Standardized Care Process Research Articles

Evaluation of a Computer-Aided Clinical Decision Support System for Point-of-Care Use in Low-Resource Primary Care Settings: Acceptability Evaluation Study.

A clinical decision support system (CDSS) based on the logic and philosophy of clinical pathways is critical for managing the quality of health care and for standardizing care processes. Using such a system at a point-of-care setting is becoming more frequent these days. However, in a low-resource setting (LRS), such systems are frequently overlooked. The purpose of the study was to evaluate the user acceptance of a CDSS in LRSs. The CDSS evaluation was carried out at the Jimma Health Center and the Jimma Higher Two Health Center, Jimma, Ethiopia. The evaluation was based on 22 parameters organized into 6 categories: ease of use, system quality, information quality, decision changes, process changes, and user acceptance. A Mann-Whitney U test was used to investigate whether the difference between the 2 health centers was significant (2-tailed, 95% CI; α=.05). Pearson correlation and partial least squares structural equation modeling (PLS-SEM) was used to identify the relationship and factors influencing the overall acceptance of the CDSS in an LRS. On the basis of 116 antenatal care, pregnant patient care, and postnatal care cases, 73 CDSS evaluation responses were recorded. We found that the 2 health centers did not differ significantly on 16 evaluation parameters. We did, however, detect a statistically significant difference in 6 parameters (P<.05). PLS-SEM results showed that the coefficient of determination, R2, of perceived user acceptance was 0.703. More precisely, the perceived ease of use (β=.015, P=.91) and information quality (β=.149, P=.25) had no positive effect on CDSS acceptance but, rather, on the system quality and perceived benefits of the CDSS, with P<.05 and β=.321 and β=.486, respectively. Furthermore, the perceived ease of use was influenced by information quality and system quality, with an R2 value of 0.479, indicating that the influence of information quality on the ease of use is significant but the influence of system quality on the ease of use is not, with β=.678 (P<.05) and β=.021(P=.89), respectively. Moreover, the influence of decision changes (β=.374, P<.05) and process changes (β=.749, P<.05) both was significant on perceived benefits (R2=0.983). This study concludes that users are more likely to accept and use a CDSS at the point of care when it is easy to grasp the perceived benefits and system quality in terms of health care professionals' needs. We believe that the CDSS acceptance model developed in this study reveals specific factors and variables that constitute a step toward the effective adoption and deployment of a CDSS in LRSs.

Smarter smiles: The role of AI in modern periodontics

The profound impact of unmet oral health needs on systemic health remains a significant concern, particularly among vulnerable populations. Disparities such as low health literacy and limited access to care contribute to higher rates of oral diseases and poorer health outcomes. These disparities can exacerbate chronic systemic conditions like diabetes, cancer, and cardiovascular disease. Additionally, the absence of standardized practices among dental clinicians regarding the diagnosis, treatment, and management of periodontitis leads to inconsistencies in care utilization. Therefore, prioritizing approaches to care that enhance patient engagement, improve health literacy, and promote standardized care is imperative. Dentistry has historically emphasized delivering comprehensive care by embracing emerging technology and scientific evidence. The integration of AI holds promises in empowering patients through standardized care processes and enhanced access to health information.

Repairing disrupted care processes as sources of stability, learning and change in a Finnish hospital: An activity-theoretical study.

In high-income countries, it is estimated that one in every 10 patients is harmed while receiving hospital care; 50% of these are preventable. The aim of this study was to deepen our understanding of disruptions of care processes and how the repairing of disruptions can be sources of stability, learning and change in complex health care settings. The organisational interactions associated with disruptions in the standard care processes of 15 surgical patients were followed in a public sector hospital in Finland. The patients and medical professionals were interviewed in situ during the observation of the care processes. An activity-theoretically informed methodological framework was used to identify and analyse disruptions and the associated repair efforts and repair solutions. Disruptions were frequent and found in all 15 care processes. These related to (1) the patient's worsening physiological state, (2) the equipment used in surgical care, (3) the information flow, (4) delays in the care process and (5) the unclear division of labour within the team. The actors carried out three types of repair efforts (technical, cognitive-emotional and extended collaborative) to overcome the disrupted processes, which usually led to repair solutions that restored stability. The different repair efforts required different kinds of collaboration and learning. Extended collaborative repair was most demanding, providing challenges and opportunities for practice change and expansive learning.

The Translational Work of Interoperability: Digital Health and Data Enabling Integrated Care Special Interest Group Workshop

Introduction: Members of the Digital Health and Data Enabling Integrated Care Special Interest Group came together at ICIC22 to discuss priority issues. One critical international struggle is the challenge of interoperability to support information and data sharing and communication as cornerstones of integrated health and social care systems. &#x0D; Aims and Objectives: The emphasis of SIG work in 2023-2024 will be to deeply engage with the critical challenge of interoperability. From an integrated care perspective what is required is understanding the translational work needed to make the sharing of information and data useful and meaningful to those who need it. In this meeting, delegates will work together to unpack the translation problem of interoperability in terms of translating information between stakeholders (e.g. between patients, families and their care teams), between disciplines (e.g. between different clinicians and providers), and between sectors (e.g. between health and social care sectors), with the aim to share current work and identify knowledge and practice gaps that we can address as a SIG for the next year. &#x0D; Audience: All existing and newly interested members of the SIG are welcome to join for this discussion. Our membership consists of patients and family caregivers, researchers, frontline providers, managers, system leaders and decision-makers, policy makers, informaticians, and industry partners. &#x0D; Structure and engagement: This session will use the hour largely to engage with delegates to meet session objectives. To set up the discussion we will begin with a short introduction from SIG leads (C. Steele Gray, L. Lewis, I. Meyer) followed by SIG member (J. Piera-Jiménez) to present the case example of Catalonia’s Digital Health Strategy and their efforts towards improved interoperability that addresses limitations of current information systems, reduces loss of meaning in information exchange, and advances standardization of care processes. Delegates will next break into small groups (5-6 per table with one facilitator), to discuss what translation needs would be required to implement an interoperable system (like Catalonia’s), and how those needs could be met (e.g. consensus group discussions, technological solutions like Artificial Intelligence and Natural Language Processing). Facilitators will use a live Google Jamboard to record ideas shared by the individual groups. &#x0D; Structure: 1) Introduction (10 minutes); 2) Catalonia Example (10 minutes); 3) Table Discussions (25 minutes); 4) Identification of current work and gaps (15 minutes)&#x0D; Summarizing take home messages: In the final 15 minutes of the session the full group will reconvene to review the live Google Jamboards and engage in priority setting of translation needs. Delegates will be asked to identify where they may already be working on identified needs, and where current gaps might exist. This exercise will allow us to bring together sub-groups to tackle translation problems who would then engage in webinars and/or discussion groups between ICIC23 and ICIC24 with the aim to generate a white paper, report, or journal special issue that would bring together current and new knowledge generated by SIG members of the translational work of interoperability.

Determining essential elements and functionalities for a patient record system in community pharmacy

BackgroundAs community-based pharmacy continues to evolve from a focus on product distribution to a practice focused on patient care, a key requirement is for pharmacists to document their patient care activities. Some community-based pharmacies are working to routinely use the Pharmacist eCare Plan standard in documenting their new care activities. ObjectivesWith the need for a robust patient record in community-based pharmacies, the purpose of this study was to identify key elements and functionalities for a community-based pharmacy patient record. MethodsAn expert panel of 26 individuals participated in 3 rounds of surveys using an online Delphi method to develop consensus about the key data elements and functionalities for a pharmacy patient record system. ResultsA total of 46 items reached consensus: 16 as essential elements for a longitudinal pharmacy patient record, 7 as essential elements for a patient encounter, and 23 functionalities for a pharmacy patient record system. A rubric was developed to assess community-based pharmacy patient record systems. ConclusionThe functionalities can support pharmacists in fully adopting a standard care process and providing and documenting patient care, while coordinating and improving communication with patients, providers, and payers. Pharmacists are encouraged to use the rubric in evaluating software for their practices.

Improving Medication Safety in Cancer Services for Ethnic Minority Consumers: Protocol for a Pilot Feasibility and Acceptability Study of a Co-Designed Consumer Engagement Intervention.

People from ethnic minorities are often exposed to unsafe care contributing to poorer health care outcomes. Medication safety is a high-risk area requiring intervention to improve care outcomes. Using an adapted, experience-based co-design process with cancer service staff and patients from ethnic minorities, a medication communication tool was created: Making it Meaningful (MiM). We aim to test whether the MiM tool is feasible and acceptable for use with ethnic minority consumers in cancer services in Australia. A single site, controlled before and after this pilot study, will be used. Patients from Mandarin- and Russian-speaking backgrounds are eligible for inclusion. In total, 40 patients from these cultural backgrounds will be recruited and stratified by language to the intervention and control groups, with 20 participants in the intervention and 20 in the control group. Further, 4 health practitioners will be recruited and trained to use the MiM. Clinicians providing care for patients in the intervention will use the MiM during their usual appointment while providing medication communication using standard care processes for the control group. Telephone surveys will be conducted with participants at 3 time points, T1 before the intervention, T2 1 week post intervention, and T3 1 month post intervention, to assess knowledge and self-efficacy in medication management, perceived usability, and acceptability of the MiM. Qualitative interviews with clinicians who have used the MiM will be conducted 1 month postintervention to explore their perceptions of MiM feasibility and acceptability. Ethical approval for this research has been provided by the South Eastern Sydney Area Health Human Research Ethics Committee (HRECXXX). Bilingual field-workers, 1 Mandarin-speaking and 1 Russian-speaking, are contacting eligible patients to enroll. It is anticipated that recruitment will be completed by October 2023, with data collection completed by December 2023. Using experience-based co-design, we identified communication about medication, particularly between appointments, as a key issue impacting the safety of care for patients from ethnic minorities accessing cancer services. Increasing consumer engagement in medication management was identified as a strategy to reduce medication safety problems in cancer care; the MiM strategy was developed to address this issue. It is anticipated that by using the MiM, patient knowledge about prescribed medications and confidence in medication management will increase. Evidence from the pilot study will be used to inform a full-scale trial of the MiM tool with a range of ethnic minority communities accessing cancer services. A full-scale trial will seek to determine whether the MiM intervention is effective in knowledge and confidence about medication management, but also whether this improves patient outcomes in cancer care. Australian New Zealand Clinical Trials ACTRN12622001260718p; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=384658&isReview=true. DERR1-10.2196/49902.

Race-Based Differences in ST-Segment-Elevation Myocardial Infarction Process Metrics and Mortality From 2015 Through 2021: An Analysis of 178 062 Patients From the American Heart Association Get With The Guidelines-Coronary Artery Disease Registry.

Systems of care have been developed across the United States to standardize care processes and improve outcomes in patients with ST-segment-elevation myocardial infarction (STEMI). The effect of contemporary STEMI systems of care on racial and ethnic disparities in achievement of time-to-treatment goals and mortality in STEMI is uncertain. We analyzed 178 062 patients with STEMI (52 293 women and 125 769 men) enrolled in the American Heart Association Get With The Guidelines-Coronary Artery Disease registry between January 1, 2015, and December 31, 2021. Patients were stratified into and outcomes compared among 3 racial and ethnic groups: non-Hispanic White, Hispanic White, and Black. The primary outcomes were the proportions of patients achieving the following STEMI process metrics: prehospital ECG obtained by emergency medical services; hospital arrival to ECG obtained within 10 minutes for patients not transported by emergency medical services; arrival-to-percutaneous coronary intervention time within 90 minutes; and first medical contact-to-device time within 90 minutes. A secondary outcome was in-hospital mortality. Analyses were performed separately in women and men, and all outcomes were adjusted for age, comorbidities, acuity of presentation, insurance status, and socioeconomic status measured by social vulnerability index based on patients' county of residence. Compared with non-Hispanic White patients with STEMI, Hispanic White patients and Black patients had lower odds of receiving a prehospital ECG and achieving targets for door-to-ECG, door-to-device, and first medical contact-to-device times. These racial disparities in treatment goals were observed in both women and men, and persisted in most cases after multivariable adjustment. Compared with non-Hispanic White women, Hispanic White women had higher adjusted in-hospital mortality (odds ratio, 1.39 [95% CI, 1.12-1.72]), whereas Black women did not (odds ratio, 0.88 [95% CI, 0.74-1.03]). Compared with non-Hispanic White men, adjusted in-hospital mortality was similar in Hispanic White men (odds ratio, 0.99 [95% CI, 0.82-1.18]) and Black men (odds ratio, 0.96 [95% CI, 0.85-1.09]). Race- or ethnicity-based disparities persist in STEMI process metrics in both women and men, and mortality differences are observed in Hispanic White compared with non-Hispanic White women. Further research is essential to evolve systems of care to mitigate racial differences in STEMI outcomes.

PENERAPAN PROSES ASUHAN GIZI TERSTANDAR TERHADAP ASUPAN ZAT GIZI MAKRO DAN LAMA HARI RAWAT PADA PASIEN GERIATRI DI RUMAH SAKIT

ABSTRACT Geriatric patients are elderly patients with multi-diseases who are prone to malnutrition. One of the efforts to improve macronutrient intake and the length of stay for geriatric patients who are hospitalized in a hospital is the standardized nutrition care process (NCP). Objective: To determine differences in macronutrient intake and length of stay between geriatric patients with standardized NCP and geriatric patients without standardized NCP in the hospital. Method: The type of research that has been done is a quasi-experimental with post test only control group design. The subjects who had fulfilled the inclusion criteria were 36 people then divide into 2 groups, namely the standardized NCP group at RSUD Klungkung and non-standardized NCP group at RSUD Bangli. Data collection on macronutrient intake was carried out by the food weighing method, and data on length of stay was collected by medical record observation. Hypothesis testing is done by unpaired t-test and Mann-Whitney. Results: The average age of the study subjects was 70,08 years and most were in 61-69 years. Assessment of nutritional status based on MNA was obtained at 44,4% of the subjects were malnourished. The results of the unpaired t-test produced a p-value of 0,001 (p0,05) which showed that the average macronutrient intake in the standardized NCP group was significantly higher than the non-standardized NCP group. The average length of stay in the standardized NCP group (7,33 days) was shorter when compared to the non-standardized NCP (10 days). Mann-Whitney’s test produced a p-value of 0,023 (p0,05) showed that there were significant differences in the average length of stay of the two groups. Conclusions and Suggestions. The application of standardized NCP has an effect on improving macronutrient intake and length of stay in geriatric patients, so nutritionists are advised to apply the standardized NCP to geriatric patients to improve their nutritional status. Keyword: the standardized nutrition care process, macronutrient intake, length of stay

Evaluating a clinical decision support point of care instrument in low resource setting

BackgroundClinical pathways are one of the main tools to manage the health care’s quality and concerned with the standardization of care processes. They have been used to help frontline healthcare workers by presenting summarized evidence and generating clinical workflows involving a series of tasks performed by various people within and between work environments to deliver care. Integrating clinical pathways into Clinical Decision Support Systems (CDSSs) is a common practice today. However, in a low-resource setting (LRS), this kind of decision support systems is often not readily accessible or even not available. To fill this gap, we developed a computer aided CDSS that swiftly identifies which cases require a referral and which ones may be managed locally. The computer aided CDSS is designed primarily for use in primary care settings for maternal and childcare services, namely for pregnant patients, antenatal and postnatal care. The purpose of this paper is to assess the user acceptance of the computer aided CDSS at the point of care in LRSs.MethodsFor evaluation, we used a total of 22 parameters structured in to six major categories, namely “ease of use, system quality, information quality, decision changes, process changes, and user acceptance.” Based on these parameters, the caregivers from Jimma Health Center's Maternal and Child Health Service Unit evaluated the acceptability of a computer aided CDSS. The respondents were asked to express their level of agreement using 22 parameters in a think-aloud approach. The evaluation was conducted in the caregiver's spare-time after the clinical decision. It was based on eighteen cases over the course of two days. The respondents were then asked to score their level of agreement with some statements on a five-point scale: strongly disagree, disagree, neutral, agree, and strongly agree.ResultsThe CDSS received a favorable agreement score in all six categories by obtaining primarily strongly agree and agree responses. In contrast, a follow-up interview revealed a variety of reasons for disagreement based on the neutral, disagree, and strongly disagree responses.ConclusionsThough the study had a positive outcome, it was limited to the Jimma Health Center Maternal and Childcare Unit, and hence a wider scale evaluation and longitudinal measurements, including computer aided CDSS usage frequency, speed of operation and impact on intervention time are needed.

Healthcare providers’ knowledge, attitude, and practice on quality of nutrition care in hospitals from a developing country: a multicenter experience

BackgroundDespite the fact that malnutrition can affect both recovery and outcome in acute care patients, little is known about malnutrition in Palestine, and even less is known about the assessment of malnutrition knowledge, attitudes, and practices (M-KAP) toward healthcare providers and nutrition care quality measures in hospitalized patients. Therefore, this study aimed to evaluate the M-KAP of physicians and nurses in routine clinical care and determine the influencing factors.MethodsFrom April 1 to June 31, 2019, cross-sectional research was performed at governmental (n = 5) and non-governmental (n = 4) hospitals in the North West Bank of Palestine. Data were collected using a structured self-administered questionnaire from physicians and nurses to collect information on knowledge, attitude, and practices related to malnutrition and nutrition care, alongside sociodemographic characteristics.ResultsA total of 405 physicians and nurses were participated in the study. Only 56% of participants strongly agreed that nutrition was important, only 27% strongly agreed that there should be nutrition screening, only 25% felt food helped with recovery, and around 12% felt nutrition as part of their job. Approximately 70% of participants said they should refer to a dietitian, but only 23% knew how and only 13% knew when. The median knowledge/attitude score was 71, with an IQR ranging from 65.00 to 75.00, and the median practice score was 15.00 with an IQR of 13.00–18.00. The mean knowledge attitude practice score was 85.62 out of 128 with SD (9.50). Respondents who worked in non-governmental hospitals showed higher practice scores (p < 0.05), while staff nurses and ICU workers showed the highest practice score (p < 0.001). Respondents with younger age categories, working in non-governmental hospitals in the ICU as practical and staff nurses, showed the highest KAP score (p < 0.05). Significance positive correlations were found between respondents’ knowledge/attitude and practice scores regarding the quality of nutrition care in hospitals (r = 0.384, p value < 0.05). In addition, the result also revealed that almost half of respondents believed that the most important barriers to inadequate intake of food at the bedside are related to food appearance, taste, and aroma of meals served (58.0%).ConclusionsThe research revealed that inadequate knowledge was perceived as a barrier to effective nutrition care to the patient. Many beliefs and attitudes do not always translate into practice. Although the M-KAP of physicians and nurses is lower than in some other countries/studies, it highlights a strong need for more nutrition professionals in the hospital and increasing nutrition education to improve nutrition care in hospitals in Palestine. Furthermore, establishing a nutrition task force in hospitals elaborated by dietitians as the unique nutrition care provider will assure to implementation of a standardized nutrition care process.

Effective and Efficient Delivery of Genome-Based Testing-What Conditions Are Necessary for Health System Readiness?

Health systems internationally must prepare for a future of genetic/genomic testing to inform healthcare decision-making while creating research opportunities. High functioning testing services will require additional considerations and health system conditions beyond traditional diagnostic testing. Based on a literature review of good practices, key informant interviews, and expert discussion, this article attempts to synthesize what conditions are necessary, and what good practice may look like. It is intended to aid policymakers and others designing future systems of genome-based care and care prevention. These conditions include creating communities of practice and healthcare system networks; resource planning; across-region informatics; having a clear entry/exit point for innovation; evaluative function(s); concentrated or coordinated service models; mechanisms for awareness and care navigation; integrating innovation and healthcare delivery functions; and revisiting approaches to financing, education and training, regulation, and data privacy and security. The list of conditions we propose was developed with an emphasis on describing conditions that would be applicable to any healthcare system, regardless of capacity, organizational structure, financing, population characteristics, standardization of care processes, or underlying culture.

A quasi-experimental study provides evidence that registered dietitian nutritionist care is aligned with the Academy of Nutrition and Dietetics evidence-based nutrition practice guidelines for type 1 and 2 diabetes.

BackgroundOne previous study examined implementation of evidence-based nutrition practice guidelines (EBNPG).ObjectivesTo describe alignment of registered dietitian nutritionists' (RDNs) documented nutrition care with the Academy of Nutrition and Dietetics' EBNPG for Type 1 and Type 2 diabetes and examine impact of a midpoint training on care alignment with the guideline.MethodsIn this 2-year, quasi-experimental study, 19 RDNs providing outpatient medical nutrition therapy to adults with diabetes (n = 562) documented 787 initial and follow-up encounters. At study midpoint, RDNs received a guideline content training. A validated, automated tool was used to match standardized nutrition care process terminology (NCPT) in the documentation to NCPT expected to represent guideline implementation. A congruence score ranging from 0 (recommendation not identified) to 4 (recommendation fully implemented) was generated based on matching. Multilevel linear regression was used to examine pre-to-post training changes in congruence scores.ResultsMost patients (~75%) had only one documented RDN encounter. At least one guideline recommendation was fully implemented in 67% of encounters. The recommendations “individualize macronutrient composition” and “education on glucose monitoring” (partially or fully implemented in 85 and 79% of encounters, respectively) were most frequently implemented. The mean encounter congruence scores were not different from pre-to-post guideline training (n = 19 RDNs, 519 encounters pre-training; n = 14 RDNs, 204 encounters post-training; β = −0.06, SE = 0.04; 95% CI: −0.14, 0.03).ConclusionsMost RDN encounters had documented evidence that at least one recommendation from the EBNPG was implemented. The most frequently implemented recommendations were related to improving glycemic control. A midpoint guideline training had no impact on alignment of care with the guideline.

A Breakthrough Improvement Collaborative Significantly Reduces Hospital Stay After Elective Colectomy for Cancer Across a Healthcare System.

Objective:This multicenter study aimed to assess (1) the effect of an improvement collaborative on enhanced recovery after surgery (ERAS) protocol adherence after elective colectomy and (2) the association between adherence and patient outcomes.Background:ERAS pathways provide a framework to standardize care processes and improve postoperative outcomes in patients after colon surgery. Despite growing evidence of its effectiveness, adherence to these guidelines remains a challenge.Methods:This prospective, multicenter collaborative was initiated throughout 11 hospitals in Flanders, Belgium. A structured audit tool was used to study patient outcomes and adherence to 12 ERAS components, defined by the collaborative. Three retrospective audits (based on patient record analysis) were conducted in 2017, 2019, and 2021, respectively.Results:Overall, 740 patients were included (45.4% female; mean±SD age, 71±12 years). The overall adherence increased from 42.8% in 2017 to 58.4% in 2019 and 69.2% in 2021. Compared with low adherence, length of stay was increasingly reduced by 1.3 days for medium [95% confidence interval (95% CI): −2.5; 0.0], 3.6 days for high (95% CI: −4.9; −2.2), and up to 4.4 days for very high adherence (95% CI: −6.1; −2.7). Corresponding odds ratios for postoperative complications were 0.62 (95% CI: 0.33; 1.17), 0.19 (95% CI: 0.09; 0.43), and 0.14 (95% CI: 0.05; 0.39), respectively. No increase in 30-day readmissions was observed.Conclusions:A peer-constructed improvement collaborative effectively increases adherence to an ERAS protocol in individual hospitals. Across time, length of stay and postoperative complications decreased significantly, and a dose-response relationship was observed.

Exploring the Role of Job Crafting in Managing the Tensions of Standardized Work in Healthcare Opera

Combining both HOM and organizational research, this paper examined how a bottom-up approach to job design termed job crafting, manifests in standardized work procedures and how it affects the performance of standardized operations. The research is built upon an in-depth longitudinal case study that investigated the adoption of national standardized stroke care process in a UK general hospital. This study identified many multi-level tensions of standardized work in healthcare operations previously discussed in the HOM literature, reinforcing the idea that and any implementation mechanism must be multi-faceted and dynamic. Detailed observation of pathway implementation confirms the vital influence of professional autonomy on the pathway performance by crafting their work. The study found that all the different forms of the initial model of job crafting i.e. task, relational and cognitive were present among different groups of staff during standardized work operations at the hospital. Positive and negative consequences of job crafting to both the staff and the operational procedures were clearly observed. Drawing on organizational and HRM literature interventions to facilitate positive job crafting to improve the performance in standardized operations were discussed. Directions for further studies are also suggested. Keywords: standardized work, healthcare operations, implementation tensions, autonomous professionals, job crafting

State of the art of enhanced recovery after surgery (ERAS) protocols in esophagogastric cancer surgery: the Western experience.

Enhanced recovery after surgery (ERAS) programs provide a framework to standardize care processes and improve outcomes. The results of this multimodal and multidisciplinary approach based on actions focused on reducing physiological surgical stress in the preoperative, intraoperative, and postoperative periods are beneficial in reducing morbidity and hospital stay, without increasing readmissions across different surgical settings. The implementation of ERAS in resection procedures of esophageal and gastric cancer has been challenging due to the complexity of these surgical techniques and the high risk of complications. Despite the limited evidence of ERAS in esophagectomy operations, systematic reviews and meta-analysis have confirmed a reduction of pulmonary complications and hospital stay without increasing readmissions. In gastrectomy operations, the implementation of ERAS reduces the use of nasogastric tubes and intraabdominal drains, facilitates early diet, and reduces the length of hospital stay, without increasing complications. There is, however, wide heterogeneity and absence of standardization in the number and definition of the ERAS components. The development of ERAS consensus guidelines including procedure-specific components may reduce this variability. Regardless growing evidence of the effectiveness of ERAS, the adherence rate is still low. The commitment of the multidisciplinary team and leadership is critical in the application and refinement of ERAS protocols in parallel with periodic audits. Pre- and post-habilitation methods are emerging concepts to be incorporated in ERAS protocols.

Development of a human factors-based tool for evaluating and improving infection prevention and control protocols

Background: Infection prevention and control (IPC) protocols and guidelines are important quality management tools for educating care professionals and standardizing care processes. However, most of the actual care (ie, work as done) differ from protocol recommendations (ie, work as imagined). No tool or set of criteria has been established for how to develop human-centered IPC protocols. The goal of this research was to develop a standardized human-factors analysis method to provide healthcare organizations with a tangible framework to improve protocol usefulness and usability. Methods: The proposed analysis method combines principles from human-factors engineering (ie, usability heuristics, systems ambiguity framework) and instructional design. Relevant literature was analyzed by experts in human factors and clinical experts to develop a tool with criteria such as visualization and method ambiguity. Overall, 5 IPC-related protocols from a large academic hospital were selected from an electronic database and were evaluated using the proposed criteria. Results: During application of the analysis method, 70 human-factors–related problems were identified across 5 IPC protocols (eg, heater cooler cleaning), including violation of design heuristics and the presence of ambiguity. Frequently violated human-factors design principles included appearance and/or visibility (ie, visual display of content), visualization (ie, providing illustrative examples), and method ambiguity (ie, lack of clarity on how to complete a task). Figure 1 provides a sample of the human-factors problems identified and suggested solutions. Only minor modifications (ie, clarification of criteria definitions) were needed on the final tool. Conclusions: The human-factors–based tool developed in this study can be used both to develop new IPC protocols and to evaluate and improve existing protocols.Funding: The CDC funded this work. This material is based upon work supported by the Naval Sea Systems Command under Contract No. N00024-13-D-6400, Task Order NH076. Any opinions, findings and conclusions or recommendations expressed in this material are those of the author(s) and do not necessarily reflect the views of the Naval Sea Systems Command (NAVSEA) or the US CDC.Disclosures: None

Delays in Diagnosis, Treatment, and Surgery: Root Causes, Actions Taken, and Recommendations for Healthcare Improvement.

Although patient safety continues to be a priority in the U.S. healthcare system, delays in diagnosis, treatment, or surgery still led to adverse events for patients. The purpose of this study was to review root cause analysis (RCA) reports in the Veterans Health Administration to identify the root causes and contributing factors of delays in diagnosis, treatment, or surgery in an effort to prevent avoidable delays in future care. The RCA reports from Veterans Health Administration hospitals from October 2016 through September 2019 were reviewed and the root causes and contributory factors were identified. These elements were coded by consensus and analyzed using descriptive statistics. During the 3-year study period, 206 RCAs were identified and 163 were analyzed that were specific to delays in diagnosis, treatment, and surgery. The reports identified 24 delays in diagnosis, 117 delays in treatment, and 22 delays in surgery. Delays occurred most often in outpatient settings. Results supported the need for standardization of care processes and procedures, improved communication between and within department personnel, and improved policies and procedures that will be followed as intended. By reviewing adverse events, root causes, and contributing factors identified by local RCA teams, strategies can be developed to reduce delays in diagnosis and treatment of patients and lead to safer care.

Anal cancer in Sweden 2015–2019. Implementation of guidelines, structural changes, national registry and early results

Background Squamous cell cancer of the anus is an uncommon malignancy, usually caused by human papilloma virus (HPV). Chemoradiotherapy (CRT) is the recommended treatment in localized disease with cure rates of 60–80%. Local failures should be considered for salvage surgery. With the purpose of improving and equalizing the anal cancer care in Sweden, a number of actions were taken between 2015 and 2017. The aim of this study was to describe the implementation of guidelines and organizational changes and to present early results from the first 5 years of the Swedish anal cancer registry (SACR). Methods The following were implemented: (1) the first national care program with treatment guidelines, (2) standardized care process, (3) centralization of CRT to four centers and salvage surgery to two centers, (4) weekly national multidisciplinary team meetings where all new cases are discussed, (5) the Swedish anal cancer registry (SACR) was started in 2015. Results The SACR included 912 patients with a diagnosis of anal cancer from 2015 to 2019, reaching a national coverage of 95%. We could show that guidelines issued in 2017 regarding staging procedures and radiotherapy dose modifications were rapidly implemented. At baseline 52% of patients had lymph node metastases and 9% had distant metastases. Out of all patients in the SACR 89% were treated with curative intent, most of them with CRT, after which 92% achieved a local complete remission and the estimated overall 3-year survival was 85%. Conclusions This is the first report from the SACR, demonstrating rapid nation-wide implementation of guidelines and apparently good treatment outcome in patients with anal cancer in Sweden. The SACR will hopefully be a valuable source for future research.

De-escalation of High-flow Respiratory Support for Children Admitted with Bronchiolitis: A Quality Improvement Initiative.

Introduction:Bronchiolitis is the most common cause for hospitalization in the first year of life, with hypoxemia and acute respiratory failure as major determinants leading to hospitalization. In addition, the lack of existing guidelines for weaning and discontinuing supplemental oxygen, including high-flow nasal cannula, may contribute to prolonged hospitalization and increased resource utilization.Methods:This single-center quality improvement initiative assessed the effect of implementing a standardized care process for weaning and discontinuing high-flow oxygen for patients hospitalized with bronchiolitis. Patients aged 1–24 months with bronchiolitis admitted to the general wards or ICU step-down unit from February 1, 2018, and January 31, 2020 were included in the study. Primary outcomes included length of stay and time on supplemental oxygen, with time on high-flow oxygen and length of time in ICU step-down unit as secondary outcomes. Balancing measures included transfer rate to Pediatric Intensive Care Unit, intubation rate, 7- and 30-day readmission rates, and 7- and 30-day ED visits after discharge.Results:Following the standardized care process implementation, the mean length of stay decreased from 60.7 hours to 46.7 hours (P < 0.01). In addition, the mean time on any supplemental oxygen decreased by 47% (P < 0.01), the mean time on high-flow oxygen decreased by 45% (P < 0.01), and the mean time in the ICU step-down unit decreased by 27% (P =< 0.01). Balancing measures remained unchanged with no statistically significant differences.Conclusion:Implementing a standardized care process for weaning and discontinuing high-flow oxygen may reduce the length of stay and resource utilization for patients hospitalized with bronchiolitis.

“Can we have a little humanity here?”: Patient perspectives on the impact of a standardized care process for patients who use opioids for the management of chronic pain

ObjectiveStandardized processes have evolved in response to the opioid epidemic. The impact of standardized processes on patients has not been adequately described. MethodsFive focus groups were held at four affiliated academic family medicine clinics. All participants experienced a transition to a standardized process for their ongoing opioid use for chronic, non-cancer pain. Data was analyzed and coded using a grounded theory approach with NVivo12 (QSR International). ResultsThirty patients participated. Five main themes emerged: experience of pain; view of opioid medications; view of opioid prescribing process changes; “good patients” and trust; and experience with medical clinicians and clinics. ConclusionsStandardized processes created to improve the safety of opioid prescribing have burdened patients and resulted in a loss of trust and autonomy. Patients perceived greater risks for other patients prescribed opioids and processes are a result of their actions. Practice ImplicationsHealthcare systems must acknowledge patients’ burden, shift away from interventions that are limited in supporting data, reinforce patient agency and shift the conversation to unsafe medications rather than supervision of “bad actors”.