Browsing by Subject "Quality"
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Item A Quality Improvement Initiative to Reduce Unnecessary Screening Chest Radiographs in a Pediatric ICU(American Association of Respiratory Care, 2023) Malin, Stefan W.; Maue, Danielle K.; Cater, Daniel T.; Ealy, Aimee R.; McCallister, Anne E.; Valentine, Kevin M.; Abu-Sultaneh, Samer M.; Pediatrics, School of MedicineBackground: The Critical Care Societies Collaborative included not ordering diagnostic tests at regular intervals as one of their Choosing Wisely initiatives. A reduction in unnecessary chest radiographs (CXRs) can help reduce exposure to radiation and eliminate health care waste. We aimed to reduce daily screening CXRs in a pediatric ICU (PICU) by 20% from baseline within 4 months of implementation of CXR criteria. Methods: All intubated patients in the PICU were included in this quality improvement project. Patients with tracheostomies were excluded. We developed criteria delineating which patients were most likely to benefit from a daily screening CXR, and these criteria were discussed for each patient on rounds. Patients on extracorporeal membrane oxygenation, on high-frequency oscillatory ventilation, or on high support on conventional mechanical ventilation were included as needing a daily screening CXR. We tracked the percentage of intubated subjects receiving a screening CXR as an outcome measure. Unplanned extubations and the number of non-screening CXRs per intubated subject were followed as balancing measures. Results: The percentage of intubated subjects receiving a daily screening CXR was reduced from 79% to 31%. There was no increase in frequency of unplanned extubations or number of non-screening CXRs. With an estimated subject charge of roughly $270 and hospital cost of $54 per CXR, this project led to an estimated $300,000 in patient charge savings and $60,000 in hospital cost savings. Conclusions: Adopting criteria to delineate which patients are most likely to benefit from screening CXRs can lead to a reduction in the percentage of intubated patients receiving screening CXRs without appearing to increase harm.Item A Quality Improvement Initiative to Reduce Unneeded Screening Chest Radiographs in a Pediatric Cardiovascular ICU(Daedalus Enterprises, 2023) Malin, Stefan W.; McCallister, Anne E.; Abu-Sultaneh, Samer M.; Valentine, Kevin M.; Pediatrics, School of MedicineBackground: Adult critical care and radiographical societies have recommended changing practice from routine screening radiographs to on-demand chest radiographs (CXRs) for stable mechanically ventilated adult patients. There are no similar recommendations for patients in the pediatric ICU. Reducing the frequency with which unneeded CXRs are obtained can decrease radiation exposure and reduce waste, a substantial contributor to rising health care costs. We aimed to reduce unneeded daily screening CXRs in a pediatric cardiovascular ICU (CICU) by 20% in 6 months. Methods: Criteria delineating which subjects in the CICU required daily screening CXRs were created and added to the daily rounding sheet for discussion for each subject. The primary goal of this study was to reduce CXRs in mechanically ventilated subjects as our previous practice had been to order daily CXRs. Respiratory therapists increased the frequency of evaluating and documenting endotracheal tube positioning prior to the initiation of this project. The outcome measure was the percentage subjects who received a daily screening CXR. The ratio of daily screening CXRs to the number of total CXRs ordered and unplanned extubations were followed as balancing measures. Results: The number of subjects who received a daily screening CXR decreased from a baseline of 67% to 44% over the course of this project. There was no change in the ratio of daily screening CXRs to the number of total CXRs ordered or an increase in unplanned extubations. With an estimated cost of $268 per CXR, a reduction of 33% in routine screening CXRs saves an estimated $250,000 annually. Conclusions: A decrease in daily screening CXRs can be sustained through the development of specific criteria to determine which patients need screening radiographs. This can be achieved without an increase in CXRs obtained at other times throughout the day or an increase in unplanned extubations. This eliminates unneeded health care expenditures, improves resource allocation for radiology technicians, and decreases disruptive interventions for patients.Item Analysis of standards of quality for outcomes in acute heart failure patients directly discharged home from emergency departments and their relationship with the emergency department direct discharge rate(Elsevier, 2021) Miró, Òscar; López-Díez, María Pilar; Rossello, Xavier; Gil, Víctor; Herrero, Pablo; Jacob, Javier; Llorens, Pere; Escoda, Rosa; Aguiló, Sira; Alquézar, Aitor; Tost, Josep; Valero, Amparo; Gil, Cristina; Garrido, José Manuel; Alonso, Héctor; Lucas-Invernón, Francisco Javier; Torres-Murillo, José; Torres-Gárate, Raquel; Mecina, Ana B.; Traveria, Lissette; Agüera, Carmen; Takagi, Koji; Möckel, Martin; Pang, Peter S.; Collins, Sean P.; Mueller, Christian E.; Martín-Sánchez, Francisco Javier; ICA-SEMES Research Group; Emergency Medicine, School of MedicineObjective: Experts recommended that direct discharge without hospitalization (DDWH) for emergency departments (EDs) able to observe acute heart failure (AHF) patients should be >40%, and these discharged patients should fulfil the following outcome standards: 30-day all-cause mortality <2% (outcome A); 7-day ED revisit due to AHF < 10% (outcome B); and 30-day ED revisit/hospitalization due to AHF < 20% (outcome C). We investigated these outcomes in a nationwide cohort and their relationship with the ED DDWH percentage. Methods: We analyzed the EAHFE registry (includes about 15% of Spanish EDs), calculated DDWH percentage of each ED, and A/B/C outcomes of DDWH patients, overall and in each individual ED. Relationship between ED DDWH and outcomes was assessed by linear and quadratic regression models, non-weighted and weighted by DDWH patients provided by each ED. Results: Among 17,420 patients, 4488 had DDWH (25.8%, median ED stay = 0 days, IQR = 0-1). Only 12.9% EDs achieved DDWH > 40%. Considering DDWH patients altogether, outcomes A/C were above the recommended standards (4.3%/29.4%), while outcome B was nearly met (B = 10.1%). When analyzing individual EDs, 58.1% of them achieved the outcome B standard, while outcomes A/C standards were barely achieved (19.3%/9.7%). We observed clinically relevant linear/quadratic relationships between higher DDWH and worse outcomes B (weighted R2 = 0.184/0.322) and C (weighted R2 = 0.430/0.624), but not with outcome A (weighted R2 = 0.002/0.022). Conclusions: The EDs of this nationwide cohort do not fulfil the standards for AHF patients with DDWH. High DDWH rates negatively impact ED revisit or hospitalization but not mortality. This may represent an opportunity for improvement in better selecting patients for early ED discharge and in ensuring early follow-up after ED discharge.Item Cardiac Catheterization Laboratories as Learning Health Systems(Elsevier, 2024-12-19) Kalra, Ankur; Rosenzveig, Akiva; Reed, Grant W.; Medicine, School of MedicineItem Cecal retroflexion is infrequently performed in routine practice and the retroflexed view is of poor quality(BMC, 2021-07-31) Keswani, Rajesh N.; Kahi, Charles J.; Benson, Mark; Gawron, Andrew J.; Kaltenbach, Tonya R.; Yadlapati, Rena H.; Gregory, Dyanna L.; Duloy, Anna; Medicine, School of MedicineBackground: As right colon polyps are challenging to detect, a retroflexed view of right colon (RV) may be useful. However, cecal retroflexion (CR) without a RV to the hepatic flexure (HF) is inadequate. We aimed to determine the frequency of CR and quality of the RV in routine practice. Methods: This prospective observational study performed at an academic medical center assessed colonoscopy inspection technique of endoscopists who had performed ≥ 100 annual screening colonoscopies. We video recorded ≥ 28 screening/surveillance colonoscopies per endoscopist and randomly evaluated 7 videos per endoscopist. Six gastroenterologists blindly reviewed the videos to determine if CR was performed and HF withdrawal time (cecum to HF time, excluding ileal/polypectomy time). Results: Reviewers assessed 119 colonoscopies performed by 17 endoscopists. The median HF withdrawal time was 3 min and 46 s. CR was performed in 31% of colonoscopies. CR frequency varied between endoscopists with 9 never performing CR and 2 performing CR in all colonoscopies. When performed, nearly half (43%) of RVs did not extend to the HF with median RV duration of 16 s (IQR 9-30 s). Three polyps were identified in the RV (polyp detection rate of 8.1%), all identified prior to a forward view. Conclusions: CR is performed infrequently in routine practice. When CR is performed, the RV is of low quality with a very short inspection duration and insufficient ascending colon examination. Further education is required to educate endoscopists in optimal technique to improve overall colonoscopy quality.Item The Cost of Complications Following Major Resection of Malignant Neoplasia(Springer Nature, 2018-11) Zogg, Cheryl K.; Ottesen, Taylor D.; Kebaish, Kareem; Galivanche, Anoop; Murthy, Shilpa; Changoor, Navin R.; Zogg, Donald L.; Pawlik, Timothy M.; Haider, Adil H.; Surgery, School of MedicineBACKGROUND: Rising healthcare costs have led to increased focus on the need to achieve a higher "value of care." As value-maximization efforts expand to include more complex surgical patients, evidence to support meaningful implementation of complication-based initiatives is lacking. The objective of this study was to compare incremental costs of complications following major gastrointestinal (GI) resections for organ-specific malignant neoplasia using nationally representative data. METHODS: National (Nationwide) Inpatient Sample data, 2001-2014, were queried for adult (≥ 18 years) patients undergoing major resections for malignant neoplasia. Based on system-based complications considered relevant to the long-term treatment of GI disease, stratified differences in risk-adjusted incremental hospital costs and complication probabilities were compared. Differences in surgical outcomes and costs over time were also assessed. RESULTS: A total of 293,967 patients were included, weighted to represent 1,408,117 patients nationwide. One fourth (26.1%; 95% CI, 25.7-26.4%) experienced ≥ 1 pre-discharge complication (range, 45.3% esophagectomy to 24.0% rectal resection). Resultant annual risk-adjusted incremental hospital costs totaled $540 million nationwide (19.5% of the overall cost of care and an average of $20,900 per patient). Costs varied substantially with both cancer/resection type and complication group, ranging from $76.7 million for colectomies with infectious complications to $0.2 million for rectal resections with urinary complications. For each resection type, infectious ($154.7 million), GI ($85.5 million), and pulmonary ($77.9 million) complications were among the most significant drivers of increased hospital cost. CONCLUSIONS: Quantifying and comparing the impact of complications on an indication-specific level in more complex patients offers an important step toward allowing providers/payers to meaningfully prioritize the design of novel and adaptation of existing value-maximization approaches.Item Digital Scientific Platform for Independent Content in Neurology: Rigorous Quality Guideline Development and Implementation(JMIR, 2022-06-09) Kantor, Daniel; Farlow, Martin; Ludolph, Albert; Montaner, Joan; Sankar, Raman; Sawyer, Robert N., Jr.; Stocchi, Fabrizio; Lara, Agnès; Clark, Sarah; Deschet, Karine; Ouyahia, Loucif; Hadjiat, Yacine; Neurology, School of MedicineBackground: Digital communication has emerged as a major source of scientific and medical information for health care professionals. There is a need to set up an effective and reliable methodology to assess and monitor the quality of content that is published on the internet. Objective: The aim of this project was to develop content quality guidelines for Neurodiem, an independent scientific information platform dedicated to neurology for health care professionals and neuroscientists. These content quality guidelines are intended to be used by (1) content providers as a framework to meet content quality standards and (2) reviewers as a tool for analyzing and scoring quality of content. Methods: Specific scientific criteria were designed using a 5-point scale to measure the quality of curated and original content published on the website: for Summaries, (1) source reliability and topic relevance for neurologists, (2) structure, and (3) scientific and didactic value; for Congress highlights, (1) relevance of congress selection, (2) congress coverage based on the original program, and (3) scientific and didactic value of individual abstracts; for Expert points of view and talks, (1) credibility (authorship) and topic relevance for neurologists, (2) scientific and didactic value, and (3) reliability (references) and format. The criteria were utilized on a monthly basis and endorsed by an independent scientific committee of widely recognized medical experts in neurology. Results: Summary content quality for the 3 domains (reliability and relevance, structure, and scientific and didactic value) increased in the second month after the implementation of the guidelines. The domain scientific and didactic value had a mean score of 8.20/10. Scores for the domains reliability and relevance (8-9/10) and structure (45-55/60) showed that the maintenance of these 2 quality items over time was more challenging. Talks (either in the format of interviews or slide deck-supported scientific presentations) and expert point of view demonstrated high quality after the implementation of the content quality guidelines that was maintained over time (15-25/25). Conclusions: Our findings support that content quality guidelines provide both (1) a reliable framework for generating independent high-quality content that addresses the educational needs of neurologists and (2) are an objective evaluation tool for improving and maintaining scientific quality level. The use of these criteria and this scoring system could serve as a standard and reference to build an editorial strategy and review process for any medical news or platforms.Item Effects of a structured SBIRT training program for hospital nursing leaders on utilization of SBIRT within their medical-surgical units: cohort study(Springer Nature, 2025-04-23) Newhouse, Robin; Agley, Jon; Bakoyannis, Giorgos; Ferren, Melora; Mullins, C. Daniel; Keen, Alyson; Parker, Erik; School of NursingBackground: Psychoactive substances contribute to numerous deaths annually, and more than 60% of the US population aged 12 + years reports past-month substance use. Screening, brief intervention, and referral to treatment (SBIRT) may support identification of substance-related risks and facilitate targeted interventions, but best practices and implementation designs remain elusive. Our study examined whether a standardized SBIRT toolkit and training-of-trainers for nurse site coordinators was prospectively associated with documented performance of core SBIRT-related functions in medical-surgical hospital units. Methods: This was a prospective cohort study conducted from January 2018 to May 2019 in 14 adult medical-surgical units (one/hospital). Hospitals were randomly allocated to two groups (n = 7 hospitals/each), which received identical interventions: an SBIRT training-of-trainers (8 h), supportive follow-up, and a toolkit containing information, resources, and guidance. However, group 1 sites were trained four months earlier than group 2 sites. At three points (baseline, 10-months, and 16-months), 61 patient records per hospital unit (n = 854) were randomly selected for extraction. Inclusion criteria for random selection were age (18+) and being admitted and discharged from the selected unit. Main outcome measures were analyzed using generalized linear mixed models, including screening within 24 h of admission, using a validated screening tool, screening positive, and receiving a brief intervention or referral to treatment. Results: For groups 1 and 2, patients had 1.81 and 2.66 greater odds, respectively, of being screened for alcohol at 10-months, 1.92 and 4.68 greater odds of being screened for drugs, and 1.96 and 2.06 greater odds of being screened for tobacco. For hospital group 2, patients also had greater odds of being screened for alcohol (3.92), drugs (6.31), and tobacco (2.41) at 16-months. For both hospital groups and benchmarks, patients were hundreds of times more likely to be screened with a validated tool, reflecting a shift from near absence of such behaviors (around 1% prevalence) to prevalence rates from 24 to 56%. Conclusions: The SBIRT intervention was associated with the initiation and sustained use of validated screening tools for alcohol and drugs, and with short-term increases in overall alcohol, tobacco, and drug screening prevalence.Item Existing Transplant Nephrology Compensation Models and Opportunities for Equitable Pay(Wolters Kluwer, 2022) Josephson, Michelle A.; Wiseman, Alexander C.; Tucker, J. Kevin; Segal, Mark S.; Schmidt, Rebecca J.; Mujtaba, Muhammad A.; Gurley, Susan B.; Gaston, Robert S.; Doshi, Mona D.; Brennan, Daniel C.; Moe, Sharon M.; Medicine, School of MedicineThe American Society of Nephrology (ASN) formed the ASN Task Force on Academic Nephrologist Compensation and Productivity in 2020 to understand how the subspecialty is evolving and where there are needs for alignment in compensation in US transplant centers. The task force's review of the roles and responsibilities of transplant nephrologists is in the companion perspective (1). Transplant nephrologists are required for successful kidney transplantation, the ideal treatment from a survival and quality-of-life perspective for patients with kidney failure (2,3). Unfortunately, work relative value unit (wRVU) requirements for compensation models vary tremendously across institutions and limit the ability to adequately staff programs. This article addresses transplant nephrology models of care, how different models affect funds flow and compensation, and opportunities to more equitably compensate transplant nephrologists.Item Identifying the Implementation Conditions Associated With Positive Outcomes in a Successful Nursing Facility Demonstration Project(Oxford Academic, 2020-11-23) Hickman, Susan E.; Miech, Edward J.; Stump, Timothy E.; Fowler, Nicole R.; Unroe, Kathleen T.; Emergency Medicine, School of MedicineBackground and objectives: To identify the implementation barriers, facilitators, and conditions associated with successful outcomes from a clinical demonstration project to reduce potentially avoidable hospitalizations of long-stay nursing facility residents in 19 Indiana nursing homes. Research design and methods: Optimizing Patient Transfers, Impacting Medical quality, Improving Symptoms-Transforming Institutional Care (OPTIMISTIC) is a multicomponent intervention that includes enhanced geriatric care, transition support, and palliative care. The configurational analysis was used to analyze descriptive and quantitative data collected during the project. The primary outcome was reductions in hospitalizations per 1,000 eligible resident days. Results: Analysis of barriers, facilitators, and conditions for success yielded a model with 2 solution pathways associated with a 10% reduction in potentially avoidable hospitalizations per 1,000 resident days: (a) lower baseline hospitalization rates and investment of senior management; or (b) turnover by the director of nursing during the observation period. Conditions for success were similar for a 20% reduction, with the addition of increased resident acuity. Discussion and implications: Key conditions for successful implementation of the OPTIMISTIC intervention include strong investment by senior leadership and an environment in which baseline hospitalization rates leave ample room for improvement. Turnover in the position of director of nursing also linked to successful implementation; this switch in leadership may represent an opportunity for culture change by bringing in new perspectives and viewpoints. These findings help define the conditions for the successful implementation of the OPTIMISTIC model and have implications for the successful implementation of interventions in the nursing facility more generally.