SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): revised publication guidelines from a detailed consensus process

Reducing Central Line-Associated Bloodstream Infections in a Burn Intensive Care Unit: Using a Business Framework for Quality Improvement

Central line-associated bloodstream infections (CLABSIs) pose a unique risk in burn patients, with rates of infection 2-3 times that of other Intensive Care Unit (ICU) populations. Here we present a detailed account of our experience in reducing CLABSI rates utilizing a business framework called the Four Disciplines of Execution (4DX). The Burn ICU CLABSI rate had risen to the 90th percentile nationally when compared to other burn units on the National Healthcare Safety Network. We applied the 4DX framework. This is a four-step method which includes creating a Wildly Important Goal, establishing measurable and accomplishable process measures, creating a scoreboard, and using a weekly meeting to provide accountability. Process changes included both physician and nursing practices. The physicians changed the criteria for when to order blood cultures, as well as requiring attending approval for cultures. The nurses engaged in a peer-observation practice improvement for "scrub the hub" and line dressing conditions and improved their own expertise for peripheral IV placement. The multidisciplinary team initiated a daily review of line indications to ensure removal as soon as possible. Overall, the CLABSI rate decreased from 7.39 infections per 1000 line days to 2.29 infections per 1000 line days over 1 year. We subsequently achieved over 635 days without a CLABSI. In conclusion, the 4DX was a successful quality improvement technique in our healthcare context. Because of the simplicity of implementation, we think it is broadly applicable in the healthcare setting.

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

OBJECTIVES

To reduce unnecessary antibiotic exposure in a pediatric cardiac intensive care unit (CICU).

DESIGN

Single-center, quality improvement initiative. Monthly antibiotic utilization rates were compared between 12-month baseline and 18-month intervention periods.

SETTING

A 25-bed pediatric CICU.

PATIENTS

Clinically stable patients undergoing infection diagnosis were included. Patients with immunodeficiency, mechanical circulatory support, open sternum, and recent culture-positive infection were excluded.

INTERVENTIONS

The key drivers for improvement were standardizing the infection diagnosis process, order-set creation, limitation of initial antibiotic prescription to 24 hours, discouraging indiscriminate vancomycin use, and improving bedside communication and situational awareness regarding the infection diagnosis protocol.

RESULTS

In total, 109 patients received the protocol; antibiotics were discontinued in 24 hours in 72 cases (66%). The most common reasons for continuing antibiotics beyond 24 hours were positive culture (n = 13) and provider preference (n = 13). A statistical process control analysis showed only a trend in monthly mean antibiotic utilization rate in the intervention period compared to the baseline period: 32.6% (SD, 6.1%) antibiotic utilization rate during the intervention period versus 36.6% (SD, 5.4%) during the baseline period (mean difference, 4%; 95% CI, -0.5% to -8.5%; P = .07). However, a special-cause variation represented a 26% reduction in mean monthly vancomycin use during the intervention period. In the patients who had antibiotics discontinued at 24 hours, delayed culture positivity was rare.

CONCLUSIONS

Implementation of a protocol limiting empiric antibiotic courses to 24 hours in clinically stable, standard-risk, pediatric CICU patients with negative cultures is feasible. This practice appears safe and may reduce harm by decreasing unnecessary antibiotic exposure.

Introducing a structured daily multidisciplinary board round to safely enhance surgical ward patient flow in the bed shortage era: a quality improvement research report

Hospital bed shortage is a worldwide concern. Their unavailability has caused elective surgery cancellations at our hospital peaking in spring 2016 at over 50%. This is often due to difficult patient step-down from intensive care (ICU) and high-dependency units (HDU). In our general/digestive surgery service admitting approximately 1000 patients yearly, ward rounds were run on a consultant firm basis.We report quality improvement (ISRCTN13976096) after we introduced a structured daily multidisciplinary board round framework (SAFER Surgery R2G) adapted from the 'SAFER patient flow bundle' and the 'Red to Green days' approaches to enhance flow. We compare 2016-2017, when our framework was applied for 12 months.We used a Plan-Do-Study-Act (PDSA) methodology. Our intervention consisted in (1) systematically communicating the key care plan after the afternoon ward rounds to the nurse in charge; (2) 30' 10:00 hours Monday-to-Friday multidisciplinary board rounds, attended daily by the senior team and weekly by hospital and site managers, revising the key care plan to aim at safe, early discharges, assessing the appropriateness of each inpatient day and tackling any cause of delay. We measured patient flow by average length of stay (LOS), ICU/HDU step-downs and operation cancellations count, monitoring safety through early 30-day readmissions. Compliance was assessed by board round attendance and staff satisfaction rate surveys.After 12 months of intervention (PDSA-1-2, N=1032), compared with baseline (PDSA-0, N=954) average LOS significantly decreased from 7.2 (8.9) to 6.3 (7.4) days (p=0.003); ICU/HDU bed step-down flow increased by 9.3% from 345 to 375 (p=0.197), surgery cancellations dropped from 38 to 15 (p=0.100). 30-day readmissions increased from 0.9% (N=9) to 1.3% (N=14)(p=0.390). Average cross-specialty attendance was 80%. Satisfaction rates were >75%, regarding enhanced teamwork and faster decisions.The SAFER Surgery R2G framework has increased patient flow in the context of an enhanced multidisciplinary approach, requiring senior staff commitment to remain sustainable.

Neonatal Thermoregulation: A Golden Hour Protocol Update

BACKGROUND

Premature infants are poor regulators of body temperature and are subjected to environmental factors that can lead to rapid heat loss, leaving them vulnerable to an increased risk of morbidity and mortality from hypothermia. Thermoregulation protocols have proven to increase survival in preterm infants.

PURPOSE

To evaluate a Plan-Do-Study-Act (PDSA) cycle on a previously implemented Golden Hour protocol at a military medical care facility for infants born at less than 32 weeks of gestation and weighing less than1500 g. Specific aims included the use of increased delivery/operating room temperatures and proper use of thermoregulatory devices (polyethylene bags and thermal mattress).

METHODS

Outcomes were analyzed and compared using a pre/postdesign. The data was collected using the neonatal intensive care unit admission worksheet.

RESULTS

Although statistical analysis was not significant, clinical significance was illustrated by a decrease in hypothermia rates on admission and at 1 hour of life. There was a 100% compliance rate with increasing delivery room/operating room temperatures and thermal mattress use. Polyethylene bag use compliance was 50%.

IMPLICATIONS FOR PRACTICE

Golden Hour protocols have proven to be an effective tool. Thermoregulation is a significant component of these protocols, and it is imperative that every step is taken to manage the environmental temperature during the birth and admission process.

IMPLICATIONS FOR RESEARCH

There is a need for continued research on the impacts of thermoregulatory devices and protocols, with resulting practice and device recommendations.

Dialogical Family Guidance (dfg)-Development and implementation of an intervention for families with a child with neurodevelopmental disorders

Aim

To describe the development and implementation of a Dialogical Family Guidance (DFG) intervention, aimed at families with a child with neurodevelopmental disorders (NDD).

Design

The DFG components are presented and the content of a DFG training course. Professionals' experiences after the DFG training were evaluated.

Methods

Dialogical Family Guidance development phases and implementation process are examined. The Revised Standards for Quality Improvement Reporting Excellence checklist (SQUIRE 2.0) was used to provide a framework for reporting new knowledge.

Results

The DFG training course seemed to increase possibilities of a more independent role as a nurse to deliver the DFG family intervention. The project showed that the use of dialogue can be difficult for some professionals. Analysis of the questionnaire completed after DFG training reported a high level of satisfaction. DFG training offered a new approach to deliver knowledge and understanding to families using dialogue, including tailored psychoeducation and emotional and practical guidance.

Improving medication safety practice at a community hospital: a focus on bar code medication administration scanning and pain reassessment

INTRODUCTION

In the USA over 30% of medication errors occur at the point of administration. Among non-surgical patients in US hospitals exposed to opioids, 0.6% experience a severe opioid-related adverse event. In September 2018, Sierra View Medical Center identified two areas of opportunity for quality improvement: bedside bar code medication administration (BCMA) and pain reassessments. At baseline (April 2018 to September 2018) only 81% of medications were scanned prior to administration with pain reassessments completed only 41% of the time 1 hour postopioid administration.

OBJECTIVE

To improve BCMA scanning rates (goal ≥95%) and pain reassessments within 1 hour postopioid administration (goal ≥90%).

METHODS

Implementation methods included data transparency, weekly dashboards, education and plan-do-study-act (PDSA) cycles informed by feedback from key stakeholders.

RESULTS

Following a series of PDSA cycle implementations, barcode medication administration (BCMA) scanning rates improved by 14% (from 81% to 95%) and pain reassessments improved by 50% (from 41% to 91%), sustained 17 months postproject implementation (October 2018 to February 2019). The number of adverse drug events (ADEs) related to administration errors decreased by 17% (estimated annual cost savings of $120 750-239 725 per year) and opioid-related ADEs decreased by 2.6% (estimated annual cost savings of $72 855-80 928 per year).

CONCLUSION

Adopting John Kotter's model for change, developing performance dashboards and sustaining engagement among stakeholders on a weekly basis improved bar code medication scanning rates and pain reassessment compliance. The stakeholders created momentum for change in both practice and culture resulting in improved patient safety with a favourable financial impact.

Choosing Wisely: Decreasing the incidence of perioperative blood transfusions in gynecologic oncology

OBJECTIVE

To evaluate the efficacy and economic impact of a transfusion reduction initiative for patients undergoing gynecologic surgery.

METHODS

We conducted a prospective healthcare improvement study to align transfusion practices with the American Society of Hematology's Choosing Wisely® campaign. Baseline transfusion rates were determined retrospectively for all major gynecologic surgical cases from 3/1/14 to 6/30/14. Data for the post-intervention period from 5/15/15 to 5/16/16 were captured prospectively. The primary outcome was transfusion within 72 h of surgery. Secondary outcomes included perioperative morbidity, mortality, number of units ordered per transfusion episode and cost.

RESULTS

We identified 1281 surgical cases, 334 in the baseline and 947 in the post-implementation cohort. The baseline cohort was noted to have a higher median estimated blood loss (100 v. 75 mL, P < 0.01). Otherwise, there were no differences in clinical or perioperative characteristics between the two cohorts. The perioperative transfusion rate decreased from 24% to 11% (adjusted OR 0.27, 95% CI 0.16 to 0.45; P < 0.001). The perioperative laparotomy transfusion rate decreased from 48% to 23% (adjusted OR 0.21, 95% CI 0.12, 0.37; P < 0.001). The number of occurrences in which more than one unit of blood was ordered at a time decreased from 65% to 23%, P < 0.001. The incidence of surgical site infections declined in the post-intervention group, otherwise there were no differences in 30-day mortality, cardiac, venous thromboembolism or readmission rates between the groups. The projected cost savings was $161,112 over the 12-month intervention period.

CONCLUSIONS

Implementation of an educational based transfusion reduction program was associated with substantial reductions in perioperative transfusions and cost without significant changes in morbidity or mortality.