Ensuring success and sustainability of a quality improvement project

Sustained Performance of Cardiac Arrest Prevention in Pediatric Cardiac Intensive Care Units

Importance

The Pediatric Cardiac Critical Care Consortium (PC4) cardiac arrest prevention (CAP) quality improvement (QI) project facilitated a decreased in-hospital cardiac arrest (IHCA) incidence rate across multiple hospitals. The sustainability of this outcome has not been determined.

Objective

To examine the IHCA incidence rate at participating hospitals after the QI project ended and discern which factors best aligned with sustained improvement.

Design, Setting, and Participants

This observational cohort study compared IHCA data from the CAP era (July 1, 2018, to December 31, 2019) with data from the 2-year follow-up era (March 1, 2020, to February 28, 2022). Data were obtained from pediatric cardiac intensive care units (CICUs) from 17 PC4 CAP-participating hospitals.

Intervention

The CAP practice bundle was designed to facilitate local practice integration, with the intention to implement, adapt, and continue CAP processes beyond the CAP era. A web-based survey was administered 2 years after the end of the project to estimate CAP-specific QI work.

Main Outcomes and Measures

Risk-adjusted IHCA incidence rates across all admissions were compared between study eras. The survey generated a novel hospital-specific QI sustainability score, which is generally reflective of the sum of local CAP work performed.

Results

There were no clinically important differences in demographic and admission characteristics between the 13 082 CAP era admissions and 16 284 follow-up admissions (total mean [SD] age, 5.1 [8.4] years; 56.1% male). Risk-adjusted IHCA incidences were not different between the CAP vs follow-up eras (2.8% vs 2.8%; odds ratio, 1.03; 95% CI, 0.89-1.19), suggesting sustained prevention improvement. There was also no difference between eras in risk-adjusted IHCA incidence within medical, surgical, or high-risk subgroups. A lower hospital QI sustainability score was correlated with higher odds for IHCA in the follow-up vs CAP era (correlation coefficient, -0.58; P = .02). Five hospitals had increases of 1% or greater in risk-adjusted IHCA rates in the follow-up era; these hospitals had significantly lower QI sustainability scores and were less likely to have adopted sustainability elements during the CAP era or report persistent engagement for CAP-related QI processes during follow-up.

Conclusions and Relevance

In this cohort study of all CICU admissions across 17 hospitals, IHCA prevention was feasible and sustainable; the established reduction in risk-adjusted IHCA rate was maintained for at least 2 years after the end of the CAP project. Both implementation strategies and continued engagement in CAP processes during the follow-up era were associated with sustained improvement.

A Quality Improvement Project to Reduce Unplanned Extubations in the Neonatal Intensive Care Unit

BACKGROUND

Unplanned extubations (UEs) continue to be one of the most common adverse events in the neonatal intensive care unit (NICU). Management of endotracheal tubes (ETTs) can be particularly challenging in neonates due to the unique needs and physical characteristics of this patient population.

PURPOSE

The purpose of this quality improvement project was to decrease the rate of UEs from 0.76 to less than 0.5 per 100 ventilator days in an urban level III NICU in the Midwest, United States.

METHODS

A newly formed interprofessional team created an evidence-based, standardized, bedside nurse-led care bundle for intubations and ETT care in the NICU. This project also created standardized, clear, closed-loop communication for the transition of bedside staff at shift change.

RESULTS

The UE rate decreased from 0.76 to 0 per 100 ventilator days, reaching the goal of less than 0.5 per 100 ventilator days, during the 10-week project implementation period from December 2021 to February 2022.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Many NICUs focus on reducing UEs due to the impact on healthcare resource utilization, acute complications, and long-term outcomes for infants. The development of a standardized, nurse-led care bundle for ETTs decreased the rate of UEs. Future research is needed to study the potential for generalization to different units and beyond the scope of the neonatal population.

Looking Back, Looking Forward: A Study Protocol for a Mixed-Methods Multiple-Case Study to Examine Improvement Sustainability of Large-Scale Initiatives in Tertiary Hospitals

Background Hospitals invest extensive resources in large-scale initiatives to improve patient safety and quality at an organizational level. However, initial success, if any, does not guarantee longer-term improvement. Empirical and theoretical knowledge that informs hospitals on how to attain sustained improvement from large-scale change is lacking. Aim The proposed study aims to examine improvement sustainability of two large-scale initiatives in an Australian tertiary hospital and translate the lessons into strategies for achieving sustained improvement from large-scale change in hospital settings. Design and Methods The study employs a single-site, multiple-case study design to evaluate the initiatives separately and comparatively using mixed methods. Semi-structured staff interviews will be conducted in stratified cohorts across the organizational hierarchy to capture different perspectives from various staff roles involved in the initiatives. The output and impact of the initiatives will be examined through organizational documents and relevant routinely collected organizational indicators. The obtained data will be analyzed thematically and statistically before being integrated for a synergic interpretation. Implications Capturing a comprehensive organizational view of large-scale change, the findings will have the potential to guide the practice and contribute to the theoretical understandings for achieving meaningful and longer-term organizational improvement in patient safety and quality.

Sustaining improvement of hospital-wide initiative for patient safety and quality: a systematic scoping review

BACKGROUND

Long-term sustained improvement following implementation of hospital-wide quality and safety initiatives is not easily achieved. Comprehensive theoretical and practical understanding of how gained improvements can be sustained to benefit safe and high-quality care is needed. This review aimed to identify enabling and hindering factors and their contributions to improvement sustainability from hospital-wide change to enhance patient safety and quality.

METHODS

A systematic scoping review method was used. Searched were peer-reviewed published records on PubMed, Scopus, World of Science, CINAHL, Health Business Elite, Health Policy Reference Centre and Cochrane Library and grey literature. Review inclusion criteria included contemporary (2010 and onwards), empirical factors to improvement sustainability evaluated after the active implementation, hospital(s) based in the western Organisation for Economic Co-operation and Development countries. Numerical and thematic analyses were undertaken.

RESULTS

17 peer-reviewed papers were reviewed. Improvement and implementation approaches were predominantly adopted to guide change. Less than 6 in 10 (53%) of reviewed papers included a guiding framework/model, none with a demonstrated focus on improvement sustainability. With an evaluation time point of 4.3 years on average, 62 factors to improvement sustainability were identified and emerged into three overarching themes: People, Process and Organisational Environment. These entailed, as subthemes, actors and their roles; planning, execution and maintenance of change; and internal contexts that enabled sustainability. Well-coordinated change delivery, customised local integration and continued change effort were three most critical elements. Mechanisms between identified factors emerged in the forms of Influence and Action towards sustained improvement.

CONCLUSIONS

The findings map contemporary empirical factors and their mechanisms towards change sustainability from a hospital-wide initiative to improve patient safety and quality. The identified factors and mechanisms extend current theoretical and empirical knowledgebases of sustaining improvement particularly with those beyond the active implementation. The provided conceptual framework offers an empirically evidenced and actionable guide to assist sustainable organisational change in hospital settings.

Improving documentation of prescriptions for as-required medications in hospital inpatients

It is estimated that 1 in 10 hospital inpatients in Scotland have experienced a medication error. In our unit, an audit in 2019 identified documentation of as-required prescriptions on drug Kardexes as an important target for improvement. This project aimed to reduce the percentage of these errors to <5% in the ward in 6 months.Weekly point prevalence surveys were used to measure medication error rates over a 12-week baseline period. Errors in route, frequency of dose and maximum dose accounted for >80% of all prescribing errors. The intervention was a poster reminder about the three most common errors linked to standards for prescribing pain medication. Barriers to change were identified through inductive thematic analysis of semistructured interviews with five ward doctors and two staff nurses.In the 6 weeks after intervention, our run chart showed a shift in maximum dose errors per patient, which fell from 75% to 26%. However, route and frequency errors remained high at >70% per patient. Most of these errors were due to use of abbreviations, and qualitative interviews revealed that senior doctors and nurses believed that these abbreviations were safe. We found some evidence from national guidelines to support these beliefs.Overall, the intervention was associated with decreased prevalence of patients without a maximum dose written on their prescription, but lack of space on drug prescriptions was identified as a key barrier to further improvement in both maximum dose and abbreviation errors.

Multifaceted strategies to improve blood pressure control in a primary care clinic: A quality improvement project

BACKGROUND

Approximately 80% of patients with hypertension in the Internal Medicine Clinic were uncontrolled (BP > 130/80 mmHg), according to the 2017 American College of Cardiology (ACC)/American Heart Association (AHA) hypertension guidelines, leading to increased morbidity and mortality. The aim of this quality improvement (QI) was to improve BP control <130/80 from the baseline rates of 20%-30% and <140/90 from the baseline rates of 40%-60% between ages of 18-75 years, within 12 months.

METHODS

We used the Plan-Do-Study-Act method. A multidisciplinary QI team identified barriers by fish bone diagram. Barriers included: 1) Physicians' knowledge gap and clinical inertia in optimization of medications, and 2) Patients' nonadherence to medication and appointments. The outcome measures were the percentage of patients with BP < 140/90 and < 130/80. Process measures included: 1) attendance rates of physician and nurses at educational sessions, 2) medication reconciliation completion rates and 3) care guide order rates. Key interventions were: 1) physicians and nurses' education regarding ACC/AHA guidelines, 2) patient education and engagement and 3) enhancement of health information technology. Data analysis was performed using monthly statistical process control charts.

RESULTS

We achieved 62.6% (n = 885/1426) for BP < 140/90 and 24.47% (n = 349/1426) for BP < 130/80 within 12 months project period. We sustained and exceeded at 72.64% (n = 945/1301) for BP < 140/90 and 44.58% (n = 580/1301) for BP < 130/80 during the 10 months post-project period.

CONCLUSIONS

Overcoming physician clinical inertia, enhancing patient adherence to appointments and medications, and a high functioning multidisciplinary team were the key drivers for the success.

CT Abdominal Tomography Indications: Are We All Sticking to the Plan?

OBJECTIVE

Ultra-low radiation dose computed tomography (CT) abdominal tomography was introduced in our institution in 2016 to replace standard abdominal radiography in the investigation of emergency department patients. This project aims to ascertain whether investigation of emergency department patients using ultra-low radiation dose CT abdominal tomography complies with original indication guidelines and/or if there has been any "indication creep" 3 years after inception.

METHODS

Retrospective, quality assurance project with research ethics waiver. A review of 200 consecutive patients investigated with CT abdominal tomography between February and May 2017 was performed. This was compared with 200 consecutive patients investigated between February and May 2019. Data analyzed included patient demographics, indication for scan, as well as scan and patient outcomes.

RESULTS

In the 2017 group, 29/200 scans were noncompliant with approved indication guidelines. In the 2019 group, 30/200 scans were also noncompliant. There was no statistically significant difference between groups (P < .05) regarding the use of approved indications. Forty of 200 scans performed in 2017 revealed additional findings which are not specifically addressed on the reporting template. Forty-one of 200 scans in 2019 revealed these findings.

CONCLUSIONS

There has been no "indication creep" for CT abdominal tomography over time.