Special-cause Variation Research Articles

Synergizing Safety: A Customized Approach to Curtailing Unplanned Extubations through Shared Decision-making in the NICU.

Unplanned Extubation (UE) remains an important patient safety issue in the Neonatal Intensive Care Unit. Our SMART AIM was to decrease the rate of UE by 10% from the baseline from January to December 2022 by emphasizing collaboration among healthcare professionals and through the use of shared decision-making. We established an interdisciplinary Quality Improvement team composed of nurses, respiratory therapists, and physicians (MDs). The definition of UE was standardized. UE was audited using an apparent cause analysis form to discern associated causes and pinpoint areas for improvement. Interventions were implemented in a step-by-step fashion and reviewed monthly using the model for improvement. A shared decision-making approach fostered collaborative problem-solving. Our baseline UE rate was 2.3 per 100 ventilator days. Retaping, general bedside care, and position change accounted for over 50% of the UE events in 2022. The rate of UE was reduced by 48% by the end of December 2022. We achieved special-cause variation by the end of March 2023. The sole education of medical and nursing providers about various approaches to decreasing unnecessary retaping was ineffective in reducing UE rates. Shared decision-making incorporating inputs from nurses, respiratory therapists, and MDs led to a substantial reduction in the UE rate and underscores the potential of systematic evaluation of risk factors combined with collaborative best practices.

540 Increasing Discharges Prior to 11am in Patients with Burn Injuries

Abstract Introduction This study describes a quality improvement project to increase the number of patient discharges prior to 11am in a high-volume Burn Center. A limited supply of staffed inpatient beds creates capacity constraints and can adversely affect patient flow. Discharging patients earlier has been shown to promote throughput, improving length of stay (LOS), patient satisfaction, and decrease costs. Burn patients face unique barriers to discharge compared to other inpatient groups. Methods This initiative utilized the Four Disciplines of Execution (4DX) framework, which focuses on identifying key drivers to achieve a specific, time-delimited quality improvement goal. Our primary target was increasing the number of discharges prior to 11am to 30% over the span of 6 months. Lead measures included (a) designation of a “priority discharge” patient, (b) discharge order entry prior to 0930, and (c) discharge prescriptions filled by the pharmacy the night before discharge. Baseline data was gathered from June 1st until Dec 11th 2022 and compared to the intervention period December 12th, 2022 through May 31st, 2023. Results Discharges prior to 11am increased from 11.8% to 27.1% over the course of the study. Median discharge time improved by 72 minutes. Discharge order entry time improved by 121 minutes. Potential special-cause variation was identified in January 2023. Conclusions Discharges prior to 11am were significantly increased after implementing a multidisciplinary approach between nursing, providers, case management and social work. Applicability of Research to Practice The techniques we used to increase early discharges should be easily transferable to other Burn Centers, with positive impact on LOS and amount of time patients spend boarding in the ED.

Efficacy and Impact of a Multimodal Intervention on CT Pulmonary Angiography Ordering Behavior in the Emergency Department

ObjectiveTo evaluate the efficacy of a multimodal intervention in reducing CT pulmonary angiography (CTPA) overutilization in the evaluation of suspected pulmonary embolism in the emergency department (ED). MethodsPrevious mixed-methods analysis of barriers to guideline-concordant CTPA ordering results was used to develop a provider-focused behavioral intervention consisting of a clinical decision support tool and an audit and feedback system at a multisite, tertiary academic network. The primary outcome (guideline concordance) and secondary outcomes (yield and CTPA and D-dimer order rates) were compared using a pre- and postintervention design. ED encounters for adult patients from July 5, 2017, to January 3, 2019, were included. Fisher’s exact tests and statistical process control charts were used to compare the pre- and postintervention groups for each outcome. ResultsOf the 201,912 ED patient visits evaluated, 3,587 included CTPA. Guideline concordance increased significantly after the intervention, from 66.9% to 77.5% (P < .001). CTPA order rate and D-dimer order rate also increased significantly, from 17.1 to 18.4 per 1,000 patients (P = .035) and 30.6 to 37.3 per 1,000 patients (P < .001), respectively. Percent yield showed no significant change (12.3% pre- versus 10.8% postintervention; P = .173). Statistical process control analysis showed sustained special-cause variation in the postintervention period for guideline concordance and D-dimer order rates, temporary special-cause variation for CTPA order rates, and no special-cause variation for percent yield. ConclusionOur success in increasing guideline concordance demonstrates the efficacy of a mixed-methods, human-centered approach to behavior change. Given that neither of the secondary outcomes improved, our results may demonstrate potential limitations to the guidelines directing the ordering of CTPA studies and D-dimer ordering.

Implementation of a 24-hour infection diagnosis protocol in the pediatric cardiac intensive care unit (CICU).

To reduce unnecessary antibiotic exposure in a pediatric cardiac intensive care unit (CICU). Single-center, quality improvement initiative. Monthly antibiotic utilization rates were compared between 12-month baseline and 18-month intervention periods. A 25-bed pediatric CICU. Clinically stable patients undergoing infection diagnosis were included. Patients with immunodeficiency, mechanical circulatory support, open sternum, and recent culture-positive infection were excluded. The key drivers for improvement were standardizing the infection diagnosis process, order-set creation, limitation of initial antibiotic prescription to 24 hours, discouraging indiscriminate vancomycin use, and improving bedside communication and situational awareness regarding the infection diagnosis protocol. In total, 109 patients received the protocol; antibiotics were discontinued in 24 hours in 72 cases (66%). The most common reasons for continuing antibiotics beyond 24 hours were positive culture (n = 13) and provider preference (n = 13). A statistical process control analysis showed only a trend in monthly mean antibiotic utilization rate in the intervention period compared to the baseline period: 32.6% (SD, 6.1%) antibiotic utilization rate during the intervention period versus 36.6% (SD, 5.4%) during the baseline period (mean difference, 4%; 95% CI, -0.5% to -8.5%; P = .07). However, a special-cause variation represented a 26% reduction in mean monthly vancomycin use during the intervention period. In the patients who had antibiotics discontinued at 24 hours, delayed culture positivity was rare. Implementation of a protocol limiting empiric antibiotic courses to 24 hours in clinically stable, standard-risk, pediatric CICU patients with negative cultures is feasible. This practice appears safe and may reduce harm by decreasing unnecessary antibiotic exposure.

Addressing drivers of healthcare utilization for neonatal opioid withdrawal syndrome.

ObjectiveAim to reduce healthcare utilization (HU) for infants at risk of neonatal opioid withdrawal syndrome (NOWS) by 30% in 1 year and sustain for 2 years.Study designBaseline data from three Level I & II newborn nurseries from January 2016 to June 2018 informed PDSA cycles from August 2018 to December 2021. Shewhart process control charts evaluated length of stay (LOS), pharmacologic treatment (PT) rates, direct cost (DC), process, and balancing measures for special cause variation (SCV).ResultsTwo hundred and seventeen infants showed downward SCV in LOS (12.6 to 4.4 days), PT (53% to 17%) and DC ($12593.82 to $5219.17). Onset of the COVID-19 pandemic coincided with reversible SCV. DC varied by provider specialty.ConclusionTransition from MFNASS to ESC led to decrease in healthcare utilization for infants at risk of NOWS. QI methodology identified persistent drivers of variability, including the COVID-19 pandemic and provider specialty.

A Quality Improvement Project to Reduce Time to Full Enteral Feeds for Very Low Birth Weight Neonates

Adherence to standardized feeding guidelines has been proposed as a strategy to limit morbidity in very low birth weight neonates. Fostering adherence limits the variability in medicine that affects the quality of patient care. The aim of this study was to reduce by 20% the time to full enteral feeds in very low birth weight neonates in the NICU within a 12-month period. In a level IV regional perinatal center with low utilization of its feeding protocol, a 12-month quality improvement project was conducted with a key intervention of a feeding schedule calculator based on the unit standardized feeding protocol. Through studied education and implementation cycles, these feeding schedules were used to reduce time to full enteral feeds while monitoring adverse events related to their use. During the course of this quality improvement project, our time to full enteral feeds of 160 ml/kg/day of feeds reduced from 24.7 days to 17.7 days after process changes with special-cause variation noted on control charts. We also showed a significant reduction in mean central line duration over the course of the project from a baseline of 19 days to 14.5 days. Through a key intervention of a feeding volume calculator, we were able to reduce the time to full enteral feeds in neonates without any increase in adverse events of necrotizing enterocolitis or poor weight gain.

An Opioid Sparing Anesthesia Protocol for Pediatric Open Inguinal Hernia Repair: A Quality Improvement Project.

Introduction:Using plan-do-study-act (PDSA) cycles, this quality improvement (QI) project aimed to standardize an anesthetic protocol to optimize multimodal pain management for pediatric open inguinal hernia repair (OIHR).Methods:PDSA cycle 1: in December 2017, we standardized the intraoperative OIHR anesthesia protocol by replacing transversus abdominis plane (TAP) or ilioinguinal-iliohypogastric (II) blocks and fentanyl with exclusively II blocks and fentanyl. PDSA cycle 2: in January 2019, we used an opioid sparing strategy, replacing II blocks and fentanyl with II blocks and dexmedetomidine. We used statistical process control (SPC) charts to analyze data from the medical record. Outcome measures included the percent of patients requiring rescue morphine in the postanesthesia care unit (PACU), maximum PACU pain score, PACU length of stay (LOS), and anesthesia preparation duration.Results:The team performed a total of 641 pediatric OIHRs between July 2015 and June 2021. The three groups included 203 patients in our baseline group, 127 patients in the PDSA cycle 1 group, and 311 patients in the PDSA cycle 2 group. Special cause variation (SCV) occurred for the percent of patients requiring rescue morphine, anesthesia preparation duration, and PACU LOS. The percent of patients requiring rescue morphine showed improvement. Anesthesia preparation duration improved compared to baseline. There was no SCV detected in the SPC chart for maximum PACU pain score.Conclusion:We implemented an opioid sparing anesthetic protocol for pediatric OIHR utilizing II blocks and dexmedetomidine without adversely affecting postoperative pain score or morphine rescue rate over 6 years.

Improving Compliance With Revised Newborn Hepatitis B Vaccination Policy.

In September 2017, the American Academy of Pediatrics issued guidance recommending hepatitis B vaccine be administered to well newborns with birth weight ≥2000 g within 24 hours after birth. At that time, ∼85% of well newborns were vaccinated before discharge at our center; however, only 35% were vaccinated within 24 hours after birth. Our aim was to vaccinate 70% of eligible newborns within 24 hours after birth by June 2018 while maintaining the overall rate of vaccination. A multidisciplinary improvement team analyzed existing vaccine administration processes in the well-newborn nursery. From October 2017 to January 2018, changes were made to activation of vaccine orders and to obtaining and documenting the consent processes. Vaccine administration was bundled with routine care given ≤24 hours after birth, and parent scripting was changed from offering vaccine as an option to stating it as a recommendation. From November 2016 to June 2019, we determined the overall rate and timing of vaccination using statistical process control methods. Among 10 887 eligible infants, the proportion administered hepatitis B vaccine ≤24 hours after birth increased from 35.5% to 78.8% after process changes with special-cause variation on process control charts. Proportion of infants receiving vaccine any time before discharge also increased from 86.5% to 92.3%. Specific process changes allowed our birth center to comply with the recommended timing for hepatitis B vaccination of ≤24 hours after birth among eligible newborns.

Quality Improvement of Primary Care Provider Communication on Hospital Discharge.

Effective communication between inpatient and primary care providers (PCPs) is important for safe transition of care for hospitalized patients. In 2017, communication with PCPs was prioritized for the pediatric hospital medicine division. Our primary aim was to improve documented attempted communication with PCPs within 72 hours of discharge from 41% to at least 60% by January 1, 2018, and maintain this performance through 2019. This study included all inpatient encounters discharged by a pediatric hospital medicine provider from March 2017 to April 2020. An electronic health record phrase debuted March 2017. Successful documentation was defined as any attempt to contact the PCP, regardless of whether actual communication occurred. Group and individual audit and feedback occurred in July 2017 to April 2020. Provider communication was financially incentivized in July 2018 to June 2019. An annotated P-chart for the proportion of encounters with documented PCP communication occurring within 72 hours was established. Special-cause variation was determined by using Shewhart rules. The mean proportion of encounters with documented PCP communication increased from 41% at baseline (March 2017 through July 2017) to 60% in August 2017 and 66% in December 2017. After the financial incentive was removed in July 2019, documentation decreased to 54%. Phone calls with clinic staff were the most common communication method (40% to 71%). Direct conversations with the PCP occurred rarely (0% to 3%). Even when coupled with audit and feedback with EHR interventions, our work suggests that shifting to external financial motivation may hinder sustainability of behavior change to improve attempted documented PCP communication.

Development of a clinical practice guideline for weaning and discontinuing parenteral nutrition in hospitalized children as part of a central line-associated bloodstream infection-focused quality improvement initiative.

Overprescribing of parenteral nutrition (PN) increases costs and risks to patients, including from central line-associated bloodstream infection (CLABSI). With CLABSI reduction in mind, our children's hospital began an iterative quality improvement effort to decrease PN utilization by first ensuring appropriate initiation and then defining and ensuring appropriate discontinuation. Education was launched along with audits to evaluate for appropriate PN indications. Next, a literature review was conducted to guide the development of an algorithm to appropriately wean and discontinue PN. Lastly, all PN discontinuations were audited for agreement with the new guideline. Retrospectively, monthly PN utilization index (orders per patient-day) was plotted on a statistical process control chart to assess change over time. The presence of PN as a risk factor for CLABSI events and the overall hospital CLABSI rate were trended. Mean PN utilization index fell from 0.156 (July 2018 to January 2019) to 0.12 (February 2019 to August 2020) (P < .01). For 18 months, no PN utilization index reached the baseline lower control limit of 0.144, demonstrating special-cause variation and sustained change. PN as a risk factor for hospital CLABSI cases decreased from most prevalent (49% of cases) to fifth most prevalent (29%) as the CLABSI rate trended down. Engaging frontline staff in the development of a clinical practice guideline and increased accountability to reduce potential patient harm led to a significant and sustained reduction in PN utilization, as well as decreased prevalence of PN as a risk factor in hospital CLABSI cases.

The Effect of Single-Room Care Versus Open-Bay Care on the Incidence of Bacterial Nosocomial Infections in Pre-Term Neonates: A Retrospective Cohort Study.

IntroductionNosocomial infections (NIs) are a major source of iatrogenic harm in neonatal intensive care units (NICUs). The influence of the infrastructure of NICUs on NIs is not well documented. This study aims to examine the effect of single-room units (SRU) versus open-bay units (OBU) on the incidence of NIs, including central-line-associated bloodstream infections (CLABSI), in preterm neonates.MethodsAll preterm neonates (< 32 weeks gestational age) admitted to our NICU were included. Two study periods were compared: one prior to (May 2015–May 2017) and one following (May 2017–May 2019) transition from OBU to SRU. Incidence density (number of infections per 1000 patient-days) and cumulative incidence (number of infections per 100 neonates) for NIs were calculated. CLABSIs were calculated per 1000 central-line days. U chart analysis was performed to determine special-cause variation in quarterly CLABSI and NI rates. Multivariate competing risk regression was performed to identify independent NI risk factors.ResultsOf the 712 included infants, 164 (23%) infants acquired ≥ 1 NIs. No differences were found in incidence density (13.68 vs. 12.62, p = 0.62) or cumulative incidence of NI (23.97 vs. 22.02, p = 0.59) between OBU and SRU. CLABSIs showed a similar non-significant reduction after the move (14.00 vs. 10.59, p = 0.51). U chart analysis did not identify unit transition as a potential source of special-cause variation for CLABSI and NI. Competing risks regression analysis revealed longer duration of invasive mechanical ventilation as a significant risk factor for NI (subhazards ratio: 1.03 per day on ventilation, p = 0.01).ConclusionSingle-rooms are not associated with a significant reduction in NIs in the NICU. This study therefore does not add evidence that could support the transition to SRUs if based only on a large multimodal infection control strategy. Recommendations to build SRUs would require a wider justification, also taking into account other SRU benefits.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40121-020-00380-9.

Charge Nurses Taking Charge, Challenging the Culture of Culture-Negative Sepsis, and Preventing Central-Line Infections to Reduce NICU Antibiotic Usage.

We aimed to reduce our monthly antibiotic usage rate (AUR, days of treatment per 1,000 patient-days) in the neonatal intensive care unit (NICU) from a baseline of 330 (July 2015-April 2016) to 200 by December 2018. We identified three key drivers as follows: (1) engaging NICU charge nurses, (2) challenging the culture of culture-negative sepsis, and (3) reducing central-line associated bloodstream infections (CLABSI). Our main outcome was AUR. The percentage of culture-negative sepsis that was treated with antibiotics for >48 hours and CLABSI was our process measure. We used hospital cost/duration of hospitalization and mortality as our balancing measures. After testing several plan-do-study-act (PDSA) cycles, we saw a modest reduction in AUR from 330 in the year 2016 to 297 in the year 2017. However, we did not find a special-cause variation in AUR via statistical process control (SPC) analysis (u'-chart). Thereafter, we focused our efforts to reduce CLABSI in January 2018. As a result, our mean AUR fell to 217 by December 2018. Our continued efforts resulted in a sustained reduction in AUR beyond the goal period. Importantly, cost of hospitalization and mortality did not increase during the improvement period. Our sequential quality improvement (QI) efforts led to a reduction in AUR. We implemented processes to establish a robust antibiotic stewardship program that included antibiotic time-outs led by NICU charge nurses and a focus on preventing CLABSI that were sustained beyond the QI period. · This is a quality improvement project to reduce antibiotic usage in NICU.. · Charge nurses should take charge to reduce infections in NICU.. · Central line infections should be reduced to decrease antibiotic usage..

Silk Nanoparticle Manufacture in Semi-Batch Format.

Silk nanoparticles have demonstrated utility across a range of biomedical applications, especially as drug delivery vehicles. Their fabrication by bottom-up methods such as nanoprecipitation, rather than top-down manufacture, can improve critical nanoparticle quality attributes. Here, we establish a simple semi-batch method using drop-by-drop nanoprecipitation at the lab scale that reduces special-cause variation and improves mixing efficiency. The stirring rate was an important parameter affecting nanoparticle size and yield (400 < 200 < 0 rpm), while the initial dropping height (5.5 vs 7.5 cm) directly affected nanoparticle yield. Varying the nanoparticle standing time in the mother liquor between 0 and 24 h did not significantly affect nanoparticle physicochemical properties, indicating that steric and charge stabilizations result in high-energy barriers for nanoparticle growth. Manufacture across all tested formulations achieved nanoparticles between 104 and 134 nm in size with high β-sheet content, spherical morphology, and stability in aqueous media for over 1 month at 4 °C. This semi-automated drop-by-drop, semi-batch silk desolvation offers an accessible, higher-throughput platform for standardization of parameters that are difficult to control using manual methodologies.

Improving Timeliness of Lung Cancer Diagnosis and Staging Investigations Through Implementation of Standardized Triage Pathways.

Timely care for patients with lung cancer (LC) is associated with improved clinical outcomes. In Southeastern Ontario, Canada, we identified delays in the diagnostic process for patients undergoing evaluation for suspected LC through a rapid assessment clinic. We developed improvement initiatives with an aim of reducing the time from referral to diagnosis. A Standardized Triage Process (STP) was implemented for patients referred with suspected LC, including routine interdisciplinary triage, standardized pathways with preordered staging tests, and a new Small Nodule Clinic. We retrospectively analyzed all patients referred pre-STP (January to April 2018) and prospectively for improvement (May 2018 to March 2019). Process measures included STP compliance and time to completion of staging investigations (positron emission tomography [PET] and computed tomography/magnetic resonance imaging of brain). Data are reported as means; significance was determined by special-cause variation using Statistical Process Control charts; unpaired t tests were compared between groups. We reviewed 833 referrals (207 baseline and 626 post-STP). STP compliance improved monthly to 99.4%. Post-STP, time from referral to PET decreased (from 38.5 to 15.7 days), time from referral to brain imaging decreased (from 33.4 to 13.1 days), and time from referral to diagnosis decreased (from 38.0 to 22.7 days), all demonstrating special-cause variation. Patients completing preordered staging tests experienced significantly faster care than those without preordered tests, including time to PET (23.0 v 35.9 days), computed tomography/magnetic resonance imaging of brain (16.2 v 29.9 days), and diagnosis (39.9 v 28.1 days), all P < .001. An STP significantly improved timeliness of diagnosis and staging for patients with suspected LC undergoing evaluation in a rapid assessment clinic.

The Trach Safe Initiative: A Quality Improvement Initiative to Reduce Mortality among Pediatric Tracheostomy Patients.

To describe the Trach Safe Initiative and assess its impact on unanticipated tracheostomy-related mortality in outpatient tracheostomy-dependent children (TDC). An interdisciplinary team including parents and providers designed the initiative with quality improvement methods. Three practice changes were prioritized: (1) surveillance airway endoscopy prior to hospital discharge from tracheostomy placement, (2) education for community-based nurses on TDC-focused emergency airway management, and (3) routine assessment of airway events for TDC in clinic. The primary outcome was annual unanticipated mortality after hospital discharge from tracheostomy placement before and after the initiative. In the 5 years before and after the initiative, 131 children and 155 children underwent tracheostomy placement, respectively. At the end of the study period, the institution sustained Trach Safe practices: (1) surveillance bronchoscopies increased from 104 to 429 bronchoscopies, (2) the course trained 209 community-based nurses, and (3) the survey was used in 488 home ventilator clinic visits to identify near-miss airway events. Prior to the initiative, 9 deaths were unanticipated. After Trach Safe implementation, 1 death was unanticipated. Control chart analysis demonstrates significant special-cause variation in reduced unanticipated mortality. We describe a system shift in reduced unanticipated mortality for TDC through 3 major practice changes of the Trach Safe Initiative. Death in a child with a tracheostomy tube at home may represent modifiable tracheostomy-related airway events. Using Trach Safe practices, we address multiple facets to improve safety of TDC out of the hospital.

Use of the stochastic frontier and the grey relational analysis in robust design of multi-objective problems

A generic procedure for robust design in developing products and processes, which is referred to as RDPP-SF has been proposed. The method uses the stochastic frontier model to encompass both stochastic noise (e.g. manufacturing unit-to-unit variation, and measurement errors) and special-cause variation (e.g. environment, customer use, wearing, and deterioration noises). Even then, the RDPP-SF method has fallen short of tackling robust design of multi-objective problems, and its applicability is restrained to the performance characteristics of magnitude type (i.e., “the larger is the better” or “the smaller is the better”). Aiming at these limitations, the article seeks to address the robust design of the multi-objective problems using the RDPP-SF method. This is performed by reassessing the procedural scheme of the RDPP-SF method and the statistical significance of the hypothesis test (H0: γ = 0 vs H1: γ &gt; 0) at 5% level. Depending on the statistical significance of the test (H0: γ = 0 vs H1: γ &gt; 0), the arrays of the extrinsic and/or the intrinsic noise insensitivity scores are assigned to the grey relational analysis matrix as performance measures. The most robust design solution for the multi-objective problem is then obtained by sorting the overall grey relational grades. The amended RDPP-SF method is finally demonstrated using three industrial multi-objective case studies.

Got stage fright? A fellow-led initiative to improve cancer staging documentation.

310 Background: Accurate cancer staging is essential for estimating prognosis, guiding treatment, populating cancer registries, and assessing clinical trial eligibility. Hence, timely staging of new solid oncology patients (NSOP) is an ASCO QOPI priority. At our institution, baseline review of staging documentation revealed fellows staged only 47% of NSOP, generally as unstructured free text. During the 2017-18 academic year, our structured electronic medical record (EMR) staging tool (ST) was used in only 11% of NSOP. We used Quality Improvement (QI) methods to improve structured EMR staging documentation rates of NSOP seen by fellows during the 2018-19 academic year. Methods: A fellow focus group identified poor integration of the EMR ST as root cause of our low staging rates. We set a cumulative goal of 70% structured EMR staging of NSOP within 1 month of initial visit as our target (50% increase from baseline). We incorporated the EMR ST into our visit workflow and used promotional flyers and fellow orientation to introduce our QI initiative. Staging rates were tracked by EMR-generated reports. We used periodic emails and QI-specific boards to disseminate progress among our oncology practices. Fellows were anonymously surveyed for feedback. Results: Over an 8-month period, the cumulative rate of NSOP staging by fellows increased from 47% to 70% (Table). Statistical process control analysis showed special-cause variation in July 2018 (low performance) and December 2018 (high performance). Fellow feedback highlighted the educational value of this QI intervention and identified incomplete workup as a barrier to staging. Conclusions: Our fellow-led QI intervention achieved our goal of leveraging an existing EMR tool to increase staging documentation. In addition, this QI intervention facilitated fellow education and use of data for clinical and research purposes. Future steps include ensuring sustainability and expansion into our hematology clinics. [Table: see text]

Early-Onset Sepsis Risk Calculator Integration Into an Electronic Health Record in the Nursery.

An early-onset sepsis (EOS) risk calculator tool to guide evaluation and treatment of infants at risk for sepsis has reduced antibiotic use without increased adverse outcomes. We performed an electronic health record (EHR)-driven quality improvement intervention to increase calculator use for infants admitted to a newborn nursery and reduce antibiotic treatment of infants at low risk for sepsis. This 2-phase intervention included programming (1) an EHR form containing calculator fields that were external to the infant's admission note, with nonautomatic access to the calculator, education for end-users, and reviewing risk scores in structured bedside rounds and (2) discrete data entry elements into the EHR admission form with a hyperlink to the calculator Web site. We used statistical process control to assess weekly entry of risk scores and antibiotic orders and interrupted time series to assess trend of antibiotic orders. During phase 1 (duration, 14 months), a mean 59% of infants had EOS calculator scores entered. There was wide variability around the mean, with frequent crossing of weekly means beyond the 3σ control lines, indicating special-cause variation. During phase 2 (duration, 2 years), mean frequency of EOS calculator use increased to 85% of infants, and variability around the mean was within the 3σ control lines. The frequency of antibiotic orders decreased from preintervention (7%) to the final 6 months of phase 2 (1%, P < .001). An EHR-driven quality improvement intervention increased EOS calculator use and reduced antibiotic orders, with no increase in adverse events.

Country Characteristics and Variation in Diabetes Prevalence among Asian Countries – an Ecological Study

ObjectivesTo determine the variation in diabetes prevalence across Asian countries and its relationship with the quality of health system and socioeconomic characteristics of the country.MethodologyAn ecological analysis was conducted using publicly available data from the World Bank, the World Health Organization and the International Diabetes Federation. Geographical variation in diabetes prevalence across countries was examined using control charts while the relationships between country-level determinants and diabetes prevalence were investigated using linear regression analysis.ResultsThe control chart shows special-cause variation in diabetes prevalence in 21 (58%) of the Asian countries; nine countries were below the 99.8% control limits while twelve were above it.Fifteen (42%) countries suggest common-cause variation. Three country characteristics independently associated with diabetes prevalence were hypertension prevalence (OR 0.39, 95% CI 0.22 to 0.55; p-value<0.001), obesity prevalence (OR 0.15, 95% CI 0.13 to 0.18; p-value<0.001), and quality of health care governance (OR 0.18, 95% CI 0.04 to 0.34; p-value=0.02).ConclusionsThere is a considerable geographical variation in diabetes prevalence across Asian countries. A substantial part of this variation could be explained by differences in the quality of health care governance, hypertension prevalence and obesity prevalence.

Hand hygiene compliance surveillance with time series anomaly detection

Hand hygiene is the most important intervention to reduce the risk of transmission of pathogens in health care. Assurance of effective hand hygiene improvement campaigns includes adequate data analytics for reporting compliance. Traditional analytical approaches for monitoring hand hygiene compliance suffer from several limitations, including autocorrelation. The objective of this study was to use a novel time series anomaly detection algorithm to analyze routine hand hygiene compliance data. Hand hygiene compliance data were collected daily by trained observers in a large academic medical center. Statistical process control p-charts were used as a comparison method of analysis per facility protocol. Time series anomaly detection was carried out using the seasonal and trend decomposition using LOESS (STL) algorithm. A total of 34 months of hand hygiene compliance data were analyzed. Traditional statistical process control p-charts identified over 76% of rates as special-cause variation, whereas STL identified 18% of rates as anomalous. This study supports the use of time series anomaly detection for the routine surveillance of hand hygiene compliance data. This method will facilitate specific and accurate feedback, helping to improve this critical approach for improving patient safety.