Conceptual Model of Emergency Department Utilization among Deaf and Hard-of-Hearing Patients: A Critical Review

Deaf and hard-of-hearing (DHH) populations are understudied in health services research and underserved in healthcare systems. Existing data indicate that adult DHH patients are more likely to use the emergency department (ED) for less emergent conditions than non-DHH patients. However, the lack of research focused on this population’s ED utilization impedes the development of health promotion and quality improvement interventions to improve patient health and quality outcomes. The purpose of this study was to develop a conceptual model describing patient and non-patient (e.g., community, health system, provider) factors influencing ED utilization and ED care processes among DHH people. We conducted a critical review and used Andersen’s Behavioral Model of Health Services Use and the PRECEDE-PROCEED Model to classify factors based on their theoretical and/or empirically described role. The resulting Conceptual Model of Emergency Department Utilization Among Deaf and Hard-of-Hearing Patients provides predisposing, enabling, and reinforcing factors influencing DHH patient ED care seeking and ED care processes. The model highlights the abundance of DHH patient and non-DHH patient enabling factors. This model may be used in quality improvement interventions, health services research, or in organizational planning and policymaking to improve health outcomes for DHH patients.

Improving Follow-Up of Tests Pending at Discharge

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.

Factors Affecting the Sustainment, Sustainability, and Spread of Practice Changes in Canadian Long-Term Care Homes

Our understanding of the post-implementation sustainment, sustainability, and spread (SSS) of complex quality improvement interventions is limited. We explored factors that influenced the SSS of a care aide-led quality improvement initiative (Safer Care for Older Persons (in residential) Environments [SCOPE]) implemented in 6 Manitoba long-term care homes two years after the conclusion of SCOPE in 2017. We analyzed small group interview data collected from all unit- and facility-level managers who participated in SCOPE and were still working in these facilities. We asked about SCOPE implementation, post-SCOPE quality improvement activities, factors that influenced them, and about inter-unit spread of SCOPE following the project’s conclusion. The interviews were audio-recorded, transcribed verbatim, de-identified, and analyzed using thematic analysis. Five of the 6 facilities reported sustained SCOPE quality improvement activities, tools, and facilitative structures. In the same 5 facilities, SCOPE benefits (e.g., increases in care aide empowerment and self-efficacy, manager belief in care aide capacity) continued post-implementation. Spread beyond the original SCOPE units had occurred in 3 facilities. Factors that influenced the SSS of SCOPE were related to the team (e.g., care aides' quality improvement capacity), to the unit and facility (e.g., culture of innovation and change), and to the long-term care system (e.g., competing imperatives). Some factors influencing SSS differ from factors known to influence implementation. The identified factors affecting SSS highlight the influence of social dynamics (i.e., interactions, communication, relationships) among staff on SSS. Further research is warranted to explore interactions among these influencing factors and how they lead to SSS.

P-P50 Analysis of the efficiency of the hepatobiliary multidisciplinary team meeting to identify quality improvement strategies

Background The multidisciplinary team meeting is the mainstay of management of patients with hepatopancreatobiliary (HPB) cancer and is considered the gold standard of care. Disadvantages of these meetings include large numbers of patients to be discussed covering multiple super-specialities over a short time span. This can lead to decision fatigue amongst clinicians. Logistical factors such as information technology and presence of clinicians with relevant expertise may also hamper the progress of the meeting. The aim of this study was to analyse the efficiency of our HPB MDT with a view to identifying multi-factorial quality improvement interventions. Methods 13 weeks of prospectively generated multidisciplinary team meeting outcomes were analysed from our departments weekly 150-minute long MDT meeting between 01/06/21 and 24/08/21. Patient demographics and pathology were noted. The number of overall discussions in each meeting were recorded. Number of patients in each sub-category (1. Regional pancreatic cancer service, 2. Hepatocellular carcinoma or liver adenoma, 3. pancreatic cystic neoplasms, 4. Gallbladder cancer and cholangiocarcinoma, 5. Pancreatic neuroendocrine tumours and 6. Other) were recorded. The number of patients without a recorded outcome was collated and reasons for no outcome being generated were categorised. Results 174/ 869 patients (20 %) did not receive an outcome from the meeting and were carried forward to the next week. Of the patients carried forward to the next week; 33/177 (18.6%) had no available histopathology following biopsies. Of these 33 patients, 23 did not have post-operative histopathology yet available for discussion. 82/177 (46 %) patients did not have the relevant investigations performed or available to move the discussion forward. These investigations were wide ranging and included radiological and endoscopic interventions. Of these, 19 patients (2 % over-all) had not had images sent across from a peripheral centre. 3 patients required both histology and radiology for further discussion. 59/869 (6%) of patients were not discussed due to time constraints. This equated to an average of 4 patients per meeting. Conclusions This study demonstrates the breadth and depth of a general HPB MDT. Strategies are required to simplify the MDT process to allow for time for discussion of the most complex patients, in particular those requiring surgery. Multifactorial reasons for a lack of MDT outcome at any single meeting have been found in this study. This signifies that a more robust triage process involving multiple specialities needs to be considered. Logistical factors also need to be in place allowing for transfer of relevant images from peripheral units. Histopathology reporting takes time and appropriate expectations for the availability of these results needs to be in place. The next step in this study is to identify and implement effective quality improvement strategies to improve outcome rates and allow more time for complex case discussions.

The effect of quality improvement interventions on inpatient cancer malnutrition documentation and coding in an academic medical center.

38 Background: Malnutrition (MN) is common yet underdiagnosed in hospitalized cancer patients. Effective assessments can identify those who need nutritional care and help plan intervention. We examined the effect of quality improvement (QI) interventions on the dietitian documented MN (DDMN) and physician coded malnutrition (PCMN). We also determined if the registered dietitian (RD) and physician assessments of MN agreed. Methods: Electronic medical records (EMR) were reviewed for a consecutive cohort of inpatients with a solid tumor diagnosis staged I-IV and admitted to Atrium Health’s Carolinas Medical Center at least once between 1/1/2016 to 5/31/2019. Data were collected from the first admission EMR encounter closest to the cancer diagnosis date. RD assessments were reviewed for DDMN. PCMN diagnosis was based on MN ICD-10 codes in the discharge summary. MN was graded as mild, moderate, and severe. Two QI interventions were implemented during the study period: 1) 8/2016: RD message via EMR to query MD approval for MN diagnosis; 2) 4/2018: Clinical Documentation Integrity Team query MD by sending ASPEN criteria via an alert integrated into MD workflow. Agreement in MN identification was defined as the absence or presence of both DDMN and PCMN; agreement in severity was defined as the absence of DDMN and PCMN or the agreement in presence and severity of DDMN and PCMN. Cochran-Armitage tests for trend assessed prevalence and agreement across the three periods (N1=652; N2=2858; N3=1622) defined by the two sequential QI interventions. Results: N=5143; 52% males. Median age 63 (range 18-102) years. 70% White; 24% Black, 3% Latino. Commonest cancer diagnostic groups: Upper Gastrointestinal 22%, Thoracic (19%), Genitourinary 18%. 28% had stage IV disease. 11% (N=557) met criteria for DDMN and/or PCMN. Of the 557, 40% (N=223) met criteria for both DDMN and PCMN. DDMN (N=420) was mild 2%, moderate 19%, and severe 79%. On discharge, PCMN (N=360) was mild in 10%, moderate in 21%, and severe in 69%. The RD and MD agreed on the presence or absence (94%) and severity (93%) of MN. Significant trends were observed as DDMN prevalence increased from 3.1%, 8.1%, to 10.3% (p<.001), and PCMN prevalence from 0.5%, 7.8%, to 8.2% (p<.001). While rates of mild, moderate, and severe MN varied across the periods, statistically significant change in these distributions was not identified in DDMN (p=0.62) or PCMN (p=0.20) after the second QI intervention. Conclusions: MN was under-diagnosed compared to nutrition intervention studies. When MN was identified, it was moderate or severe in the majority. Evaluations by RD and MD were highly congruent for MN prevalence and severity. Implementation of nutrition-focused QI interventions improved documentation and coding of MN. Improved communication between the RD and the MD could improve the recognition and diagnosis of MN.

Older adult guidelines: What is patient reported experience across five cancer programs?

186 Background: ASCO’s Guideline for Geriatric Oncology (Mohile SG, Et al 2018) and NCCN’s Guideline for Older Adult Oncology (v1.2021) include patient self-assessment for falls, memory/concentration, and activities of daily living. Our study collected patient reported experience with self-assessing these concerns, discussing them with clinicians, and receiving relevant referrals across adult patients with cancer. We also examined differences in reported experiences between younger and older patients. Methods: We surveyed patients 18 and over with breast, colorectal, lung or head neck cancer who received care from January 2020 to April 2021 across 5 cancer programs in Chicago: 3 academic and 2 community based. Survey included 7 items adapted from older adult oncology guidelines and associated instruments including PROMIS. Analyses used chi-square method with Yate’s correction. Results: 243 patients completed a survey, about half over and half under 65. Only 16% of patients reported that clinicians asked them about falls/walking, concentration/memory, or daily activity concerns; an additional 28% of patients brought up these concerns with clinicians (Table). Over half (51%) of all patients had at least once concern, 17% falls/walking, 30% concentration/memory and 35% daily activities. About 1/3 (35%) of patients were referred to services. Importantly, the rates of experiencing concerns associated with older adult care, initiating relevant discussions with clinicians, and receiving referrals were similar between younger and older patients (Table). Patients with concerns were more likely to get PT/OT, Geriatrics, or home health support, p =.02, p =.03, p =.04, respectively (data not shown). Conclusions: Regardless of age, half of patients reported at least one concern that is typically associated with older cancer patients. Future studies should study concerns for falls, memory, concentration, and daily activities among younger patients, with the potential to expand the guidelines accordingly. We also found gaps in identifying these concerns even within the older patient cohort, suggesting that quality improvement interventions are necessary.[Table: see text]

Improving the safety of outpatient parenteral antimicrobial therapy for patients with solid tumors

Background and objectives Outpatient parenteral antimicrobial therapy (OPAT) for infections has been in use for nearly 40 years, and although it has been found safe and efficacious, its use has been studied primarily among otherwise healthy patients. We aimed to develop and evaluate an OPAT program for patients with cancer, particularly solid tumors. Methods We implemented multiple quality improvement interventions between June 2018 and January 2020. We retrospectively and prospectively collected data on demographics, the completeness of infectious diseases (ID) physician consultation notes, rates of laboratory test result monitoring, ID clinic follow-up, and 30-day outcomes, including unplanned OPAT-related readmissions, OPAT-related emergency center visits, and deaths. Results Completeness of ID provider notes improved from a baseline of 77 to 100% (p < .0001) for antimicrobial recommendations, 75 to 97% (p < .0001) for follow-up recommendations, and 19 to 98% (p < .0001) for laboratory test result monitoring recommendations. Completion of laboratory tests increased from a baseline rate of 24 to 56% (p = .027). Thirty-day unplanned OPAT-related readmission, ID clinic follow-up, 30-day emergency center visit, and death rates improved without reaching statistical significance. Conclusions Sustained efforts, multiple interventions, and multidisciplinary engagement can improve laboratory test result monitoring among solid tumor patients discharged with OPAT. Although demonstrating a decrease in unplanned readmissions through institution of a formal OPAT program among patients with solid malignancies may be more difficult compared with the general population, the program may still result in improved safety.