integral to a QICs success, as well as lessons learned and future directions.Recent findings The literature has demonstrated an increase in the number of pediatric QI collaboratives in recent years. These collaboratives have varied in size, duration, and composition of team members. While some QICs have included members at the organizational level, others have included more novel groups such as insurance companies. Novel methodologies have also been utilized such as N of 1 trials focused on continued interventions for one patient and provider dyad. Successful QICs include use of a steering committee or pre-planning group to guide measures development, use of robust QI methodology to implement small tests of change and continuous feedback of individual and aggregate data and transparency among benchmarking sites. Ideal QI methods for use within QICs have been vetted in prior collaboratives and include formal barriers assessments using driver diagrams, PDSA cycles and analyzing data and measures using run and statistical process control (SPC) charts to inform real-time change and interventions.Summary QICs are pivotal to closing the gap in delivery of evidence based practice while minimizing widespread unnecessary practice variation across multiple organizations using available QI methodologies and tools. Novel approaches to funding such as partnership with insurance companies and educational organizations can allow for more robust participation. Future research should broaden the scope of their measures to include patient centered outcomes.

What the FLOQ? A quality improvement project to reduce unnecessary paediatric respiratory viral swabs in a peripheral metropolitan hospital.

To reduce the number of paediatric respiratory viral swabs (locally referred to as a FLOQ) performed across the authors clinical centre from a baseline of over 800 ($38 000) per year by 25% over 4 months from 6 February 2017 to 31 May 2017. A quality improvement project 'What the FLOQ?' (WTF) was instigated from 6 February 2017 to complement the Emergency Department (ED) 'Sensible Test Ordering Process' project from 1 April 2017. Stakeholder engagement across ED and general paediatric staff was sought. Alterations in practice included education of staff, targeted feedback to groups frequently ordering a FLOQ and rationalising patients appropriate for testing. Monthly requests were tallied on a run chart for FLOQs ordered in ED and the paediatric ward. A monthly audit of FLOQs performed on ED-discharged patients was conducted with feedback. Total FLOQ swabs decreased by 55% from 336 (February to May 2016) to 151 (February to May 2017). ED performed 66% less FLOQs from 237 (February to May 2016) to 82 (February to May 2017). There was no increase in the number of FLOQs performed on the paediatric ward February to May 2017. Monthly auditing of ED discharged patients under 2 years with a FLOQ went from 40 to 3%. Rationalising patient groups appropriate for testing with targeted feedback and broad stakeholder engagement successfully reduced FLOQs performed by 55%. This has projected savings of over $21 000 by 12 months. WTF has reduced the number of invasive patient procedures performed, benefitting staff and patients. Sustaining this change will be achieved through ongoing staff education on rationalisation criteria and consultant only requests outside of these parameters.

Improving Human Papilloma Virus Vaccination Rates: Quality Improvement.

Background:Human papilloma virus (HPV) is a sexually transmitted infection with a national prevalence of greater than 70 million. Most infections are among persons 15–24 years of age. The HPV vaccine has nearly 100% efficacy when administered before natural exposure. However, national vaccination rates remain less than 50%. Our objective was to improve the rate of initiation of the HPV vaccination series in a resident teaching practice.Methods:We used the Plan Do Study Act methodology for quality improvement. Eligible patients included children 9 through 13 years of age who presented to a general pediatric clinic. We established baseline data by reviewing HPV immunization rates taken from a convenience sample of ≤20 patients per month over 7 months. A key driver diagram guided interventions including resident communication, nursing staff education, family knowledge, and an electronic medical record prompt beginning at age 9. Using standard run chart rules, we plotted monthly postintervention vaccination rates over 7 months of data collection.Results:Baseline data included 136 patients age 9–13. Run chart monitoring revealed an increase in our HPV vaccination rate from 53% at baseline to 62% by October 2015. Additionally, we observed a statistically significant increase in mean vaccination rates from 50% to 69% (odds ratio 2.071; P = 0.0042). We noted an increase in vaccination rates after resident education initiatives and after implementation of an electronic medical record prompt.Conclusions:Simple and practical interventions involving residents led to a marked increase in HPV vaccination in our patient population.

Improving handover between the transport team and neonatal intensive care unit staff in neonatal transports using the plan-do-study-act tool.

The aim was to achieve 100% effective handover from the critical care transport team to the neonatal intensive care unit (NICU) medical team. All patients transferred from referring hospitals by the critical care transport team to the Level IV NICU were included. Data for each infant was collected prospectively. The percentage of transported patients for which medical team and nursing handover occurred was recorded. A quality improvement project was launched using the Plan-Do-Study-Act (PDSA) tool. We implemented several processes including call from the transport team before arrival and the completion of a transfer of care form on arrival to the NICU. The process measures and the outcome measure of completion of handover were monitored. Run charts of process measures and the outcome measure were analyzed. Completion of medical handover increased from 95% (baseline) to 100% after 3 PDSA cycles and this has been maintained for 18 consecutive months. Medical handover from the critical care transport team to the NICU medical staff has been achieved and sustained for all neonatal transports.

Quality Improvement Feature Series Article 2: Displaying and Analyzing Quality Improvement Data.

In this second article in the quality improvement (QI) methods series, we discuss how data are best displayed and analyzed in QI projects while focusing on some similarities with and differences from traditional clinical research. We demonstrate why displaying data over time on a run or control chart is superior to using pre-post analysis for QI studies. We introduce several types of statistical process control charts for data commonly collected during QI programs and provide guidance on how to use the proper chart. Last, we present solutions to several common data challenges in QI projects.

Quality Initiative to Introduce Pediatric Venous Thromboembolism Risk Assessment for Orthopedic and Surgery Patients.

Pediatric hospital-acquired venous thromboembolism (VTE) is costly, has high morbidity, and is often preventable. The objective of this quality-improvement effort was to increase the percentage of general surgery and orthopedic patients ≥10 years of age screened for VTE risk from 0% to 80%. At a freestanding children's hospital, 2 teams worked to implement VTE risk screening for postoperative inpatients. The general surgery team used residents and nurse practitioners to perform screening whereas the orthopedic team initially used bedside nursing staff. Both groups employed multiple small tests of change. Shared key interventions included refinement of a screening tool, provider education, mitigation of failures, and embedding the risk assessment task into staff workflow. The primary outcome measure, the percentage of eligible patients with a completed VTE risk assessment, was plotted on run charts. Secondary outcome measures for screened patients included the level of risk, the use of appropriate prophylaxis, and VTE events. Median weekly percentage of general surgery patients screened for VTE risk increased from 0% to 86% within 12 months, and median weekly percentage of orthopedic patients screened for VTE risk increased from 0% to 46% within 8 months. Among screened patients, the majority were at low or moderate risk for VTE and received prophylaxis in accordance with or beyond guideline recommendations. No screened patients developed VTE. Quality-improvement methods were used to implement a VTE risk screening process for postoperative patients. Using providers as screeners, as opposed to bedside nurses, led to a greater percentage of patients screened.

Improvement in patient and physician notification of cardiac rhythm device report transmissions

Background Cardiac rhythm devices (CRD) require complex management to identify potential device or patient issues. While easy to obtain, report processing is complex and time consuming. In our population, a...