Targets For Quality Improvement Research Articles

Reducing Unnecessary Acid Suppression Use in Hospitalized Patients: A Description of Targeted Strategies Implemented Across a Large Health System.

Ensuring the appropriate use of proton pump inhibitors (PPIs) and histamine type 2-receptor antagonists (H2RAs) is an important hospital patient safety and quality initiative because therapy may be inappropriately continued during transitions of care. In this article, we aim to describe the impact of targeted quality improvement strategies to reduce unnecessary acid suppression use in hospitalized patients across a large health system. Beginning January 1, 2018, focused quality improvement strategies to prevent unnecessary initiation and continuation of proton pump inhibitors (PPIs) and histamine type 2-receptor antagonists (H2RAs) were implemented throughout a large health system. Targeted strategies were initially tested as part of the PPI deprescribing Institute for Healthcare Improvement (IHI) International Innovators Network initiative and were expanded to include H2RAs for hospitalized patients. Strategies to decrease PPIs and H2RAs during hospitalization included standardization of stress ulcer prophylaxis care pathways, evidence-based order set modifications, technology-driven support, and clinical pharmacy metric performance to goal. PPI/H2RA days of therapy (DOT) per 1000 patient days were measured from the first quarter (1Q) of 2017 to the fourth quarter (4Q) of 2021 to determine if implemented strategies resulted in improvement. After quality improvement strategies were implemented, the number of PPI/H2RA DOT was reduced by 7.9 days per 1000 patient days each quarter over 4 years. The average PPI/H2RA DOT per 1000 patient days decreased from 592 (1Q 2017) to 439 (4Q 2021). In the fourth quarter of 2018, 45 hospitals (28%) achieved a 10% reduction in combined PPI/H2RA DOT per 1000 patient days, and 121 hospitals (97%) attained the goal of greater than 25% of eligible patients deprescribed PPI/H2RA for ICU patients in the fourth quarter of 2019. In the fourth quarter of 2020, 97 hospitals (87%) met the metric of 40% or more of eligible patients deprescribed from PPI/H2RA in or after an ICU stay, and 85 hospitals (87%) reached 50% or more of eligible patients deprescribed PPI/H2RA in or after an ICU stay in 4Q2021. Targeted quality improvement strategies decreased unnecessary PPI and H2RA use for a large health system over 4 years. Continually evaluating measured results along with establishing a new clinical pharmacy metric goal each year to encourage further improvement contributed to deprescribing success.

Augmenting project ECHO for opioid use disorder with data-informed quality improvement

BackgroundNational opioid-related overdose fatalities totaled 650,000 from 1999 to 2021. Some of the highest rates occurred in New Hampshire, where 40% of the population lives rurally. Medications for opioid use disorder (MOUD; methadone, buprenorphine, and naltrexone) have demonstrated effectiveness in reducing opioid overdose and mortality. Methadone access barriers disproportionally impact rural areas and naltrexone uptake has been limited. Buprenorphine availability has increased and relaxed regulations reduces barriers in general medical settings common in rural areas. Barriers to prescribing buprenorphine include lack of confidence, inadequate training, and lack of access to experts. To address these barriers, learning collaboratives have trained clinics on best-practice performance data collection to inform quality improvement (QI). This project sought to explore the feasibility of training clinics to collect performance data and initiate QI alongside clinics’ participation in a Project ECHO virtual collaborative for buprenorphine providers.MethodsEighteen New Hampshire clinics participating in a Project ECHO were offered a supplemental project exploring the feasibility of performance data collection to inform QI targeting increased alignment with best practice. Feasibility was assessed descriptively, through each clinic’s participation in training sessions, data collection, and QI initiatives. An end-of-project survey was conducted to understand clinic staff perceptions of how useful and acceptable they found the program.ResultsFive of the eighteen health care clinics that participated in the Project ECHO joined the training project, four of which served rural communities in New Hampshire. All five clinics met the criteria for engagement, as each clinic attended at least one training session, submitted at least one month of performance data, and completed at least one QI initiative. Survey results showed that while clinic staff perceived the training and data collection to be useful, there were several barriers to collecting the data, including lack of staff time, and difficulty standardizing documentation within the clinic electronic health record.ConclusionsResults suggest that training clinics to monitor their performance and base QI initiatives on data has potential to impact clinical best practice. While data collection was inconsistent, clinics completed several data-informed QI initiatives, indicating that smaller scale data collection might be more attainable.

Prevalence of antimicrobial use and healthcare-associated infections in China: Results from the first point prevalence survey in 18 hospitals in Shanxi Province

Inappropriate antimicrobial use (AMU) and healthcare-associated infections (HAIs) are important drivers of antimicrobial resistance, but data from the developing world are scarce. We conducted the first point prevalence survey (PPS) to determine the prevalence of AMU and HAIs and the suggested targeted interventions for appropriate AMU and HAI prevention in Shanxi Province, China. A multicentre PPS was performed in 18 hospitals in Shanxi. Detailed data on AMU and HAI were collected using the Global-PPS method developed by the University of Antwerp and the methodology developed by the European Centre for Disease Prevention and Control, respectively. There were 2171 (28.2%) of the 7707 inpatients receiving at least one antimicrobial. The most commonly prescribed antimicrobials were levofloxacin (11.9%), ceftazidime (11.2%), and cefoperazone and beta-lactamase inhibitor (10.3%). Out of the total indications, 89.2% of antibiotics were prescribed for therapeutic, 8.0% for prophylaxis, and 2.8% for either unknown or other. Of the total surgical prophylaxis, 96.0% of antibiotics were given for more than one day. In general, antimicrobials were given mainly parenterally (95.4%) and empirically (83.3%). A total of 264 active HAIs were identified in 239 patients (3.1%), of which 139 (52.3%) were culture positive. The most common HAI was pneumonia (41.3%). This survey indicated the relatively low prevalence of AMU and HAIs in Shanxi Province. However, this study has also highlighted several priority areas and targets for quality improvement, and repeated PPSs in the future will be useful to gauge progress at controlling AMU and HAIs.

Infarcts in a New Territory: Insights From the ESCAPE-NA1 Trial

Infarct in a new territory (INT) is a known complication of endovascular stroke therapy. We assessed the incidence of INT, outcomes after INT, and the impact of concurrent treatments with intravenous thrombolysis and nerinetide. Data are from ESCAPE-NA1 trial (Safety and Efficacy of Nerinetide [NA-1] in Subjects Undergoing Endovascular Thrombectomy for Stroke), a multicenter, international randomized study that assessed the efficacy of intravenous nerinetide in subjects with acute ischemic stroke who underwent endovascular thrombectomy within 12 hours from onset. Concurrent treatment and outcomes were collected as part of the trial protocol. INTs were identified on core lab imaging review of follow-up brain imaging and defined by the presence of infarct in a new vascular territory, outside the baseline target occlusion(s) on follow-up brain imaging (computed tomography or magnetic resonance imaging). INTs were classified by maximum diameter (<2, 2-20, and >20 mm), number, and location. The association between INT and clinical outcomes (modified Rankin Scale and death) was assessed using standard descriptive techniques and adjusted estimates of effect were derived from Poisson regression models. Among 1092 patients, 103 had INT (9.3%, median age 69.5 years, 49.5% females). There were no differences in baseline characteristics between those with versus without INT. Most INTs (91/103, 88.3%) were not associated with visible occlusions on angiography and 39 out of 103 (37.8%) were >20 mm in maximal diameter. The most common INT territory was the anterior cerebral artery (27.8%). Almost half of the INTs were multiple (46 subjects, 43.5%, range, 2-12). INT was associated with poorer outcomes as compared to no INT on the primary outcome of modified Rankin Scale score of 0 to 2 at 90 days (adjusted risk ratio, 0.71 [95% CI, 0.57-0.89]). Infarct volume in those with INT was greater by a median of 21 cc compared with those without, and there was a greater risk of death as compared to patients with no INT (adjusted risk ratio, 2.15 [95% CI, 1.48-3.13]). Infarcts in a new territory are common in individuals undergoing endovascular thrombectomy for acute ischemic stroke and are associated with poorer outcomes. Optimal therapeutic approaches, including technical strategies, to reduce INT represent a new target for incremental quality improvement of endovascular thrombectomy. URL: https://www. gov; Unique identifier: NCT02930018.

Surgeon Postoperative Opioid Prescribing Intensity and Risk of Persistent Opioid Use Among Opioid-naive Adult Patients: A Population-based Cohort Study.

The aim of this study was to determine the relationship between surgeon opioid prescribing intensity and subsequent persistent opioid use among patients undergoing surgery. The extent to which different postoperative prescribing practices lead to persistent opioid use among surgical patients is poorly understood. Retrospective population-based cohort study assessing opioid-naive adults who underwent 1 of 4 common surgeries. For each surgical procedure, the surgeons' opioid prescribing intensity was categorized into quartiles based on the median daily dose of morphine equivalents of opioids dispensed within 7 days of the surgical visit for all the surgeons' patients. The primary outcome was persistent opioid use in the year after surgery, defined as 180 days or more of opioids supplied within the year after the index date excluding prescriptions filled within 30 days of the index date. Secondary outcomes included a refill for an opioid within 30 days and emergency department visits and hospitalizations within 1 year. Among 112,744 surgical patients, patients with surgeons in the highest intensity quartile (Q4) were more likely to fill an opioid prescription within 7 days after surgery compared with those in the lowest quartile (Q1) (83.3% Q4 vs 65.4% Q1). In the primary analysis, the incidence of persistent opioid use in the year after surgery was rare in both highest and lowest quartiles (0.3% Q4 vs 0.3% Q1), adjusted odds ratio (AOR) of 1.18, 95% CI 0.83-1.66). However, multiple analyses using stricter definitions of persistent use that included the requirement of a prescription filled within 7 days of discharge after surgery showed a significant association with surgeon quartile (up to an AOR 1.36, 95% CI 1.25, 1.47). Patients in Q4 were more likely to refill a prescription within 30 days (4.8% Q4 vs 4.0% Q1, AOR 1.14, 95% CI 1.04-1.24). Surgeons' overall prescribing practices may contribute to persistent opioid use and represent a target for quality improvement. However, the association was highly sensitive to the definition of persistent use used.

COVID-19 vaccine uptake among healthcare workers: an achievable quality improvement target.

There is a need to optimize SARS-CoV-2 vaccination rates amongst healthcare workers (HCWs) to protect staff and patients from healthcare-associated COVID-19 infection. During the COVID-19 pandemic, many organizations implemented vaccine mandates for HCWs. Whether or not a traditional quality improvement approach can achieve high-rates of COVID-19 vaccination is not known. Our organization undertook iterative changes that focused on the barriers to vaccine uptake. These barriers were identified through huddles, and addressed through extensive peer outreach, with a focus on access and issues related to equity, diversity and inclusion. The outreach interventions were informed by real-time data on COVID-19 vaccine uptake in our organization. The vaccine rate reached 92.3% by 6 December 2021 with minimal differences in vaccine uptake by professional role, clinical department, facility or whether the staff had a patient facing role. Improving vaccine uptake should be a quality improvement target in healthcare organizations and our experience shows that high vaccine rates are achievable through concerted efforts targeting specific barriers to vaccine confidence.

Lessons Learned Using Rapid Human Factors Methods: Condensed Timeline with Effective and Impactful Results

Contextual inquiry and discount usability represent a powerful combination of human factors methods as a responsive and rapid approach to better understand end users’ interactions with a new electronic health record (EHR) system as an enterprise capability. Contextual inquiry is an approach to conducting ethnographic field studies and discount usability is a simplified and efficient technique to identify usability issues. This paper describes how the Veterans Health Administration (VHA) Office of Health Informatics Human Factors Engineering (OHI HFE) responded to a request from VHA leadership to provide rapid support to assess EHR post-implementation system performance to discover if there are barriers or shortcomings. The team utilized contextual inquiry methods and principles of discount usability to assess system usability and effectiveness in meeting end-user needs. OHI and the Electronic Health Record Modernization Integration Office (OEHRM IO) formed a team to conduct semi-structured interviews and observations with health care providers at a VHA facility to gather qualitative data showcasing representative users’ experiences with the EHR. The team analyzed the data collected to identify themes and created an affinity map and two service blueprints. It then used this information to produce a report of findings and recommendations. The study identified areas that required remediation, actions that would facilitate success, and opportunities for improvement. Key contributors to the success of this rapid and important effort included the team’s ability to accommodate a compressed schedule by carefully targeting scope; focusing on a smaller number of participants than originally planned; asking direct, targeted questions developed in advance; and capturing data during short interview and observation windows. The data collected also highlights opportunities to continue the use of discount usability methods, when necessary, to continuously improve OHI HFE data collection and achieve targeted quality improvement in a condensed timeframe.

Key performance indicators for improving outcomes from retroperitoneal sarcoma surgery in New Zealand.

Retroperitoneal sarcomas are a rare and heterogenous group of tumours. There is increasing evidence that high volume sarcoma units achieve superior outcomes than low volume units. Due to the relatively small population, New Zealand is unlikely to generate a sufficient case volume to be considered high volume. To our knowledge, no well-established key performance indicators (KPIs) exist for retroperitoneal sarcoma surgery. In order to ensure quality standards we aim to propose KPIs which will act as a benchmark and a target for future quality improvement. Potential KPIs were generated by internal discussion within the sarcoma team, taking into consideration available guidelines and evidence. Cases treated through the unit since 2015 were audited to determine historical performance against these KPIs. Eighty-six patients with primary retroperitoneal sarcomas were identified. 69% of patients were discussed at the sarcoma MDM prior to treatment, 62% underwent preoperative core biopsy. 82% of patients were seen and treated within target timeframes set by the Ministry of Health. 53% of patients underwent surgery with a sarcoma trained surgeon. R0/R1 rate was 88%. 90-day mortality was 4.6%. Surgical treatment of retroperitoneal sarcomas is complex and can be associated with significant morbidity. The proposed KPIs provide a measure of service performance and provide targets for quality improvement.

Off-Hours Intensive Care Unit Transfer Is Associated With Increased Mortality and Failure to Rescue

BackgroundCardiac postoperative intensive care unit (ICU) beds are a limited resource, and when a patient no longer requires this level of care they are quickly transferred out. We hypothesized that complications and ICU readmission increased when transfer occurred during off-hours compared with regular work hours. MethodsFrom 2010 to 2021, patients who underwent a Society of Thoracic Surgeons index operation at a single center were assigned a group based on their ICU transfer time, defined as when they physically arrived on the acute care floor. Patients were stratified into off-hours vs regular hours by their transfer time. Off-hours was defined as 9 pm to 5 am. Risk-adjusted multivariable logistic regression analyzed the association of ICU readmission, postoperative complications, operative mortality, and failure to rescue by group. ResultsThe cohort included 5951 patients (off-hours n = 292 [4.9%], regular-hours n = 5659 [95.1%]). Patients in the off-hours group had significantly greater odds of risk-adjusted ICU readmission (odds ratio 1.99, 95% CI 1.25-3.04, P < .002) and mortality (odds ratio 3.88, 95% CI 2.27-6.33, P < .001). In the major complications subgroup (Off-hours n = 55, Regular-hours n = 603), Off-hours transfer was associated with increased mortality (failure to rescue) (odds ratio 3.05, 95% CI 1.58-5.69, P = .001). ConclusionsOff-hours ICU to floor transfer was associated with increased postoperative complications, ICU readmission, and mortality, suggesting that the timing of ICU transfer may impact outcomes. This elucidates targets for quality and process improvement for our center and others facing the same resource constraints.

Comparison of care and outcomes for myocardial infarction by heart failure status between United Kingdom and Japan.

Prognosis for ST-segment elevation myocardial infarction (STEMI) is worse when heart failure is present on admission. Understanding clinical practice in different health systems can identify areas for quality improvement initiatives to improve outcomes. In the absence of international comparison studies, we aimed to compare treatments and in-hospital outcomes of patients admitted with ST elevation myocardial infarction (STEMI) by heart failure status in two healthcare-wide cohorts. We used two nationwide databases to capture admissions with STEMI in the United Kingdom (Myocardial ischemia National Audit Project, MINAP) and Japan (Japanese Registry of All Cardiac and Vascular Diseases-Diagnostic Procedure Combination, JROAD-DPC) between 2012 and 2017. Participants were stratified using the HF Killip classification into three groups; Killip 1: no congestive heart failure, Killip 2-3: congestive heart failure, Killip 4: cardiogenic shock. We calculated crude rate and case mix standardized risk ratios (CSRR) for use of treatments and in-hospital death. Patients were younger in the United Kingdom (65.4 [13.6] vs. 69.1 [13.0] years) and more likely to have co-morbidities in the United Kingdom except for diabetes and hypertension. Japan had a higher percentage of heart failure and cardiogenic shock patients among STEMI during admission than that in the United Kingdom. Primary percutaneous coronary intervention (pPCI) rates were lower in the United Kingdom compared with Japan, especially for patients presenting with Killip 2-3 class heart failure (pPCI use in patients with Killip 1, 2-3, 4: Japan, 86.2%, 81.7%, 78.7%; United Kingdom, 79.6%, 58.2% and 79.9%). In contrast, beta-blocker use was consistently lower in Japan than in the United Kingdom (61.4% vs. 90.2%) across Killip classifications and length of hospital stay longer (17.0 [9.7] vs. 5.0 [7.4] days). The crude rate of in-hospital mortality increased with increasing Killip class group. Both the crude rate and CSRR was higher in the United Kingdom compared with Japan for Killip 2-3 (15.8% vs. 6.4%, CSRR 1.80 95% CI 1.73-1.87, P<0.001), and similar for Killip 4 (36.9% vs. 36.3%, CSRR 1.11 95% CI 1.08-1.13, P<0.001). Important differences in the care and outcomes for STEMI with heart failure exist between the United Kingdom and Japan. Specifically, in the United Kingdom, there was a lower rate of pPCI, and in Japan, fewer patients were prescribed beta blockers and hospital length of stay was longer. This international comparison can inform targeted quality improvement programmes to narrow the outcome gap between health systems.

A national audit of performance standards for blood cultures in Aotearoa New Zealand: opportunities for improvement.

To audit key quality indicators for blood culture (BC) practices across Aotearoa New Zealand to facilitate national BC practice peer review and promote BC quality improvement interventions. Microbiology laboratories providing diagnostic services to district health board (DHB) hospitals were invited to participate. Practice was compared against published BC recommendations. Laboratories were required to submit data for BC positivity and contamination rates, BC bottle fill volume and the proportion of BC received as a single set. Laboratories serving 15 of the 20 DHBs participated in the audit. Nine DHBs (60%) demonstrated a positivity rate within the target range of 8% to 15%. Eight DHBs (53%) reported a contamination rate lower than the accepted 3%, but seven (47%) DHBs exceeded this target and two reported a contamination rate greater than 5%. Mean BC bottle fill volumes were generally greater than the target of 8mL, but this volume was not reached by three DHBs and a further three were unable to provide fill volume data. No DHB met the audit standard for single-set BCs representing <20%, and for six DHBs single-set BC comprised more than half of all samples. No DHB failed all audit targets. This audit demonstrates wide variation in BC performance across New Zealand. In most instances an inadequate volume of blood is being collected, lowering the chance of culturing a pathogen. A significant opportunity for improvement exists; clinical services and laboratories are encouraged to work together to implement targeted quality improvement processes to correct deficiencies in practice.

Air Quality Scenario Analysis Application of Multi-Domain Linkage Development in the Pearl River Delta

In the background of constructing a wold-class Guangdong-Hong Kong-Macao Great Bay Area (GBA), the growing demand for industrial, transportation and energy development in the Pearl River Delta (PRD) will put considerable pressure on improvement of regional air quality. It is important to choose a scientific development path to achieve both economic goal and air quality improvement target. This study uses scenario analysis method to construct three “industry-transport-energy” development scenarios within the region while the improvement level of air quality is simulated and analyzed. The results show that: (1) Considering the mutual constraints and influence relations between industry, transportation and energy in scenario analysis, the “industry-transport-energy” development scenario can be established to meets the same economic goal but has different development paths. (2) Along the historical track and established policy path, concentration of fine particulate matter (PM2.5) in the PRD can be reduced to 16.2 µg/m3 by 2035 as regional gross domestic product (GDP) reaching about 23.5 trillion. (3) Under the same economic goals, raising the proportion of emerging industries, freight by rail, public transport travel and non-fossil power to 95%, 10%, 73%, and 46% respectively leads to 29.6~49.2% reductions in the emissions of sulphur dioxide (SO2), nitrous oxides (NOx), primary PM2.5 and volatile organic compounds (VOCs) compared with those in 2017 that the regional PM2.5 concentration will further drop to 14.1 µg/m3. The results show that, under the constraints of economic development objectives, deepening structural adjustment can improve air quality, which gives advice for the PRD to choose its development path. Furthermore, this study can provide reference for the PRD to promote the transformation of industrial, transportation and energy development modes and structural adjustment under the dual objective of promoting the world-class bay area economic level and high-quality air level.

SWISS NURSING HOMES’ ENGAGEMENT IN QUALITY IMPROVEMENT: A MULTICENTER CROSS-SECTIONAL STUDY

Abstract Many publications have focused on quality improvement interventions in nursing homes but the self-initiated daily involvement of nursing homes in quality improvement activities has rarely been investigated (e.g., conducting surveys, using data to set quality aims and track quality of care over time, conducting quality improvement projects). Such activities can be carried out by nurses in expanded roles with competences beyond those of regular registered nurses (e.g., advanced studies, Bachelor/Master’s degree), but evidence is lacking. We aimed to described the involvement of nursing homes and of nurses working in expanded roles in quality improvement activities in Swiss nursing homes. A cross-sectional multi-center study (2018-2019) using survey data from a convenience sample of 115 Swiss nursing homes and 104 nurses in expanded roles was used and descriptive statistics applied. Most nursing homes reported carrying several quality improvement activities (median = 8 activities out of 10 surveyed). The group of nursing homes working with a nurse in an expanded role (n = 83) were more engaged in quality improvement than the other group (median = 8 versus 6.5) Higher-educated nurses participated more in a majority of quality improvement activities than lower-educated nurses (Bachelor/Master-educated nurses: median of 13 out of 17 activities surveyed, versus diploma-educated nurses: 10), except for clinical teaching. This study provides insights into nursing homes’ involvement in daily quality improvement and suggests that, depending on the targeted quality improvement needs, nursing homes use different profiles and education levels of nurses in expanded roles.

LESSONS FROM THE IMPLEMENTATION OF THE TRANSITIONAL CARE MODEL DURING THE COVID-19 PANDEMIC

Abstract Multiple randomized controlled trials (RCTs) evaluating the Transitional Care Model (TCM)- an advanced practice registered nurse-led (APRN), team-based, care management strategy- have shown improved outcomes for older adults transitioning from hospital to home. In the current RCT, enrollment of older adults hospitalized with heart failure, chronic obstructive pulmonary disease, or pneumonia began in February 2020, just as the COVID-19 pandemic developed across the U.S. The COVID-19 pandemic dramatically impacted healthcare delivery across diverse local contexts. This parallel convergent mixed methods study aimed to explore the implementation of the TCM intervention as intended during Year 2 of the RCT (February 2021 to January 2022). This mixed-methods analysis presents the challenges and strategies to a key TCM component, “hospital-to-home,” which focuses on delivering in-person visits to patients, as identified through a qualitative descriptive analysis of 63 clinical team and leadership meetings combined with implementation fidelity data collected simultaneously on 188 TCM participants. In Year 2 of the trial, COVID-19-specific challenges continued, including COVID-19 exposure, policy changes, patients declining services, and limited safety equipment. Some challenges to the hospital-to-home TCM component occurred regardless of COVID-19, including patient (e.g., lack of engagement), nurse provider (e.g., TCM learning curve), and system (e.g., reduced primary care access) barriers. Collectively, these challenges resulted in lower fidelity to APRNs visit patterns during TCM delivery. Strategies to address these challenges were identified. The findings provide critical insight into how to target quality improvement strategies to improve the delivery of services, such as the TCM, from hospital to home settings.

Maternal Centric Measurement and Data Gaps in Addressing Maternal Morbidities: A Scoping Review.

The objectives of this project were to (1) describe maternal-centric measures and survey data which are publicly available to evaluate the incidence, frequency, and distribution of maternal morbidity in the postpartum period, and (2) to identify postpartum care quality improvement targets and outline the types of measurement and data required to support them. We conducted a scoping review of two types of data sources: maternal health quality measures used by providers and payers and nationally-representative survey data sets administered by federal agencies. Each source was searched for keywords associated with pregnancy and the postpartum period. We included quality measures and survey questions that are maternal-centric and addressed the postpartum period. We excluded infant-centric measures and data. Quality measures were organized according to the Donabedian quality model. Our analysis demonstrates that existing maternal-centric quality measures and survey data offer limited insight into diagnosis and patient care delivery experiences associated with maternal morbidities during the postpartum period. There is inadequate maternal-centric data on the incidence, frequency, and distribution of postpartum maternal morbidities and associated care use. This gap reduces the ability of research to estimate the incidence of illness and injury among postpartum women and create targeted quality improvement efforts. Our findings highlight the need for quality measure stewards and data sponsors to enhance data collection and methods to become more inclusive of maternal-centric outcomes during the postpartum period.

1163: QUALITY IMPROVEMENT INITIATIVES REDUCE CHEST COMPRESSION PAUSES DURING PEDIATRIC ECPR

Introduction: Prolonged chest compression (CC) pauses in cardiopulmonary resuscitation (CPR) are associated with worse survival during in-hospital cardiac arrests. Procedures necessary to gain access for extracorporeal CPR (ECPR) can potentially prolong CC pauses during extracorporeal membrane oxygenation (ECMO) cannulation. Implementation of targeted quality improvement initiatives to improve team communication may reduce CC pauses during pediatric ECPR. Methods: Baseline data from a pediatric intensive care unit (PICU) in a tertiary care children’s hospital demonstrated significantly longer CC pauses and lower CC fraction (CCF) during ECMO cannulation when compared to similar metrics pre-cannulation. An intervention designed to improve CC metrics during ECPR was implemented, including: 1. Sharing of baseline CC data with ECPR stakeholders 2. Standardization of counting CC pauses out loud to improve team awareness of pause length 3. Creation of a reporting aid to assist with ECPR documentation and 4. Interdisciplinary ECPR simulation sessions every other month to practice communication during cannulation. CC pause characteristics were compared pre- and post- intervention using unpaired t-tests. Results: Eleven ECPRs were analyzed pre-intervention and five ECPRs post-intervention. CC pause characteristics (mean duration of pauses, individual longest pause, and CCF) improved in both pre- and during ECMO cannulation epochs post-intervention when compared to their pre-intervention counterparts. During ECMO cannulation, mean length of CC pauses was 30 seconds (pre-intervention) vs 13 seconds (post-intervention) (p < 0.02). The longest CC pause during ECMO cannulation was 337 seconds (pre-intervention) compared with 69 seconds (post-intervention) (p = 0.03). CCF during ECMO cannulation pre-intervention and post-intervention was 68% vs 83% respectively (p = 0.03). Conclusions: CC pause metrics during the cannulation phase of pediatric ECPR improved significantly after quality improvement interventions including baseline CC data review, verbal communication of CC pause length and interdisciplinary ECPR simulations. Future aims include correlating CC pause characteristics with clinical outcomes.

An assessment of burden of hospital-acquired pneumonia among abdominal surgical patients in tertiary university hospital in Serbia: A matched nested case-control study.

In the population of abdominal surgical patients hospital-acquired pneumonia (HAP) significantly increases morbidity and mortality. Through regular hospital surveillance of patients who received abdominal operations, we identified postoperative HAP from 2007 to 2019. In an initial nested case-control study, every surgical patient with HAP was compared with three control patients without HAP. Control patients were matched to the cases by age, gender, the American Society of Anesthesiologists score, and type of surgical operation. Also, the patients with HAP, who died were compared with those who survived. Multivariate logistic regression analysis (MLRA) revealed that other postoperative infections, length of intensive care unit stay, use of H2RA, use of PPI/ H2RA, multiple transfusion, and use of vancomycin in surgical prophylaxis were independent RFs for occurrence of HAP. Also, MLRA identified that age, lenght of hospital stay, use of mechanical ventilation and ceftriaxone in HAP therapy were indepedenttly associated with poor outcome of HAP. All Acinetobacter baumannii isolates were resistant to aminoglycoside antimicrobial agents and showed carbapenem resistance. The most frequently used antibiotics in patients with HAP and without HAP were vancomycin and metronidazole, respectively. Our study provided an insight into the burden of HAP in abdominal surgical patients, and highlighted several priority areas and targets for quality improvement.

Development of a 30-Day Readmission Risk Calculator for the Inpatient Rehabilitation Setting.

Readmission to acute care from the inpatient rehabilitation facility (IRF) setting is potentially preventable and an important target of quality improvement and cost savings. The objective of this study was to develop a risk calculator to predict 30-day all-cause readmissions from the IRF setting. Retrospective database analysis using the Uniform Data System for Medical Rehabilitation (UDSMR) from 2015 through2019. In total, 956 US inpatient rehabilitation facilities and 1,849,768 IRF discharges comprising patients from 14 impairment groups. Logistic regression models were developed to calculate risk-standardized 30-day all-cause hospital readmission rates for patients admitted to an IRF. Models for each impairment group were assessed using 12 common clinical and demographic variables and all but 4 models included various special variables. Models were assessed for discrimination (c-statistics), calibration (calibration plots), and internal validation (bootstrapping). A readmission risk scoring system was created for each impairment group population and was graphically validated. The mean age of the cohort was 68.7 (15.2) years, 50.7% were women, and 78.3% were Caucasian. Medicare was the primary payer for 73.1% of the study population. The final models for each impairment group included between 4 and 13 total predictor variables. Model c-statistics ranged from 0.65 to 0.70. There was good calibration represented for most models up to a readmission risk of 30%. Internal validation of the models using bootstrap samples revealed little bias. Point systems for determining risk of 30-day readmission were developed for each impairment group. Multivariable risk factor algorithms based upon administrative data were developed to assess 30-day readmission risk for patients admitted from IRF. This report represents the development of a readmission risk calculator for the IRF setting, which could be instrumental in identifying high risk populations for readmission and targeting resources towards a diverse group of IRF impairment groups.

Post-Colonoscopy Colorectal Cancer Etiologies in a Large Integrated US Health Care Setting

Post-Colonoscopy Colorectal Cancer Etiologies in a Large Integrated US Health Care Setting

Quality and Integrated Service Delivery: A Cross-Sectional Study of the Effects of Malaria and Antenatal Service Quality on Malaria Intervention Use in Sub-Saharan Africa.

Using regionally linked facility and household surveys, we measured the quality of integrated antenatal care and malaria in pregnancy services in Kenya, Namibia, Senegal, and Tanzania. We examined country heterogeneities for the association of integrated antenatal and malaria service quality scores with insecticide-treated bed net (ITN) use in pregnant women and children under-five and intermittent preventive treatment in pregnancy (IPTp-2) uptake. Malaria in pregnancy service quality was low overall. Our findings suggest modest, positive associations between malaria in pregnancy quality and ITN use and IPTp-2 uptake across pooled models and for most studied countries, with evidence of heterogeneity in the strength of associations and relevant confounding factors. Antenatal care quality generally was not associated with the study outcomes, although a positive interaction with malaria in pregnancy quality was present for pooled ITN use models. The improved quality of malaria services delivered during formal antenatal care can help address low coverage and usage rates of preventive malaria interventions in pregnancy and childhood. Study findings may be used to target quality improvement efforts at the sub-national level. Study methods may be adapted to identify low-performing facilities for intervention and adaption to other areas of care, such as HIV/AIDS, child immunizations, and postnatal care.