Special Cause Research Articles

Quality Initiative to Increase Delivery of Adolescent Hospital-Based Reproductive Health Care.

Hospitals are an important nontraditional setting in which to address adolescent reproductive health. However, opportunities for intervention are frequently missed, especially for boys and patients hospitalized for noningestion complaints. Our global aim was to increase delivery of reproductive health care to adolescents hospitalized through our children's hospital Pediatric Hospital Medicine service. We performed 2 quality improvement intervention cycles: (1) provider education and monthly reminder e-mails and (2) an automated electronic health record (EHR) adolescent history and physical note template with social history prompts while discontinuing reminder e-mails. The primary outcome measure was sexual history documentation (SHD). Secondary measures were sexually transmitted infection (STI) testing and contraception provision. Statistical process control charts were used to analyze effectiveness of interventions. From July 2018 through June 2019, 528 Primary Hospital Medicine encounters were included in this study and compared with published baseline data on 150 encounters. Control charts revealed a special cause increase in SHD from 60% to 82% overall, along with 37% to 73% for boys and 57% to 80% for noningestion hospitalizations. Increased SHD correlated with cycle 1 and was maintained through cycle 2. Percent STI testing significantly increased but did not shift or trend toward special cause variation. Contraception provision, length of stay, and patient relations consultations were not affected. The interventions were successful in increasing SHD, including among boys and noningestion hospitalizations. The EHR enhancement maintained these increases after reminder emails were discontinued. Future interventions should specifically address STI testing and provision of contraception.

Improving Shared Situation Awareness for High-risk Therapies in Hospitalized Children.

High-risk therapies (HRTs), including medications and medical devices, are an important driver of preventable harm in children's hospitals. To facilitate shared situation awareness (SA) and thus targeted harm prevention, we aimed to increase the percentage of electronic health record (EHR) alerts with the correct descriptor of an HRT from 11% to 100% on a high-acuity hospital unit over a 6-month period. The interdisciplinary team defined an HRT as a medication or device with a significant risk for harm that required heightened awareness. Our aim for interventions was to (1) educate staff on a new HRT algorithm; (2) develop a comprehensive table of HRTs, risks, and mitigation plans; (3) develop bedside signs for patients receiving HRTs; and (4) restructure unit huddles. Qualitative interviews with families, nurses, and medical teams were used to assess shared SA and inform the development and adaptation of interventions. The primary outcome metric was the percentage of EHR alerts for an HRT that contained a correct descriptor of the therapy for use by the care team and institutional safety leaders. The percentage of EHR alerts with a correct HRT descriptor increased from an average of 11% to 96%, with special cause variation noted on a statistical process control chart. Using qualitative interview data, we identified critical awareness gaps, including establishing a shared mental model between nursing staff and the medical team as well as engagement of families at the bedside to monitor for complications. Explicit, structured processes and huddles can increase HRT SA among the care team, patient, and family.

Eliminating Contamination in Umbilical Cord Blood Culture Sampling for Early-Onset Neonatal Sepsis.

Introduction: Despite the advantages of umbilical cord blood culture (UCBC) use for diagnosis of early onset sepsis (EOS), contamination rates have deterred neonatologists from its widespread use. We aimed to implement UCBC collection in a level III neonatal intensive care unit (NICU) and apply quality improvement (QI) methods to reduce contamination in the diagnosis of early onset sepsis.Methods: Single-center implementation study utilizing quality improvement methodology to achieve 0% contamination rate in UCBC samples using the Plan-Do-Study-Act (PDSA) model for improvement. UCBC was obtained in conjunction with peripheral blood cultures (PBC) in neonates admitted to the NICU due to maternal chorioamnionitis. Maternal and neonatal characteristics between clinical sepsis and asymptomatic groups were compared. Process, outcome, and balancing measures were monitored.Results: Eighty-two UCBC samples were collected in addition to peripheral blood culture from neonates admitted due to maternal chorioamnionitis. Ten (12%) neonates had a diagnosis of clinical sepsis. All PBCs were negative and 5 UCBCs were positive in the study period. After 2 PDSA cycles, there was special cause variation with improvement in the percent of contaminated samples from 7.3 to 0%. There was no change in antibiotic duration among asymptomatic neonates.Conclusions: Implementation of UCBC for the diagnosis of EOS in term infants is feasible and contamination can be minimized with the implementation of a core team of trained providers and a proper sterile technique without increasing antibiotic duration.

A High-Value Care Initiative to Reduce the Use of Intravenous Magnesium Sulfate Through an Electronic Indication-Based Order Set.

Intravenous (IV) magnesium sulfate (MgSO4) supplementation is common despite limited indications. Oral magnesium oxide (MgO) is an effective, lower-cost alternative. This project aimed to reduce IV MgSO4 use by 20% among the Internal Medicine (IM) service. Electronic health record (EHR) orders for MgSO4 and MgO within the IM service were replaced with an indication-based EHR order panel. The project team educated clinicians regarding indications for IV MgSO4 and relative costs. The mean of daily 2 g MgSO4 administrations per week and the mean of weekly proportion of 2 g MgSO4 administrations nine months before and after intervention were compared between IM and Emergency Medicine (EM) (control group). Statistical process control analysis was used to assess for special cause variation in daily MgSO4 per week and weekly proportion of MgSO4 administrations. The mean of daily 2 g IV MgSO4 administrations per week decreased among IM (19.3 vs. 12.1, p < 0.0001) but not EM (3.1 vs. 4.8, p < 0.0001). The mean of weekly proportions of IV MgSO4 administrations decreased among both IM (83.6% vs. 60.7%, p < 0.0001) and EM (97.0% vs. 93.1%, p = 0.0004). For IM, the change in daily MgSO4 per week and weekly proportion of MgSO4 occurred as a discrete initial decline consistent with special cause variation; for EM, changes in both measures were not consistent with special cause variation. Replacing stand-alone IV MgSO4 orders with an indication-based order panel along with clinician education reduced IV MgSO4 administrations and may offer a significant opportunity to reduce low-value care.

STEPP IN: A Multicenter Quality Improvement Collaborative Standardizing Postoperative Handoffs

To reduce care failures by 30% through implementation of standardized communication processes for postoperative handoff in NICU patients undergoing surgery over 12 months and sustained over 6 months. Nineteen Children's Hospitals Neonatal Consortium centers collaborated in a quality improvement initiative to reduce postoperative care failures in a surgical neonatal setting by decreasing respiratory care failures and all other communication failures. Evidence-based clinical practice recommendations and a collaborative framework supported local teams' implementation of standardized postoperative handoff communication. Process measures included compliance with center-defined handoff staff presence, use of center-defined handoff tool, and the proportion of handoffs with interruptions. Participant handoff satisfaction was the balancing measure. Baseline data were collected for 8 months, followed by a 12-month action phase and 7-month sustain phase. On average, 181 postoperative handoffs per month were monitored across sites, and 320 respondents per month assessed the handoff process. Communication failures specific to respiratory care decreased by 73.2% (8.2% to 4.6% and with a second special cause signal to 2.2%). All other communication care failures decreased by 49.4% (17% to 8.6%). Eighty-four percent of participants reported high satisfaction. Compliance with use of the handoff tool and required staff attendance increased whereas interruptions decreased over the project time line. Team engagement within a quality improvement framework had a positive impact on the perioperative handoff process for high-risk surgical neonates. We improved care as demonstrated by a decrease in postoperative care failures while maintaining high provider satisfaction.

TAUBAT SEBAGAI PENGHAPUS HAD ZINA MENURUT IBNU TAIMIYYAH

Scholars differ on whether the repentance of an adulterer can abrogate the punishment of the limit ?. Some scholars state that there is no fall at all, while others state that the punishment is limited to fall. In this regard, Ibn Taymiyyah's opinion is the same as the last opinion that the repentance of an adulterer can remove the demand of the limit as long as it has not been submitted to the ruler, but if it has been submitted to the ruler then the limit does not fall so it remains punished and his repentance is accepted by Allah SWT. As for the research method is qualitative, the type of literature research, research data from library materials in the form of books of jurisprudence, law, and other relevant literature then the data that has been collected, both from primary, secondary, and tertiary data, then analyzed by descriptive-analysis. The results of the study showed that according to Ibn Taymiyyah, the perpetrator of adultery who repented before being complained to the government, fell ḥadd adultery. The perpetrator does not have to admit his actions because the attitude is seen as better. As for the adulterer who repents after being complained to the government, then it does not fall ḥadd adultery. The perpetrator must still be punished, his repentance is accepted by Allah SWT., While the punishment of ḥadd as a consummation of his repentance. The argument used by Ibn Taymiyyah about the fall of ḥadd zina due to repentance refers to the provisions of the QS. al-Nisā 'verse 16, QS. al-Māidah verses 33-34, QS. Ṭāhā verses 121-122, and the hadith narrated by Abū Dawud about the punishment of Maiz. The method of istinbāṭ that he uses tends to use heroic reasoning, that is, looking at the sides and rules of language, general and special relations, cause and effect, and understanding the words of the Qur'an.

Changes in Rates and Modality of Interpreter Use for Pediatric Emergency Department Patients in the COVID-19 Era.

BackgroundAs the COVID-19 pandemic continues, health care systems around the world have changed care delivery in significant ways. Racial and ethnic disparities have emerged for COVID-19 infection rates, morbidity, and mortality. Inequities in care and underutilization of interpretation for patients who use a language other than English (LOE) for care existed prior to this era. This study sought to evaluate interpreter use in a pediatric emergency department (ED) as changes associated with COVID-19 were implemented.MethodsED records were reviewed from December 1, 2019, to July 31, 2020. Patients were classified as having LOE if they preferred a language other than English and consented to interpretation. Statistical process control was used to analyze changes in interpreter use over time, relative to the onset of COVID-19–related operational changes. Beginning March 1, 2020, in-person interpreters were no longer available and staff were encouraged to communicate from outside the patient room when possible; this change served as the exposure of interest. Interpreter use for LOE patients, overall and by triage acuity level, was the study outcome.ResultsA total of 26,787 encounters were included. The weekly mean proportion of encounters that used interpretation for patients with LOE increased from 59% to 73% after the onset of COVID-19. This increase met criteria for special cause variation. Interpretation modality changed to being mostly by phone from previously by video or in-person.ConclusionOperational changes in the ED related to COVID-19 were associated with increased interpreter use. Possible explanations include lower patient volumes or changes in model of care that encouraged interpreter use by a variety of modalities.

Using the Statistical Process Control to evaluate the learning process in Higher Education / Aplicación del Control Estadístico de Procesos para la evaluación de procesos de aprendizaje en la Educación Superior

The purpose of this paper is to propose an approach for incorporating Statistical Process Control (SPC) charting technique to monitor and continuously improve the learning processes by monitoring the satisfaction of students who used an interactive computer-based learning material, which was produced to solve problems in the Operation Management course. By applying SPC methods, the authors examine the sources of process variation (common or special causes) and analyse the ability of teaching strategies to ensure the acquisition and development of the competencies and skills demanded in current university studies. A total of 184 students participated in the learning experience. The findings show that the learning process is under control and therefore the variation of process is due to common causes. However, the Capability Analysis carried out, reveals that process has not enough capacity to achieve the specifications required by the teachers involved in the educational project. This quantitative approach will not only allow self-assessment, but can be used for comparative purposes (other teaching strategies, colleges, etc.). Thus, the control charting is a complementary assessment technique that should be included within the current Quality and Learning Assurance Systems at higher education institutions.

City and war

And two thousand years of war.The war without any special cause.“The star called the Sun” (band Kino)Throughout its history, humanity has been fighting almost constantly. Cities were designed either as fortresses capable to hold the fort, or as permeable structures, which can be quickly restored after destruction. People, whose profession is meant for war, have always been a special caste and evoked a special attitude. We are witnessing an unprecedented process: the war changes its character, becomes undeclared, invisible, hybrid. How will a city, its appearance and functions respond to the new concepts of the war? How should we preserve, study and comprehend the military experience of the previous eras, the experience of educating “people of war” embodied in architecture of military schools?Not so long ago, historic Irkutsk lost the complex of Red Barracks related to the history of Port Arthur. The place is troubled again. While there is no problem with the building of the military school (the Ministry of Defense took it under their wing and is transforming it into the Suvorov School), there is a real war for preservation of exactly the same building of the cadet corps, which is fought in courts and public structures. As usual, we don't try to take these issues off the table or to hide away from inconvenient topics, but start discussing them in a series of articles.

Prospective Study to Reduce Clostridium Difficile Infection in Patients Receiving Autologous Stem Cell Transplantation

Background:Clostridium difficile infection (CDI) is a major complication facing patients undergoing autologous stem cell transplantation (ASCT) and can be associated with increased morbidity and length of stay (LOS). Various institutional and multicenter studies have reported incidence rates in this population ranging from less than 5% to more than 10% in this high-risk population. CDIs are not only problematic for individual patient care, but CDI also negatively impact hospital resource utilization by increasing post-transplant LOS. A prospective quality improvement study was initiated at the University of Virginia (UVA) to decrease CDI.Methods:To decrease CDI rate, a multidisciplinary team comprised of oncology and infectious diseases physicians, pharmacists, and nurses was formed. The group used quality improvement principles to identify and target areas of greatest significance. Retrospective chart review was done of 65 consecutive patient ASCT encounters from June 2016 to July 2017 to establish the baseline cohort. For each of these encounters, extensive patient demographics, clinical, and inpatient event data were collected. Analysis of the data identified 17% CDI rate (n=11) in the 30-day period following ASCT. The aim of study was to decrease the CDI rate by 33%. The team used qualitative and quantitative tools to understand factors contributing to CDI, including: process map and a priority matrix categorizing potential interventions based on impact and ease of implementation. A statistical process control chart (p-chart with 3 sigma limits) depicted rates of CDI in the baseline cohort and intervention groups.Results:The baseline CDI rate was 17%. Three Plan-Do-Study-Act (PDSA) cycles of interventions were implemented; post-intervention data were collected and analyzed. From August 2017 to June 2018, the first PDSA cycle consisted of eliminating ciprofloxacin prophylaxis between T+0 and count recovery (which was standard of care) due to hypothesis that the prophylactic antibiotic itself was leading to increases in CDIs. The first PDSA cycle resulted in an increased CDI rate of 19% (n=12) and worsening of sepsis events. Ciprofloxacin prophylaxis was reinstituted. A second PDSA cycle was executed between July 2018 and January 2020 incorporating ultraviolet (UV) light equipment into existing post-discharge cleaning practices, resulting in a decreased CDI rate of 9% (n=11). A third PDSA cycle was conducted from February 2020 through current (July 2021) and added a 2-step C. diff PCR and toxin assay into testing protocols, leading to a further CDI rate decrease to 7% (n=9). P-chart depicting CDI reduction is shown in Figure 1. A significant difference in CDI incidence was found comparing patients before and after implementation of UV light cleaning practices (p<0.01). Figure 2 is a XMR-chart showing a numerical decrease of hospital LOS from 14.6 to 13.8 days after the 3 PDSA cycles, although this did not reach statistical significance (p=0.055).Conclusions:This prospective study surpassed the goal to reduce CDI by 33% by using quality improvement methods to drive a clinically significant special cause variation reduction in the 30-day CDI incidence after ASCT and a trend towards decreased LOS at UVA. This study not only improved patient care, but likely represents increased patient quality of life and cost savings. Future PDSA cycles are scheduled and may include other cancer patients beyond those receiving ASCT. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Improving Equity of Care for Patients with Limited English Proficiency Using Quality Improvement Methodology.

Introduction:Disparate clinical outcomes have been reported for patients with Limited English Proficiency (LEP) in the emergency department setting, including increased length of stay, diagnostic error rates, readmission rates, and dissatisfaction. Our emergency department had no standard processes for LEP patient identification or interpreter encounter documentation and a higher rate of 48-hour LEP return visits (RV) than English proficient patients. The aim was to eliminate gaps by increasing appropriate interpreter use and documentation (AIUD) for Spanish-speaking LEP (LEP-SS) patients from 35.7% baseline (10/17-05/18) to 100% by October 2020.Methods:LEP-SS patient data were reviewed in the electronic medical record to determine the AIUD and RV rates. Using the Model for Improvement and multiple Plan-Do-Study-Act (PDSA) cycles, a multi-disciplinary team encouraged stakeholder engagement and identified improvement opportunities, implemented an electronic tracking board LEP icon (PDSA1), standardized documentation using an LEP Form linked to the icon (PDSA2), and included color changes to the icon for team situational awareness (PDSA3).Results:The mean of LEP-SS patients with AIUD improved from 35.7% to 64.5% without significant changes in balancing measures. During the postintervention period (6/1/2018-10/31/2020), no special cause variation was noted from the baseline 48-hour emergency department RV rates for LEP patients (3.1%) or English proficient patients (2.6%).Conclusions:While the RV rate was not affected, this project is part of a multi-faceted approach aiming to positively impact this outcome measure. Significant improvements in AIUD were achieved without affecting balancing measures.

Meet the Team: A Quality Improvement Initiative to Improve Family Knowledge of Their Care Team.

Hospitalized families often have poor knowledge of care team members, which can negatively impact communication. Local baseline data revealed that few families had knowledge of team members. Our primary aim was to increase the percentage of families able to identify a member of their team to 75% over 1 year and sustain use of our improvement tools over 6 months. We conducted a quality improvement initiative at a tertiary pediatric academic center. Plan-do-study-act cycles were used to implement and test 3 main interventions: (1) a "Meet the Team" form (MTTF), a visual handout outlining care team members; (2) verbal introductions at the start of patient- and family-centered rounds (PFCR); and (3) data sharing regarding family feedback about tool use. The outcome measure was the percentage of families successfully identifying team members. Process measures were the percentage of families who received the MTTF and the percentage of PFCR that included verbal introductions. Balancing measures included rounds length. We conducted structured interviews of 141 families and observed 11 597 PFCR events. There was an increase in the percentage of families who could identify a team member from 10% to 84%. The percentage of PFCR events that included verbal introductions revealed special cause variation, increasing from 40% to 80%. Rounds length held steady at ∼11 minutes per patient. Implementing paired interventions of MTTF distribution and verbal team introductions was associated with increased family knowledge of team members and no change in rounds length.

Reducing Benzodiazepine Exposure by Instituting a Guideline for Dexmedetomidine Usage in the NICU.

Midazolam is a benzodiazepine sedative used in NICUs. Because benzodiazepine's effects include respiratory depression and potential detrimental developmental effects, minimizing exposure could benefit neonates. Dexmedetomidine is routinely used for sedation in older pediatric populations. We implemented a quality improvement initiative with the aim of decreasing midazolam infusions by 20% through use of dexmedetomidine. A multidisciplinary committee created a sedation guideline that included standardized dexmedetomidine dosing escalation and weaning. Baseline data collection occurred from January 2015 to February 2018, with intervention from March 2018 to December 2019. Percentage of sedation episodes with dexmedetomidine initiated was followed as a process measure. Outcomes measures were percentage of eligible infants receiving midazolam infusions and midazolam-free days per sedation episode. Bradycardia with dexmedetomidine, unplanned extubation rates, and morphine dosage were monitored as balancing measures. Our study included 434 episodes of sedation in 386 patients. Dexmedetomidine initiation increased from 18% to 49%. The intervention was associated with a significant reduction in midazolam initiation by 30%, from 95% to 65%, with special cause variation on statistical process control chart analysis. Midazolam-free days per sedation episode increased from 0.3 to 2.2 days, and patients receiving dexmedetomidine had lower midazolam doses (1.3 mg/kg per day versus 2.2 mg/kg per day, P = 5.97 × 10-04). Bradycardia requiring discontinuation of dexmedetomidine, unplanned extubation rates, and morphine doses were unchanged. Implementation of a quality improvement initiative was successful in reducing the percentage of patients receiving midazolam infusions and increased midazolam-free days per sedation episode, revealing an overall reduction in benzodiazepine exposure while maintaining adequate sedation.

Effects of an external ventricular drain alert protocol on venticulostomy placement time in the emergency department.

Timely ventriculostomy placement is critical in the management of neurosurgical emergencies. Prompt external ventricular drain (EVD) placement has been shown to improve long-term patient outcomes and decrease the length of ICU and hospital stays. Successful and efficient EVD placement requires seamless coordination among multiple healthcare teams. In this study, the authors sought to identify factors favoring delayed ventriculostomy via a quality improvement initiative and to implement changes to expedite EVD placement. Through process mapping, root cause analysis, and interviews with staff, the authors identified the lack of a standardized mechanism for alerting necessary healthcare teams as a major contributor to delays in EVD placement. In December 2019, an EVD alert system was developed to automatically initiate an EVD placement protocol and to alert the neurosurgery department, pharmacy, core laboratory, and nursing staff to prepare for EVD placement. The time to EVD placement was tracked prospectively using time stamps in the electronic medical record. A total of 20 patients who underwent EVD placement between December 2019 and April 2021, during the EVD alert protocol initiation, and 18 preprotocol control patients (January 2018 to December 2019) met study inclusion criteria and were included in the analysis. The mean time to EVD placement in the control group was 71.88 minutes compared with 50.3 minutes in the EVD alert group (two-tailed t-test, p = 0.025). The median time to EVD placement was 64 minutes in the control group compared with 52 minutes in the EVD alert group (rank-sum test, p = 0.0184). All patients from each cohort exhibited behavior typical of stable processes, with no violation of Shewhart rules and no special cause variations on statistical process control charts. A quality improvement framework helped identify sources of delays to EVD placement in the emergency department. An automated EVD alert system was a simple intervention that significantly reduced the time to EVD placement in the emergency department and can be easily implemented at other institutions to improve patient care.

Systems engineering analysis of diagnostic referral closed-loop processes

BackgroundClosing loops to complete diagnostic referrals remains a significant patient safety problem in most health systems, with 65%–73% failure rates and significant delays common despite years of improvement efforts, suggesting...

Reducing Delays in a Pediatric Procedural Unit With Ultrasound-Guided Intravenous Line Insertion.

Delay in vascular access is a leading cause of procedure delay in our pediatric procedure and infusion center. Use of ultrasound decreases time to peripheral intravenous catheter (PIV) insertion; however, ultrasound availability in our center was limited to an external venous access team (VAT). The objective of this project was to reduce PIV-related delays by 25%. Stakeholders convened and theorized that creating a unit-based nurse team specializing in ultrasound-guided peripheral intravenous catheter (USgPIV) insertion would facilitate faster access and a reduction in delayed procedures. An initial plan-do-study-act cycle was performed, training 2 nurses in USgPIV placement. Subsequent cycles were focused on increasing availability of USgPIV-trained nurses. The outcome measure was the rate of procedures delayed by PIV placement, analyzed on a statistical process control U-chart. The process measure was the percentage of USgPIV placements requiring consultations to the VAT, analyzed on a statistical process control P-chart. The balancing measure was the success rate per method of insertion. Comparisons of success rates were conducted by using a χ2 test and Fisher's exact test. The mean rate of procedures delayed because of vascular access fell by special cause variation from 10.8% to 6.4%. The mean VAT consultation rate fell from 86.4% to 32.0%. The VAT had higher rates of overall success (100% vs 87%; P = .01) and first-attempt success (93% vs 77%; P = .03) compared with unit nurse USgPIV placement. Unit-based USgPIV placement in a pediatric procedural center was successfully implemented, with a significant decline in procedures delayed by PIV access.

Ethnic Disparities in the Care of Opioid-Exposed Newborns in Colorado Birthing Hospitals.

Investigate disparities by Hispanic ethnicity in the care of opioid exposed newborns (OENs) in Colorado birthing hospitals within a statewide quality improvement collaborative. This study is a secondary analysis of a quality improvement initiative aimed at standardizing hospital-based care of OENs through implementation of the Eat, Sleep, Console Model. We used statistical process control charts to compare time to special cause variation by Hispanic ethnicity for outcomes including infant length of stay, use of pharmacologic therapy, and breastfeeding eligibility and receipt. Only hospitals that delivered both Hispanic and non-Hispanic OENs during the study period were included, documented maternal ethnicity was required for inclusion. We investigated hospital variation in these outcomes among 4 hospitals that cared for Hispanic OENs for most of the study period. We analyzed 799 mother-OEN dyads, 241 Hispanic and 558 non-Hispanic. Both Hispanic and non-Hispanic OENs experienced decreases in length of stay overall and among those who received postnatal opioids, although Hispanic OENs achieved these decreases 3 annual quarters after non-Hispanic OENs. Pharmacologic therapy use decreased by 55% for Hispanic OENs and 60% for non-Hispanic OENs. Hispanic OENs experienced a 1-quarter delay for this decrease. Although this quality improvement initiative resulted in positive outcomes for Hispanic and non-Hispanic OENs, improvement was delayed among Hispanic infants, indicating a need to explore and address care practices of Hispanic mothers and infants affected by opioid use disorders.

Who Speaks First? Promoting Senior Resident Autonomy on Family-Centered Rounds: A QI Initiative.

Graduated autonomy is fundamental as trainees 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 health care team, which is an entrustable professional activity for all pediatric residents. At our institution, senior residents (SRs) at baseline performed at a novice level on the basis of the Senior Resident Empowerment Actions 21 (SREA-21), a validated tool that is used to assess SR autonomy during FCR. Our objective for this study was to increase the median percentage of SREA-21 domains in which SRs perform at a competent level from 38% to 75% within 6 months. Researchers observed 4 FCR encounters weekly and calculated SREA-21 scores after 2 weeks on the basis of actions promoting SR autonomy performed by the SR-hospitalist dyad. The primary outcome measure was the percentage of SREA-21 domains in which the SR achieved a competent score on the SREA-21. We used the model for improvement to identify key drivers and test proposed interventions using serial plan-do-study-act cycles. Interventions included creation of unified inpatient SR expectations, introduction of a SR-hospitalist pre-FCR huddle, auditing of FCR interruptions, and direct feedback to the SR-hospitalist dyad after FCR. Run charts were used to track SR and hospitalist scores on the SREA-21. After multiple plan-do-study-act cycles, there was special cause improvement with a desirable shift upward in the centerline to 100%, which correlated with the project's interventions and surpassed our goal. Using quality improvement methodology, we improved SR autonomy during FCR, as measured by the SREA-21.

Strategies to Optimize Nephrolithiasis Emergency Care (STONE): Prospective Evaluation of an Emergency Department Clinical Pathway

To convene a multi-disciplinary panel to develop a pathway for Emergency Department (ED) patients with suspected nephrolithiasis and then prospectively evaluate its effect on patient care. The STONE Pathway was developed and linked to order sets within our Electronic Health Record in April 2019. Records were prospectively reviewed for ED patients who underwent ultrasound or Computerized Tomography (CT) to evaluate suspected nephrolithiasis between January 2019 and August 2019 within our institution. The primary outcome measure was the proportion of patients whose ED CT was low dose (<4 mSv). Secondary outcome measures included receipt of pathway-concordant pain medications and urine strainers. Order set utilization was evaluated as a process measure. Balance measures assessed included repeat ED visits, imaging, hospitalizations, and a urologic clinic visit or surgery within 30 days of discharge. 441 patients underwent ED imaging, of whom 261 (59%) were evaluated for suspected nephrolithiasis. The STONE Pathway was used in 50 (30%) eligible patients. Patients treated with the Pathway were more likely to undergo low-dose CTs (49% vs 23%, P <.001), and receive guideline-concordant pain medications such as NSAIDs (90% vs 62%, P <.001), and were less likely to return to the ED within 30 days (13% vs 2%, P = .01). These measures demonstrated special cause variation following Pathway release. Clinical pathways increase compliance with evidence-based practices for pain control and imaging in nephrolithiasis emergency care and may improve the delivery of value-based care.

Sand Casting Implementation of Two-Dimensional Digital Code Direct-Part-Marking Using Additively Manufactured Tags

Statistical quality control is used in foundries to identify special cause defects and root causes by correlating process input variations with casting defects. A difficulty exists in associating process data collected with individual cast parts as the parts are processed through the foundry and then out into the supply chain. Typically, alphanumeric labels for marking castings and manual identification of the castings with route-paper based tracing approaches have been used. Such manual-based systems make root cause analysis of quality defect issues tedious. This study presents the development of a semi-automated approach using 3D printed sand mold inserts shaped as 2D matrix codes which thereby permit directly cast identification code into the parts. This enables automated part tracking at the very beginning of the casting process including mold making. Automated scan based tracking of parts through a foundry and subsequent supply chain allows for statistical process data collected to also be associated with each part processed with unique identification, building upon the part history and pedigree.