An Advanced Nursing Directive for Children with Suspected Appendicitis: Protocol for a Quality Improvement Feasibility Study (Preprint)

2021 ◽  
Author(s):  
Hanu Chaudhari ◽  
Michelle Schneeweiss ◽  
Reid Rebinsky ◽  
Enrico Rullo ◽  
Mohamed Eltorki
Keyword(s):  
Quality Improvement ◽  
Retrospective Chart Review ◽  
Family Satisfaction ◽  
Study Endpoint ◽  
Quality Improvement Initiative ◽  
Continuous Variables ◽  
Suspected Appendicitis ◽  
Physician Assessment ◽  
Before And After ◽  
Satisfaction Surveys

BACKGROUND Pediatric appendicitis accounts for an estimated 7-10% of abdominal pain cases in the emergency department (ED). The diagnosis is time consuming, and the investigative process is dependent on physician assessment, resulting in delays in diagnosis and therapeutic management. The utility of an advanced nursing directive to expedite this process is unclear and needs further exploration. OBJECTIVE Our study aims to describe key components of ED flow in suspected appendicitis patients seen at a pediatric ED and pilot a directive that allows ED nurses to perform an order-set that includes blood work, urine tests, analgesics, fluids, and order an abdominal-pelvis ultrasound prior to physician assessment. METHODS This study involves conducting a retrospective chart review alongside a quality improvement initiative to compare key ED flow metrics before and after advanced nursing directive implementation. Primary outcome measures include median time from ED triage assessment to ultrasound completion, analgesia administration, bloodwork results, time to disposition (consult or discharge), alongside other key ED flow metrics for suspected appendicitis. Secondary outcomes will involve patient and caretaker satisfaction surveys. Descriptive statistics will be used to summarize the data. For differences in proportions, a χ2 test will be used. Student’s t-test will be used for continuous variables. A variable-controlled run chart will be performed to assess impact on ED flow metrics. Patient and family satisfaction surveys are administered immediately after the directive encounter and seven days afterwards. RESULTS There are currently 3900 patients who have been screened, 344 patients enrolled, and 90 patients who have received the medical directive since implementation in June 2020. Interim results on reduction of time to diagnostic and therapeutic ED flow parameters and satisfaction surveys are expected to be published in February 2022. The final study endpoint will be in June 2022. CONCLUSIONS This study proposes a novel protocol for improving the diagnosis and treatment of suspected pediatric appendicitis through implementation of an evidence-based advanced nursing directive. This model may provide a standardized, international pathway for management of common pediatric and adult emergencies.

scholarly journals Implementing a Protocol to Reduce Opioid Prescriptions in Military Otolaryngology: A Quality Improvement Initiative

2021 ◽  
Author(s):  
CindyLee P Neighbors ◽  
Michael W Noller ◽  
Michael P Avillion ◽  
John W Neighbors ◽  
Mark C Spaw ◽  
...  
Keyword(s):  
Retrospective Chart Review ◽  
Outcome Variable ◽  
Quality Improvement Initiative ◽  
New Order ◽  
Opioid Prescription ◽  
Medication Refill ◽  
Before And After ◽  
Patient Pain ◽  
Prescription Rates ◽  
Order Set

ABSTRACT Introduction To compare pain medication refill rates for adult septoplasty and rhinoplasty patients before and after initiating a multimodal analgesic protocol for reducing opioid prescriptions (PROP). Materials and Methods Data from 58 adult patients were retrieved by retrospective chart review (19 septoplasties and 10 rhinoplasties before initiating PROP in September 2018 and 21 septoplasties and 8 rhinoplasties after PROP). We selected consecutive septoplasties and rhinoplasties, at which time a new discharge order set was implemented. The new order set consisted of 10 oxycodone tabs (5 mg), 100 acetaminophen tabs (325 mg), and 28 celecoxib tabs (200 mg). The primary outcome variable was the number of initial opioid prescriptions and refills filled by any provider. Results Among the septoplasties, there was a 46% decrease in total morphine milligram equivalent (MME) prescribed, from a mean of 202.0 mg in the non-PROP group (95% CI, 235.4, 174.6) to 108.6 mg in the PROP group (95% CI, 135.8, 81.4), with no difference in refill rates. Among the rhinoplasties, there was a 51% decrease in total MME prescribed, from a mean of 258.8 mg in the non-PROP group (95% CI, 333.4, 184.1) to 126.6 mg in the PROP group (95% CI, 168.1, 85.0) with no difference in refill rates. Conclusions The outcomes after PROP implementation for septoplasty and rhinoplasty at our institution suggest that opioid prescription rates can be significantly decreased to manage postoperative pain, with no difference in opioid refill rates. The results also warrant further investigation into patient pain, satisfaction, provider efficiency, and healthcare costs.

Improving Hydroxychloroquine Dosing and Toxicity Screening at a Tertiary Care Ambulatory Center: A Quality Improvement Initiative

2020 ◽  
Vol 48 (1) ◽  
pp. 138-144
Author(s):  
Sahil Koppikar ◽  
Stephanie Gottheil ◽  
Chandra Farrer ◽  
Natasha Gakhal
Keyword(s):  
Quality Improvement ◽  
Tertiary Care ◽  
Retrospective Chart Review ◽  
Retinal Toxicity ◽  
Force Function ◽  
Quality Improvement Initiative ◽  
Toxicity Screening ◽  
Number Of Patients ◽  
Retinal Screening ◽  
Retinopathy Screening

Objective.Hydroxychloroquine (HCQ) is a commonly used weight-based medication with a risk of retinal toxicity when prescribed at doses above 5 mg/kg/day. The objectives of our study were (1) to characterize the frequency of inappropriate HCQ dosing and retinopathy screening, and (2) to improve guideline-based management by implementing quality improvement (QI) strategies.Methods.A retrospective chart review was performed to obtain baseline analysis of HCQ dosing, weight documentation, and retinal toxicity screening to characterize current practices. The primary aim was to increase the percentage of patients appropriately dosed from 30% to 90% over a 10-month period. The secondary aim was to increase the percentage of documented retinal screening from 59% to 90%. The process measure was the number of patients with a documented weight in the chart. The balancing measure was the physician’s perceived increase in time spent with each patient due to implemented interventions. QI methodology was used to implement sequential change ideas: (1) HCQ weight-based dosing charts to facilitate prescription regimens; (2) addition of scales to patient rooms to facilitate weight documentation; and (3) electronic medical record (EMR) “force function” involving weight documentation and autodosing prescription.Results.The percentage of patients being weighed increased from 40% to 92% after 10 months. Appropriate HCQ dosing improved from 30% to 89%. Retinal screening documentation improved by 33%.Conclusion.Dosing charts in clinic rooms, addition of weight scales, and EMR force function autodosing prescriptions significantly improved appropriate HCQ dosing practices. These interventions are generalizable and can promote safe and guideline-based care.

Impact of an Interprofessional Collaborative Quality Improvement Initiative to Decrease Inappropriate Thyroid Function Testing

2020 ◽  
pp. 001857872092079
Author(s):  
Alyssa B. Bradshaw ◽  
Alex K. Bonnecaze ◽  
Cynthia A. Burns ◽  
James R. Beardsley
Keyword(s):  
Quality Improvement ◽  
Thyroid Function ◽  
Medical Center ◽  
Cost Savings ◽  
Thyroid Stimulating Hormone ◽  
Quality Improvement Initiative ◽  
Published Data ◽  
Free T4 ◽  
Potential Cost ◽  
Before And After

Background: Published data show that thyroid function laboratory tests are often ordered inappropriately in the acute care setting, which leads to unnecessary costs and inappropriate therapy decisions. Pilot data at our institution indicated that approximately two-thirds of the thyroid-stimulating hormone (TSH) laboratories were unnecessary, correlating to a potential cost avoidance of more than $20,000 annually. The purpose of this study was to improve the appropriateness of thyroid function test ordering with a multipronged initiative. Methodology: This controlled, single-center, before and after study included inpatients or emergency department (ED) patients at Wake Forest Baptist Medical Center who were at least 18 years of age and had a TSH level ordered during the study period. Patients with a history of thyroid cancer were excluded. The initiative included an electronic ordering intervention, direct education of providers (medical residents, attendings, and clinical pharmacists), and distribution of pocket information cards with appropriate ordering criteria. The primary outcome was the number and percentage of inappropriate TSH tests ordered before and after implementing the 3 interventions. Secondary outcomes included cost savings, inappropriate changes in thyroid therapy based on improperly ordered tests, and the number of free T4 lab tests ordered on patients with a TSH within the therapeutic range. Results: All 3 interventions were implemented, except for education of ED residents and faculty, who chose to forgo the direct education component. Inappropriate ordering of TSH levels decreased from 63 to 50 (13% reduction, P = .062) after implementation. Inappropriate TSH ordering decreased across all services, except in the ED. Inappropriate Free T4 orders decreased from 191 to 133 (30% reduction, P = .01). There were no therapy changes based on inappropriate TSH orders. Extrapolated annual cost savings were approximately $6,000. Conclusion: This multipronged interprofessional collaborative quality improvement initiative was associated with a nonstatistically significant reduction in inappropriate TSH orders, statistically significant reduction in inappropriate free T4 orders, and cost savings. There was a reduction in inappropriate ordering across all services except the ED, which may have been due the ED not participating in the direct education component of the initiative.

Improving Follow-Up of Tests Pending at Discharge

2021 ◽  
Vol 11 (12) ◽  
pp. 1363-1369
Author(s):  
Andrew R. Shriner ◽  
Richelle M. Baker ◽  
Andrew Ellis ◽  
Rebecca Dixon ◽  
Michele Saysana
Keyword(s):  
Quality Improvement ◽  
Quality Care ◽  
Retrospective Chart Review ◽  
Primary Outcome Measure ◽  
Quality Improvement Initiative ◽  
Average Percentage ◽  
Ensure Patient Safety ◽  
Discharged Patients ◽  
Quality Improvement Interventions

BACKGROUND AND OBJECTIVES Follow-up on results of inpatient tests pending at discharge (TPAD) must occur to ensure patient safety and high-quality care continue after discharge. We identified a need to improve follow-up of TPAD and began a quality improvement initiative with an aim of reducing the rate of missed follow-up of TPAD to ≤20% within 12 months. METHODS The team used the Plan-Do-Study-Act method of quality improvement and implemented a process using reminder messages in the electronic health record. We collected data via retrospective chart review for the 6 months before the intervention and monthly thereafter. The primary outcome measure was the percentage of patients with missed follow-up of TPAD, defined as no documented follow-up within 72 hours of a result being available. The use of a reminder message was monitored as a process measure. RESULTS We reviewed charts of 764 discharged patients, and 216 (28%) were noted to have TPAD. At baseline, the average percentage of patients with missed follow-up was 80%. The use of reminder messages was quickly adopted. The average percentage of patients with missed follow-up of TPAD after beginning the quality improvement interventions was 35%. CONCLUSIONS We had significant improvement in follow-up after our interventions. Additional work is needed to ensure continued and sustained improvement, focused on reducing variability in performance between providers and investing in technology to allow for automation of the follow-up process.

Preventability of 30-Day Readmissions for Heart Failure Patients Before and After a Quality Improvement Initiative

2013 ◽  
Vol 29 (3) ◽  
pp. 220-226 ◽  
Author(s):  
Jason Ryan ◽  
Rebecca Andrews ◽  
Mary Beth Barry ◽  
Sangwook Kang ◽  
Aline Iskandar ◽  
...  
Keyword(s):  
Heart Failure ◽  
Quality Improvement ◽  
Quality Improvement Initiative ◽  
Heart Failure Patients ◽  
Before And After

CODE FAST: a quality improvement initiative to reduce door-to-needle times

2015 ◽  
Vol 8 (7) ◽  
pp. 661-664 ◽  
Author(s):  
Leslie Busby ◽  
Kumiko Owada ◽  
Samish Dhungana ◽  
Susan Zimmermann ◽  
Victoria Coppola ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Univariate Analysis ◽  
Substantial Reduction ◽  
Heart Association ◽  
Time Of Day ◽  
Quality Improvement Project ◽  
Quality Improvement Initiative ◽  
Improvement Project ◽  
Process Improvements ◽  
Before And After

BackgroundRapid delivery of IV tissue plasminogen activator (tPA) in qualifying patients leads to better clinical outcomes. The American Heart Association has reduced target door-to-needle (DTN) times from 60 to 45 min in the hopes of continued process improvements across institutions.ObjectiveTo start a quality improvement project called CODE FAST in order to reduce DTN times at our institution.Materials and methodsWe retrospectively reviewed data from our internally maintained database of patients treated with intravenous tPA before and after implementation of the CODE FAST protocol. We assessed demographic information, time of day and times of arrival to first image and delivery of tPA in patients from February 2014 to February 2015. Outcomes were assessed based on discharge to home. Univariate analysis was performed to assess for improvement in DTN times before and after implementation of the protocol.ResultsA total of 93 patients (41 pre-CODE FAST and 52 post-CODE FAST) received IV tPA during the study period. Patients were equally matched between the two groups except that in the pre-CODE FAST era patients receiving tPA were younger and more likely to be men. There was a substantial reduction in door-to-imaging time from a median of 16 to 8 min (p<0.0001) and DTN time with a reduction in the median from 62 to 25 min (p<0.0001). In logistic regression modeling, there was a trend towards more discharges to home in patients treated during the CODE FAST era.ConclusionsWe present a quality improvement project that has been overwhelmingly successful in reducing DTN time to <30 min. The template we present may be helpful to other institutions looking to reduce their DTN times and may also reduce costs as we note a trend towards more discharges to home.

scholarly journals Evaluating documentation of social history in paediatric medical notes at a regional paediatric centre – a quality improvement initiative

2020 ◽  
Vol 20 (1) ◽  
Author(s):  
DJ Foley ◽  
JK Hannon ◽  
CS O’Gorman ◽  
AM Murphy
Keyword(s):  
Quality Improvement ◽  
Social History ◽  
Family Environment ◽  
Retrospective Chart Review ◽  
Vital Role ◽  
University Hospital ◽  
Quality Improvement Initiative ◽  
Optimum Level ◽  
Paediatric Department

Abstract Background A child’s home and family environment plays a vital role in neuro-cognitive and emotional development. Assessment of a child’s home environment and social circumstances is an crucial part of holistic Paediatric assessment. Aims Our aim is to achieve full compliance with comprehensive documentation of biopsychosocial history, for all children medically admitted to the children’s inpatient unit in University Hospital Limerick. Methods We performed a retrospective chart review to audit documentation within our department. This was followed by teaching interventions and a survey on knowledge, attitudes and behaviour of paediatric non-consultant hospital doctors (NCHDs) towards the social history. We performed two subsequent re-audits to assess response to our interventions, and provided educational sessions to seek improvement in quality of care. Results Results showed a significant improvement in quality of documentation following interventions, demonstrated by a net increase of 53% in levels of documentation of some social history on first re-audit. Though this was not maintained at an optimum level throughout the course of the year with compliance reduced from 95% to 82.5% on second re-audit, there was nonetheless a sustained improvement from our baseline. Our qualitative survey suggested further initiatives and educational tools that may be helpful in supporting the ongoing optimisation of the quality of documentation of social history in our paediatric department. Conclusion We hope this quality improvement initiative will ultimately lead to sustained improvements in the quality of patient-centred care, and early identification and intervention for children at risk in our community.

scholarly journals Evaluating Documentation of Social History in Paediatric Medical Notes at a Regional Paediatric Centre – A Quality Improvement Initiative.

2020 ◽  
Author(s):  
DF Foley ◽  
JK Hannon ◽  
CS O'Gorman ◽  
AM Murphy
Keyword(s):  
Quality Improvement ◽  
Social History ◽  
Family Environment ◽  
Retrospective Chart Review ◽  
Vital Role ◽  
University Hospital ◽  
Quality Improvement Initiative ◽  
Optimum Level ◽  
Paediatric Department

Abstract Background A child’s home and family environment plays a vital role in neuro-cognitive and emotional development. Assessment of a child’s home environment and social circumstances is an crucial part of holistic Paediatric assessment.Aims Our aim is to achieve full compliance with comprehensive documentation of biopsychosocial history, for all children medically admitted to the children’s inpatient unit in University Hospital Limerick.Methods We performed a retrospective chart review to audit documentation within our department. This was followed by teaching interventions and a survey on knowledge, attitudes and behaviour of paediatric non-consultant hospital doctors (NCHDs) towards the social history. We performed two subsequent re-audits to assess response to our interventions, and provided educational sessions to seek improvement in quality of care.Results Results showed a significant improvement in quality of documentation following interventions, demonstrated by a net increase of 53% in levels of documentation of some social history on first re-audit. Though this was not maintained at an optimum level throughout the course of the year with compliance reduced from 95% to 82.5% on second re-audit, there was nonetheless a sustained improvement from our baseline. Our qualitative survey suggested further initiatives and educational tools that may be helpful in supporting the ongoing optimisation of the quality of documentation of social history in our paediatric department.Conclusion We hope this quality improvement initiative will ultimately lead to sustained improvements in the quality of patient-centred care, and early identification and intervention for children at risk in our community.

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