SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): Revised Publication Guidelines from a Detailed Consensus Process

Changing the Culture to Improve CCF: An Improvement Project

OBJECTIVES

After identifying chest compression fraction (CCF) as a key area for improvement, our Emergency Medical Services (EMS) agency aimed to improve our baseline monthly median CCF from 81.5% to 90% or more in paramedic-attended medical cardiac arrests by December 2023. The CCF is a process measure that, if improved, has been shown to increase likelihood of survival from cardiac arrest. Working as a hospital EMS agency within a large urban 9-1-1 system, our interventions focused on paramedics once they arrived on scene.

METHODS

This project used repeated Plan-Do-Study-Act (PDSA) cycles with brainstorming sessions, focus groups, and data review to achieve improvement. Interventions included standardized clinician feedback forms, increased follow-up for patients with ongoing resuscitation, a designated CPR team leader during resuscitations, and a pre-charged defibrillator prior to rhythm checks. These interventions were evaluated by tabulating weekly and monthly median CCF performance, seeking participant feedback, and reviewing control charts. These results were reported according to the Revised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0).

RESULTS

Our control chart analysis revealed special cause variation and an increase in average CCF to 89.0%. This improvement was achieved through successful implementation of process changes using PDSA cycles. Our most effective and popular intervention was our clinician feedback forms. Additionally, re-unifying patients and their successful resuscitation teams, participating in resuscitation academy events, and pre-charging the defibrillator to minimize CPR pauses collectively resulted in systemic improvement in resuscitation performance.

CONCLUSIONS

The findings illustrate that targeted education, increased clinician feedback, patient-team reunification, and high-performance resuscitation strategies produce measurable improvement in CCF.

Multimodal Quality Initiatives in Sepsis Care: Assessing Impact on Core Measures and Outcomes

ABSTRACT

Providing timely and effective care for patients with sepsis is challenging due to delays in recognition and intervention. The Surviving Sepsis Campaign has developed bundles that have been shown to reduce sepsis mortality. However, hospitals have not consistently adhered to these bundles, resulting in suboptimal outcomes. To address this, a multimodal quality improvement sepsis program was implemented from 2017 to 2022 in a large urban tertiary hospital. The aim of this program was to enhance the Severe Sepsis and Septic Shock Management Bundle compliance and reduce sepsis mortality. At baseline, the Severe Sepsis and Septic Shock Management Bundle compliance rates were low, at 25%, with a sepsis observed/expected mortality ratio of 1.14. Our interventions included the formation of a multidisciplinary committee, the appointment of sepsis champions, the implementation of sepsis alerts and order sets, the formation of a Code Sepsis team, real-time audits, and peer-to-peer education. By 2022, compliance rose to 62%, and the observed/expected mortality ratio decreased to 0.73. Our approach led to improved outcomes and hospital rankings. These findings underscore the efficacy of a comprehensive sepsis care initiative, emphasizing the importance of interdisciplinary collaboration. A multimodal hospital-wide sepsis performance program is feasible and can contribute to improved outcomes. However, further research is necessary to determine the specific impact of individual strategies on sepsis outcomes.

Perioperative arterial catheterization: A prospective evaluation of ultrasound, infection, and patient-focused outcomes

BACKGROUND

There is little information regarding complications of arterial catheterization in modern clinical care. We aimed to determine the incidence of abnormal duplex vascular ultrasound and catheter related infections following perioperative arterial catheterization.

METHODS

Patients requiring arterial catheterization for elective surgery were included and insertion details collected prospectively. Duplex ultrasound evaluation was performed 24 h after catheter removal. Symptomatic patients were identified by self-reported questionnaire. On Day 7, patients answered questions by telephone, related to the insertion site, pain, and function. Results of catheter tip and blood culture analyses were sought. Univariate associations of patient and surgical characteristics with abnormal ultrasound were assessed with p < 0.05 considered significant.

RESULTS

Of 339 catheterizations, 105 (40%) had ultrasound evaluation. Catheters were indwelling for median (IQR, range) duration of 6.0 h (4.4-8.2, 1.8-28) with no catheter-related infections. There were 16 (15.2%, 95% CI 9.0%-23.6%) abnormal results, including 14 radial artery thromboses, one radial artery dissection, and one radial vein thrombosis. Those with abnormal ultrasound results were more likely to have had Arrow catheters inserted (68.8% vs 27%, p = 0.023) and more than one skin puncture (37.5% vs 26.8%, p = 0.031). Two of the 16 (12.5%) patients with abnormal ultrasound results reported new symptoms related to the hand compared with nine of the 88 (10.2%) with normal results (p = 0.1). No patients required urgent referral for management.

CONCLUSIONS

Thrombosis was the most common abnormality and was usually asymptomatic. There were no infections, few post-operative symptoms, and minimal functional impairment following arterial catheterization.

Nurses' career choice and satisfaction with mental health transition-to-practice programs: A cross sectional study

WHAT IS KNOWN ON THE SUBJECT?: There are significant issues recruiting nurses into mental health due to several reasons such as dilution of curriculum, and mental health being an unpopular career choice Transition programs provide nurses entering mental health with orientation, academic and clinical skills, and knowledge. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Transition programs need to be nuanced to specialty areas (e.g. community) to ensure nurses are given the support necessary to remain working in the field. Many nurses choose to work in mental health due to a lived or personal experience and as such strengthening wellbeing supports for transitioning nurses is an important role in retention. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Tailored transition programs can help strengthen mental health nurse role clarity, and support staff retention. Transition programs should be a segue to formal postgraduate studies in mental health nursing to strengthen professional practice and retention of nurses.

ABSTRACT

INTRODUCTION: Globally, there are consistent issues recruiting staff into the mental health nursing workforce. In Australia, recent efforts to expand the workforce include recruitment of a wider range of nurses in addition to new graduates into mental health transition-to-practice programs. Understanding the career motivations of nurses entering the field is an important element of recruitment and retention.

AIM

To describe nurses' satisfaction with their mental health transition program and identify factors influencing their choice of mental health as a career.

METHODS

An online cross-sectional survey with questions on program satisfaction and career choice was responded to by n = 55 enrolled and registered nurses in a mental health transition program.

RESULTS

Nurses reported overall high satisfaction with their program and identified increased time release for professional development and being supernumerary as necessary to support role development. Almost 25% of nurses reported personal experience of mental illness as an influence in choosing a mental health career.

DISCUSSION

Mental health transition programs are important in recruitment and retention and need to be tailored to the needs of a wide range of nurses and include support for staff wellbeing.

IMPLICATIONS FOR PRACTICE

Tailored transition programs can help strengthen role clarity, and support staff retention.

Tomada de Decisão Gerencial do Enfermeiro da Área Hospitalar: construção e validação de cenário de simulação

Resumo Objetivo: construir e validar um cenário de simulação clínica sobre a competência tomada de decisão gerencial do enfermeiro hospitalar para estudantes de graduação em enfermagem. Método: estudo descritivo e metodológico realizado em uma instituição de ensino superior, com a participação de 10 juízes e cinco atores. Utilizou-se o modelo conceitual de simulação proposto por Jeffries e guias padronizadas da International Nursing Association for Clinical Simulation in Learning para a elaboração do cenário e do checklist. Resultados: o cenário ficou denominado como “Tomada de decisão gerencial do enfermeiro diante de eventos adversos no contexto hospitalar”. Construiu-se o script do cenário e o checklist para a sua validação. Realizou-se validação de face e conteúdo do checklist. Posteriormente, juízes de posse do checklist, validaram o cenário que, em sua versão final, ficou composto por Prebriefing (sete itens), Cenário em Ação (18 itens) e Debriefing (sete itens). Conclusão: o cenário mostrou-se uma estratégia de ensino capaz de antecipar a realidade do futuro enfermeiro, trazendo autoconfiança na execução de suas atividades, contribuindo para agir de forma crítica e reflexiva durante o processo de tomada de decisão.

Script-based automatic radiotherapy planning for cervical cancer

BACKGROUND

This study aimed to develop fully automated script-based radiotherapy treatment plans for cervical cancer patients, and evaluate them against clinically accepted plans, as validation before clinical implementation.

MATERIAL AND METHODS

In this retrospective planning study, treatment plans for 25 locally advanced cervical cancer (LACC) patients with up to three dose levels were included. Fully automated plans were created using an in-house developed Python script in RayStation, and compared to clinically accepted manually made plans. Quantitatively, relevant dose statistics were compared, and average dose volume histograms (DVHs) were analyzed. Qualitatively, a blinded plan comparison was conducted between the clinical and automatic plans. The accuracy of treatment plan delivery was verified with the Delta4 Phantom+.

RESULTS

The quantitative evaluation showed that target coverage was acceptable for all the automatic and clinical plans. The automatic plans were significantly more conformal than the clinical plans; median of 1.03 vs. 1.12. Mean doses to almost all organs at risk (OARs) were reduced in the automatic plans, with a median reduction of between 0.6 Gy and 1.9 Gy. In the blinded plan comparison, the automatic plans were the preferred plans or of equal quality as the clinical plans in 99% of the cases. In addition, plan delivery was excellent, with a mean gamma passing rate of 99.8%. Complete script-based plans were generated in 30-45 min; about four to ten times faster than manually made plans.

CONCLUSION

The automatic plans had acceptable target coverage, lower doses to almost all OARs, more conformal dose distributions, and were predominantly preferred by the clinicians. Based on these results, our institution has implemented the script for clinical use.

Toma de Decisiones Gerenciales del Enfermero en el Área Hospitalaria: construcción y validación de un escenario de simulación

Resumen Objetivo: construir y validar un escenario de simulación clínica sobre la competencia en la toma de decisiones gerenciales del enfermero hospitalario para estudiantes del grado en enfermería. Método: estudio descriptivo y metodológico realizado en una institución de educación superior, con la participación de 10 jueces y cinco actores. Se utilizó el modelo conceptual de simulación propuesto por Jeffries y guías estandarizadas de la International Nursing Association for Clinical Simulation in Learning para la elaboración del escenario y del checklist. Resultados: el escenario se denominó “Toma de decisiones gerenciales del enfermero ante eventos adversos en el contexto hospitalario”. Se construyó el script del escenario y el checklist para su validación. Se realizó la validez aparente y el contenido del checklist. Posteriormente, los jueces en posesión del checklist, validaron el escenario que, en su versión final, quedó compuesto por Prebriefing (siete ítems), Escenario en Acción (18 ítems) y Debriefing (siete ítems). Conclusión: el escenario demostró ser una estrategia de enseñanza capaz de anticipar la realidad del futuro enfermero, trayendo autoconfianza en la ejecución de sus actividades, contribuyendo para actuar de forma crítica y reflexiva durante el proceso de toma de decisiones.

Publishing Quality Improvement Projects: Know the Guidelines Before Starting Your Project

Health care clinicians, educators, and students who plan and implement quality improvement (QI) projects must know reporting guidelines for successful project planning and publication. We aimed to identify QI guidelines, which authors can locate, and highlight how best to use them for manuscript preparation. We also address guidelines for educational QI projects. Because of the increasing number of Doctor of Nursing Practice projects generated, these students and their mentors must be familiar with commonly used guidelines for reporting QI projects to facilitate peer review, demonstrate quality and rigor of work, reduce revisions, and potentially accelerate a paper's acceptance for publication.

Telemedicine Has a Social Impact: An Italian National Study for the Evaluation of the Cost-Opportunity for Patients and Caregivers and the Measurement of Carbon Emission Savings

Background: Owing to COVID-19, all stakeholders have recognized the advantages of telehealth and they were available for its permanent implementation, both from the normative and economic point of view. It is, therefore, necessary to understand what were the real benefits created in society through telehealth. Objective: Develop a method to identify a social impact of telemedicine in Italy, considering the reduction on the patient moves with a consequent travel cost, time (opportunity costs), and carbon emission savings. Methods: Since March 2020, we have conducted a quality improvement study in 17 centers, collecting sociodemographic variables. To assess the social impact, we transform the data into outcome measures. The protocol used "Telemedicina Subito" allows the rapid implementation of telemedicine, using operating manual, structured according Health Technology Assessment approach. Results: We collected data related to 2,091 televisits, analyzing three different perspectives. First, one patient with a televisit had a saving equal to the median of EUR 97.16 (interquartile range [IQR]: 64.29-159.69), USD 113.88; considering that the median cost for the visit in presence was EUR 105.91 (p-value <0.05) and after the use of telehealth had a median of EUR 0 (mean: EUR 14.70; p-value <0.05). Second, informal caregivers have a median savings of EUR 65.06 (IQR: 55.52-89.21), USD 76.26. Finally, for one single telemedicine visits we can contribute with a median carbon emission savings of ∼13 kg (IQR: 6-24). Conclusions: The evaluation of the social impact on telemedicine facilitated the creation of an important framework for decision-makers.

Transition to Reusable Surgical Gowns at a Hospital System

This quality improvement study investigates the feasibility of transitioning back to reusable surgical gowns at a US tertiary hospital system and projected corresponding cost savings and solid waste reduction.

Educational training to improve opioid overdose response among health center staff: a quality improvement initiative

BACKGROUND

There were seven opioid overdoses in this New York City (NYC) federally qualified health center from December 2018 through February 2019, reflecting the rising rate of overdose deaths in NYC overall at the time. In response to these overdoses, we sought to increase the readiness of health center staff to recognize and respond to opioid overdoses and decrease stigmatizing attitudes around opioid use disorder (OUD).

METHODS

An hour-long training focusing on opioid overdose response was administered to clinical and non-clinical staff of all levels at the health center. This training included didactic education on topics such as the overdose epidemic, stigma around OUD, and opioid overdose response, as well as discussion. A structured assessment was administered immediately before and following the training to evaluate change in knowledge and attitudes. Additionally, participants completed a feedback survey immediately after the training to assess acceptability. Paired t-tests and analysis of variance tests were used to assess changes in pre- and post-test scores.

RESULTS

Over 76% of the health center staff participated in the training (N = 310). There were large and significant increases in mean knowledge and attitudinal scores from pre- to post-test (p < .001 and p < .001, respectively). While there was no significant effect of profession on attitudinal change scores, profession did have a significant effect on knowledge change scores, with administrative staff, non-clinical support staff, other healthcare staff, and therapists learning significantly more than providers (p < .001). The training had high acceptability among participants from diverse departments and levels.

CONCLUSIONS

An interactive educational training increased staff's knowledge and readiness to respond to an overdose as well as improved attitudes toward individuals living with OUD.

TRIAL REGISTRATION

This project was undertaken as a quality improvement initiative at the health center and as such was not formally supervised by the Institutional Review Board per their policies. Further, per the guidelines of the International Committee of Medical Journal Editors, registration is not necessary for clinical trials whose sole purpose is to assess an intervention's effect on providers.

Improving the efficiency of virtual insulin teaching for patients admitted to hospital through the COVID-19 pandemic: a quality improvement initiative

BACKGROUND

Throughout the COVID-19 pandemic, many areas of medicine transitioned to virtual care. For patients with diabetes admitted to hospital, this included diabetes education and insulin teaching. Shifting to a virtual model of insulin teaching created new challenges for inpatient certified diabetes educators (CDE).

OBJECTIVE

We advanced a quality improvement project to improve the efficiency of safe and effective virtual insulin teaching throughout the COVID-19 pandemic. Our primary aim was to reduce the mean time between CDE referral to successful inpatient insulin teach by 0.5 days.

DESIGN, SETTING, PARTICIPANTS

We conducted this initiative at two large academic hospitals between April 2020 and September 2021. We included all admitted patients with diabetes who were referred to our CDE for inpatient insulin teaching and education.

INTERVENTION

Alongside a multidisciplinary team of project stakeholders, we created and studied a CDE-led, virtual (video conference or telephone) insulin teaching programme. As tests of change, we added a streamlined method to deliver insulin pens to the ward for patient teaching, created a new electronic order set and included patient-care facilitators in the scheduling process.

MAIN OUTCOME AND MEASURES

Our main outcome measure was the mean time between CDE referral and successful insulin teach-back. Our process measure was the percentage of successful insulin pen deliveries to the ward for teaching. As balance measures, we captured the percentage of patients with a successful insulin teach, the time between insulin teach and hospital discharge, and readmissions to hospital for diabetes-related complications.

RESULTS

Our tests of change improved the efficiency of safe and effective virtual insulin teaching by 0.27 days. The virtual model appeared less efficient than usual in-person care.

CONCLUSIONS

In our centre, virtual insulin teaching supported patients admitted to hospital through the pandemic. Improving the administrative efficiency of virtual models and leveraging key stakeholders remain important for long-term sustainability.

Implementation of a Standardized Shared Decision-making Bundle to Improve Communication Practices in the Neurocritical Care Unit

Background and Objective

Shared decision-making (SDM) aligns patient preferences with health care team treatment goals. This quality improvement initiative implemented a standardized SDM bundle within a neurocritical care unit (NCCU), where unique demands make existing, provider-driven SDM practices challenging.

Methods

An interprofessional team defined key issues, identified barriers, and created change ideas to drive implementation of an SDM bundle using the Institute for Healthcare Improvement Model for Improvement framework incorporating Plan-Do-Study-Act cycles. The SDM bundle included (1) a health care team huddle pre-SDM and post-SDM conversation; (2) a social worker-driven SDM conversation with the patient family, including core standardized communication elements to ensure consistency and quality; and (3) an SDM documentation tool within the electronic medical record to ensure the SDM conversation was accessible to all health care team members. The primary outcome measure was percentage of SDM conversations documented.

Results

Documentation of SDM conversations improved by 56%, from 27% to 83% pre/postintervention. Average time to documentation decreased by 4 days, from day 9 preintervention to day 5 postintervention. There was no significant change in NCCU length of stay, nor did palliative care consultation rates increase. Postintervention, SDM team huddle compliance was 94.3%.

Discussion

A team-driven, standardized SDM bundle that integrates with health care team workflows enabled SDM conversations to occur earlier and resulted in improved documentation of SDM conversations. Team-driven SDM bundles have the potential to improve communication and promote early alignment with patient family goals, preferences, and values.

Managerial Decision-Making of Nurses in Hospitals: creation and validation of a simulation scenario

OBJECTIVE

to build and validate a clinical simulation scenario on hospital nurse managerial decision-making competence for undergraduate nursing students.

METHOD

a descriptive and methodological study was carried out in a higher education institution, with the participation of 10 judges and five players. To do so, the conceptual simulation model proposed by Jeffries and standards of the International Nursing Association for Clinical Simulation and Learning were used to prepare the scenario and the checklist.

RESULTS

the scenario was called "Managerial decision-making of nurses in the face of adverse events in a hospital". The scenario script and checklist were built for validation. The checklist was face- and content-validated. Afterward, judges used the checklist to validate the scenario, which, in its final version, was composed of Prebriefing (seven items), Scenario in Action (18 items) and Debriefing (seven items).

CONCLUSION

the scenario proved to be a teaching strategy that anticipates the reality of future nurses, bringing them the self-confidence to perform their activities and helping them to act critically and reflectively during decision-making processes.

Improving Timely Antibiotic Administration for Pediatric Oncology Patients With Neutropenic Fever Seen in the Emergency Department

OBJECTIVE

To improve the care for pediatric oncology patients with neutropenic fever who present to the emergency department (ED) by administering appropriate empiric antibiotics within 60 minutes of arrival.

PATIENTS AND METHODS

We focused on improving the care for pediatric oncology patients at risk of neutropenia who presented to the ED with concern for fever. Our baseline adherence to the administration of empiric antibiotics within 60 minutes for this population was 53% (76/144) from January 1, 2010, to December 21, 2014. During 2015, we reviewed data monthly, finding 73% adherence. We used the Lean methodology to identify the process waste, completed a value-stream map with input from multidisciplinary stakeholders, and convened a root cause analysis to identify causes for delay. The 4 causes were as follows: (1) lack of staff awareness; (2) missing patient information in electronic medical record; (3) practice variation; and 4) lack of clear prioritization of laboratory draws. We initiated Plan-Do-Study-Act cycles to achieve our goal of 80% of patients receiving appropriate empiric antibiotics within 60 minutes of arrival in the ED.

RESULTS

Five Plan-Do-Study-Act cycles were completed, focusing on the following: (1) timely identification of patients by utilizing the electronic medical record to initiate a page to the care team; (2) creation of a streamlined intravascular access process; (3) practice standardization; (4) convenient access to appropriate antibiotics; and (5) care team education. Timely antibiotic administration increased from 73%-95% of patients by 2018. More importantly, the adherence was sustained to greater than 90% through 2021.

CONCLUSION

A structured and multifaceted approach using quality improvement methodologies can achieve and sustain improved patient care outcomes in the ED.

Implementation of an evidence-based accidental tracheostomy dislodgement bundle in a community hospital critical care unit

BACKGROUND

Tracheostomy dislodgment can lead to catastrophic neurological injury or death. A fresh tracheostomy amplifies the risk of such events, where an immature tract predisposes to false passage. Unfortunately, few resources exist to prepare healthcare professionals to manage this airway emergency.

AIM

To create and implement an accidental tracheostomy dislodgement (ATD) bundle to improve knowledge and comfort when responding to ATD.

MATERIALS & METHODS

A multidisciplinary team with expertise in tracheostomy developed a 3-part ATD bundle including (1) Tracheostomy Dislodgement Algorithm, (2) Head of Bed Tracheostomy Communication Tool and (3) Emergency Tracheostomy Kit. The team tested the bundle during the COVID-19 pandemic in a community hospital critical care unit with the engagement of nurses and Respiratory Care Practitioners. Baseline and post-implementation knowledge and comfort levels were measured using Dorton's Tracheotomy Education Self-Assessment Questionnaire, and adherence to protocol was assessed. Reporting follows the revised Standards for Quality Improvement Reporting Excellence (SQUIRE).

RESULTS

Twenty-four participants completed pre-test and post-test questionnaires. The median knowledge score on the Likert scale increased from 4.0 (IQR = 1.0) pre-test to 5.0 (IQR = 1.0) post-test. The median comfort level score increased from 38.0 (IQR = 7.0) pre-test to 40.0 (IQR = 5.0) post-test). In patient rooms, adherence was 100% for the Head of Bed Tracheostomy Communication Tool and Emergency Tracheostomy Kit. The adherence rate for using the Dislodgement Algorithm was 55% in ICU and 40% in SCU.

DISCUSSION

This study addresses the void of tracheostomy research conducted in local community hospitals. The improvement in knowledge and comfort in managing ATD is reassuring, given the knowledge gap among practitioners demonstrated in prior literature. The ATD bundle assessed in this study represents a streamlined approach for bedside clinicians - definitive management of ATD should adhere to comprehensive multidisciplinary guidelines.

CONCLUSIONS

ATD bundle implementation increased knowledge and comfort levels with managing ATD. Further studies must assess whether ATD bundles and other standardised approaches to airway emergencies reduce adverse events. Relevance to Clinical Practice A streamlined intervention bundle employed at the unit level can significantly improve knowledge and comfort in managing ATD, which may reduce morbidity and mortality in critically ill patients with tracheostomy.

Building a virtual community of practice: experience from the Canadian foundation for healthcare improvement's policy circle

BACKGROUND

Communities of Practice are formed by people who interact regularly to engage in collective learning in a shared domain of human endeavor. Virtual Communities of Practice (VCoP) are online communities that use the internet to connect people who share a common concern or passion. VCoPs provide a platform to share and enhance knowledge. The Policy Circle is a VCoP that connects mid-career professionals from across Canada who are committed to improving healthcare policy and practice. We wanted to understand the perceived value of the VCoP.

METHODS

We used qualitative and quantitative survey research to explore past and current Policy Circle members' thoughts, feelings, and behaviours related to the program. Our research was guided by the Value Creation Framework proposed by Wenger and colleagues. Three surveys were created in collaboration with stakeholders. Data were analyzed within cohort and in aggregate across cohorts. Qualitative data was analyzed thematically, and quantitative data was analyzed using descriptive statistics (means of ranked and scaled responses).

RESULTS

Survey participation was high among members (Cohort 1: 67%, Cohort 2: 64%). Participants came from a variety of disciplines including medicine, health policy, allied health, and nursing, with most members having a direct role in health services research or practice. The program was successful in helping participants make connections (mean = 2.43 on a scale from 1 to 5: 1 = yes, significantly, 5 = not at all); variances in both qualitative and quantitative data indicated that levels of enthusiasm within the program varied among individuals. Members appreciated the access to resources; quarterly meetings (n = 11/11), and a curated reading list (n = 8/11) were the most valued resources. Participants reported the development of a sense of belonging (mean = 2.29) and facilitated knowledge exchange (mean = 2.43). At the time of this study, participants felt the program had minor impact on their work (mean = 3.5), however a majority of participants (50%) from Cohort 2 planned to acknowledge the program in their professional or academic endeavours. Through reflective responses, participants expressed a desire for continued and deeper professional network development.

CONCLUSIONS

The Policy Circle was successful in facilitating knowledge exchange by creating a community that promoted trust, a sense of belonging and a supportive environment. Members were satisfied with the program; to promote further value, the Policy Circle should implement strategies that will continue member participation and networking after the program is finished.

Reducing hyperglycaemia post-kidney and liver transplant: a quality improvement initiative

Background

In-hospital glycaemic management can reduce post-transplant morbidity, but is not always part of transplant care.

Objective

We aimed to reduce the mean number of postoperative days in hyperglycaemia (≥2 blood glucose >12 mmol/L in 24 hours) in kidney and liver transplant recipients by 30%. We also aimed to reduce the mean number of days between transplant admission to endocrine consult by 2.0 days.

Design, setting, participants

We conducted a quality improvement project in liver and kidney transplant recipients admitted to an academic transplant unit in Canada between 1 March 2019 and 1 May 2021.

Intervention

We developed a bedside algorithm to monitor post-transplant capillary blood glucose; the algorithm also included thresholds for nursing-initiated inpatient endocrinology consultation.

Main outcome and measures

We examined outcome (postoperative days in hyperglycaemia, days to inpatient endocrine consultation), process (nursing documentation of postoperative blood sugars) and balancing measures (nursing workload, postoperative days in hypoglycaemia) following implementation of our algorithm. We used Plan-Do-See-Act cycles to study three iterations of our algorithm, and used box plots to present outcomes before and after algorithm implementation.

Results

In the pre-intervention period, 21 transplant recipients spent a mean of 4.1 (SD 2.4) postoperative days in hyperglycaemia before endocrine consultation. The mean number of days between hospital admission to endocrine consult was 10.7 (SD 13.0) days.

In the post-intervention period, we observed a 62% reduction in postoperative days in hyperglycaemia. The mean number of days between admission and endocrine consult was reduced by 6.3 days (59% reduction).

Conclusions

Implementation of a simple, bedside algorithm for postoperative glucose monitoring and detection of hyperglycaemia in transplant patients, reduced the mean number of postoperative days in hyperglycaemia and time to inpatient endocrine consultation. Our algorithm continues to be used in our academic transplant unit.

Care bundles to reduce unplanned extubation in critically ill children: a systematic review, critical appraisal and meta-analysis

OBJECTIVE

To assess the current evidence for the efficacy of care bundles in reducing unplanned extubations (UEs) in critically ill children.

DESIGN

Systematic review according to the Cochrane guidelines and meta-analysis using random-effects modelling.

METHODS

We searched MEDLINE, EMBASE, CINAHL, Web of Science, Scopus, Cochrane and SciELO databases from inception until April 2021. We conducted a quality appraisal for each study using the Newcastle-Ottawa Scale and Standards for Quality Improvement Reporting Excellence (SQUIRE) V.2.0 checklist.

MAIN OUTCOME

The primary outcome measure was UE rates per 100 intubation days.

RESULTS

We screened 10 091 records and finally included 11 studies. Six studies were pre/post-intervention studies, and five were interrupted time-series studies. The methodological quality was 'good' in 70%, and the remaining as 'fair' (30%). The most frequently used implementation strategies were staff education (100%), root cause analysis (100%), and audit and feedback (82%). Key bundle care components comprised identification of high-risk patients, endotracheal tube care and sedation protocol. Not all studies fully completed the SQUIRE V.2.0 checklist. Meta-analysis revealed a reduction in UE rate following the introduction of care bundles (rate ratio: 0.40 (95% CI: 0.19 to 0.84); p=0.02), which equates to a 60% reduction in UE rates.

CONCLUSIONS

We found that identifying high-risk patients, endotracheal tube care and protocol-directed sedation are core elements in care bundles for preventing UEs. However, there are several methodological gaps in the literature, including poor evaluation of adherence to bundle components. Future studies should address these gaps to strengthen their validity.

Impact of a multifaceted and multidisciplinary intervention on pain, agitation and delirium management in an intensive care unit: an experience of a Canadian community hospital in conducting a quality improvement project

BACKGROUND

Clinical guidelines suggest that routine assessment, treatment, and prevention of pain, agitation, and delirium (PAD) is essential to improving patient outcomes as delirium is associated with increased mortality and morbidity. Despite the well-established improvements on patient outcomes, adherence to PAD guidelines is poor in community intensive care units (ICU). This quality improvement (QI) project aims to evaluate the impact of a multifaceted and multidisciplinary intervention on PAD management in a Canadian community ICU and to describe the experience of a Canadian community hospital in conducting a QI project.

METHODS

A ten-member PAD advisory committee was formed to develop and implement the intervention. The intervention consisted of a multidisciplinary rounds script, poster, interviews, visual reminders, educational modules, pamphlet and video. The 4-week intervention targeted nurses, family members, physicians, and the multidisciplinary team. An uncontrolled, before-and-after study methodology was used. Adherence to PAD assessment guidelines by nurses was measured over a 6-week pre-intervention and over a 6-week post-intervention periods.

RESULTS

Data on 430 and 406 patient-days (PD) were available for analysis during the pre- and post- intervention periods, respectively. The intervention did not improve the proportion of PD with guideline compliance to the assessment of pain (23.4% vs. 22.4%, p=0.80), agitation (42.9% vs. 38.9%, p=0.28), nor delirium (35.2% vs. 29.6%, p=0.10) by nurses.

DISCUSSION

The implementation of a multifaceted and multidisciplinary intervention on PAD assessment did not result in significant improvements in guideline adherence in a community ICU. Barriers to knowledge translation are apparent at multiple levels including the personal level (low completion rates on educational modules), interventional level (under-collection of data), and organisational level (coinciding with hospital accreditation education). Our next steps include reintroduction of education modules using organisation approved platforms, updating existing ICU policy, updating admission order sets, and conducting audit and feedback.

Quality Initiative for the Administration of Vancomycin Prophylaxis in Penicillin-Allergic Neurosurgery Patients

Introduction

Vancomycin may be used as an alternative perioperative antibiotic for penicillin-allergic patients but follows a different infusion timing. At the institution presented herein, noncompliance with recommended vancomycin infusion timing has been hypothesized to contribute toward increased risk of surgical site infections and avoidable expenditures. The objective of this project was to utilize the Performance Improvement In Action methodology to identify, address, and solve the problem of vancomycin administration timing.

Methodology

This study took place at a multi-hospital, urban academic medical center. The protocol was developed by neurosurgery and anesthesia faculty, advanced practice providers, nursing, and pharmacy. Timing of the following points was recorded: initial order, order release, pharmacy verification, vancomycin infusion, and surgical incision. Fifty consecutive penicillin-allergic patients undergoing neurosurgical intervention were prospectively enrolled. Data comparison was made between the pilot and retrospective review cohorts.

Results

The pilot cohort achieved correct administration of vancomycin in 100% of cases. Average infusion start time prior to incision increased by 257% (p<0.0001).

Conclusions

This study demonstrates a departmental capacity for optimized timing of vancomycin infusions, in a budget- and workflow-neutral process, while reducing inappropriate administration. In the future, this protocol may be scaled to additional departments and institutions to appropriately and efficiently administer perioperative vancomycin and mitigate the risk for surgical site infections.

Evaluation of Sexual Harassment Policies at Medical Institutions to Understand Attention to Harassment of Physicians by Patients

This quality improvement study assesses the policies of top US medical centers for addressing sexual harassment of physicians by patients.

Utilisation of the 2019 IWGDF diabetic foot infection guidelines to benchmark practice and improve the delivery of care in persons with diabetic foot infections

Aims

To utilise the 2019 International Working Group on the Diabetic Foot (IWGDF) - diabetic foot infection (DFI) guidelines as an audit tool for clinical practice in patients with diabetes attending a High-Risk Foot Service.

Methods

Data from 93 consecutive patients were collected over a 19-month period in patients attending a High-Risk Foot Service. The diagnosis and management of each patient in the sample were compared against the 2019 IWGDF DFI guidelines, grouped into four categories: Diagnosis, Microbiology, Treatment of soft tissue infection, and Surgical treatment and osteomyelitis. Deficits in performance were recorded using the recommendations as a benchmark standard.

Results

There were 109 DFI events. Nineteen (63%) of the recommendations were met, 7 (24%) were partially met, and four (13%) recommendations were not met. Fourteen of the sample had no documented requests for full blood counts. Tissue was obtained for culture in 32 (29%) of the sample. No percutaneous bone biopsies were performed. Only 13 (28%) patients had intraoperative bone specimens sent for culture and sensitivities, with no bone specimens sent for histopathology. Modification of antibiotic therapy following available culture results was low, occurring in 12 out of 63 possible occasions (19%). The duration of antibiotic regimens in PEDIS 2 infections and osteomyelitis was greater than that recommended.

Conclusions

Utilising the IWGDF DFI guidelines to benchmark clinical practice is a useful tool to identify gaps in clinical performance or service delivery and may help to improve patient care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13047-021-00448-w.

Strategies for Strengthening Quality Improvement Projects in a Doctor of Nursing Practice Program

BACKGROUND

Doctor of Nursing Practice (DNP) programs must assure that attention to safe quality healthcare is threaded throughout the curriculum and prepare students to lead quality improvement (QI) initiatives in healthcare systems.

OBJECTIVE

This article illustrates the integration of implementation science, QI methods, process and evaluation tools, and faculty enrichment as strategies to strengthen QI projects in a DNP program.

METHODS

A three-phased approach to implement strategies to strengthen QI projects in a DNP program and to enhance faculty engagement was undertaken. A needs assessment drove the development of strategies to strengthen QI in a DNP program.

RESULTS

Outcomes of implementing strategies to strengthen QI in a DNP program showed rapid uptake of the concepts of QI process models into course content within the DNP curriculum.

CONCLUSIONS

Strategies consisted of assessment of courses for gaps in QI content, faculty enrichment sessions on implementation science, QI processes and models, QI metrics and data analytics, embedding new content in the DNP program courses and the use of a rigorous evaluation tool for QI projects.

IMPLICATIONS FOR NURSING

When provided with QI mentors and tools, DNP students are prepared to lead QI initiatives in healthcare systems to improve the safety and quality of healthcare.

Prospective Investigation of the Operating Room Time-Out Process

BACKGROUND

Although the surgical pause or time-out is a required part of most hospitals' standard operating procedures, little is known about the quality of execution of the time-out in routine clinical practice. An interactive electronic time-out was implemented to increase surgical team compliance with the time-out procedure and to improve communication among team members in the operating room. We sought to identify nonroutine events that occur during the time-out procedure in the operating room, including distractions and interruptions, deviations from protocol, and the problem-solving strategies used by operating room team members to mitigate them.

METHODS

Direct observations of surgical time-outs were performed on 166 nonemergent surgeries in 2016. For each time-out, the observers recorded compliance with each step, any nonroutine events that may have occurred, and whether any operating room team members were distracted.

RESULTS

The time-out procedure was performed before the first incision in 100% of cases. An announcement was made to indicate the start of the time-out procedure in 163 of 166 observed surgeries. Most observed time-outs were completed in <1 minute. Most time-outs were completed without interruption (92.8%). The most common reason for an interruption was to verify patient information. Ten time-out procedures were stopped due to a safety concern. At least 1 member of the operating room team was actively distracted in 10.2% of the time-out procedures observed.

CONCLUSIONS

Compliance with preincision time-outs is high at our institution, and nonroutine events are a rare occurrence. It is common for ≥1 member of the operating room team to be actively distracted during time-out procedures, even though most time-outs are completed in under 1 minute. Despite distractions, there were no wrong-site or wrong-person surgeries reported at our hospital during the study period. We conclude that the simple act of performing a preprocedure checklist may be completed quickly, but that distractions are common.

Quality Initiative to Improve time to Antibiotics for Febrile Pediatric Patients with Potential Neutropenia

Introduction

In patients who are immunocompromised, fever may indicate a life-threatening infection. Prompt time to antibiotic administration in febrile patients at risk for neutropenia has been identified by national and international panels as a key benchmark of quality care in emergent situations. A quality improvement initiative to improve health care provided in a pediatric emergency department (ED) is described.

Methods

A clinical pathway was previously initiated in a pediatric ED with a goal of improving time to antibiotics for febrile neutropenia patients. An agreed upon pathway and order set being initiated. Improvements were seen but not to the desired level. This project involved an improvement cycle that focused on nonvalue added time in the workflow.

Results

Percent of patients receiving antibiotics within the goal time of 1 hour increased from 40% to 80% with the intervention. Process measures including arrival to ED bed time, ED bed to antibiotic order time and antibiotic order time to delivery time were followed.

Conclusion

Clinical guidelines, order sets and detailed understanding of the actual workflow at the point of care delivery can be instrumental in achieving the goals of reducing time to antibiotics.