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Item A Quality Improvement Initiative to Decrease Time to Analgesia in Patients With Sickle Cell and Vaso-Occlusive Crisis: A Population With Disparities in Treatment(Springer Nature, 2022-09-25) Arnold, Tyler; Coffee, R. Lane, Jr.; Rosenberg, Leon; Jacob, Seethal A.; Thompson, Sean; Saavedra, Heather; Cico, Stephen John; Wagers, Brian; Emergency Medicine, School of MedicineIntroduction: Vaso-occlusive crises (VOCs) are the leading cause of emergency department (ED) visits and hospitalizations in patients with sickle cell disease (SCD). Timely administration of analgesia, within 60 minutes of patient registration, is the standard of care for SCD patients with VOCs. Patients with VOCs have longer times to initial analgesia compared to similar painful conditions. The primary aim of the project is to have 75% of patients with VOCs receive initial analgesia within 60 minutes of being registered, the current recommended time frame from the National Heart, Lung, and Blood Institute (NHLBI). Methods: A multi-disciplinary team used quality improvement (QI) methodology to develop a plan involving multiple Plan-Do-Study-Act (PDSA) cycles. A rapid evaluation process was employed which included notification of a patient with a VOC being placed in a room, rapid evaluation by all team members and use of an electronic order set. Results: The aim was met 72% of the time during our intervention period, compared to 17% pre-intervention. Average time to initial analgesia was decreased from 61 minutes to 42 minutes (p-value < 0.001), while time to disposition was also decreased when time goals were achieved. Conclusion: Using a rapid evaluation process we were able to decrease time to initial analgesia in a patient population that has previously experienced delays in care and decrease overall time to disposition.Item A Simulation-based PPE orientation training curriculum for novice physicians(Elsevier, 2023) Greaves, Spencer W.; Alter, Scott M.; Ahmed, Rami A.; Hughes, Kate E.; Doos, Devin; Clayton, Lisa M.; Solano, Joshua J.; Echeverri, Sindiana; Shih, Richard D.; Hughes, Patrick G.; Emergency Medicine, School of MedicineBackground: Personal protective equipment (PPE) is effective in preventing coronavirus disease (COVID-19) infection. Resident knowledge of proper use and effective training methods is unknown. We hypothesise that contamination decreases and knowledge increases after a formalised PPE educational session. Methods: Participants included first year interns during their residency orientation in June 2020. Before training, participants took a knowledge test, donned PPE, performed a simulated resuscitation, and doffed. A standardised simulation-based PPE training of the donning and doffing protocol was conducted, and the process repeated. Topical non-toxic highlighter tracing fluid was applied to manikins prior to each simulation. After doffing, areas of contamination, defined as discrete fluorescent areas on participants' body, was evaluated by ultraviolet light. Donning and doffing were video recorded and asynchronously rated by two emergency medicine (EM) physicians using a modified Centers for Disease Control and Prevention (CDC) protocol. The primary outcome was PPE training effectiveness defined by contamination and adherence to CDC sequence. Results: Forty-eight residents participated: 24 internal medicine, 12 general surgery, 6 EM, 3 neurology, and 3 psychiatry. Before training, 81% of residents were contaminated after doffing; 17% were contaminated after training (P<0.001). The most common contamination area was the wrist (50% pre-training vs. 10% post-training, P<0.001). Donning sequence adherence improved (52% vs. 98%, P<0.001), as did doffing (46% vs. 85%, P<0.001). Participant knowledge improved (62%-87%, P <0.001). Participant confidence (P<0.001) and preparedness (P<0.001) regarding using PPE increased with training. Conclusion: A simulation-based training improved resident knowledge and performance using PPE.Item Acceptability of a complex team-based quality improvement intervention for transient ischemic attack: a mixed-methods study(BMC, 2021-05-12) Damush, Teresa M.; Penney, Lauren S.; Miech, Edward J.; Rattray, Nicholas A.; Baird, Sean A.; Cheatham, Ariel J.; Austin, Charles; Sexson, Ali; Myers, Laura J.; Bravata, Dawn M.; Medicine, School of MedicineBackground: The Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurologic Symptoms (PREVENT) program was a complex quality improvement (QI) intervention targeting transient ischemic attack (TIA) evidence-based care. The aim of this study was to evaluate program acceptability among the QI teams and factors associated with degrees of acceptability. Methods: QI teams from six Veterans Administration facilities participated in active implementation for a one-year period. We employed a mixed methods study to evaluate program acceptability. Multiple data sources were collected over implementation phases and triangulated for this evaluation. First, we conducted 30 onsite, semi-structured interviews during active implementation with 35 participants at 6 months; 27 interviews with 28 participants at 12 months; and 19 participants during program sustainment. Second, we conducted debriefing meetings after onsite visits and monthly virtual collaborative calls. All interviews and debriefings were audiotaped, transcribed, and de-identified. De-identified files were qualitatively coded and analyzed for common themes and acceptability patterns. We conducted mixed-methods matrix analyses comparing acceptability by satisfaction ratings and by the Theoretical Framework of Acceptability (TFA). Results: Overall, the QI teams reported the PREVENT program was acceptable. The clinical champions reported high acceptability of the PREVENT program. At pre-implementation phase, reviewing quality data, team brainstorming solutions and development of action plans were rated as most useful during the team kickoff meetings. Program acceptability perceptions varied over time across active implementation and after teams accomplished actions plans and moved into sustainment. We observed team acceptability growth over a year of active implementation in concert with the QI team's self-efficacy to improve quality of care. Guided by the TFA, the QI teams' acceptability was represented by the respective seven components of the multifaceted acceptability construct. Conclusions: Program acceptability varied by time, by champion role on QI team, by team self-efficacy, and by perceived effectiveness to improve quality of care aligned with the TFA. A complex quality improvement program that fostered flexibility in local adaptation and supported users with access to data, resources, and implementation strategies was deemed acceptable and appropriate by front-line clinicians implementing practice changes in a large, national healthcare organization.Item Asynchronous Conferencing Through a Secure Messaging Application Increases Reporting of Medical Errors in a Mature Trauma Center(Sage, 2023) Lee, Joy L.; Isenberg, Scott; Adams, Georgann; Thurston, Maria; Hammer, Peter M.; Mohanty, Sanjay K.; Jenkins, Peter C.; Surgery, School of MedicineBackground: Medical errors occur frequently, yet they are often under-reported and strategies to increase the reporting of medical errors are lacking. In this work, we detail how a level 1 trauma center used a secure messaging application to track medical errors and enhance its quality improvement initiatives. Methods: We describe the formulation, implementation, evolution, and evaluation of a chatroom integrated into a secure texting system to identify performance improvement and patient safety (PIPS) concerns. For evaluation, we used descriptive statistics to examine PIPS reporting by the reporting method over time, the incidence of mortality and unplanned ICU readmissions tracked in the hospital trauma registry over the same, and time-to-loop closure over the study period to quantify the impact of the processes instituted by the PIPS team. We also categorized themes of reported events. Results: With the implementation of a PIPS chatroom, the number of events reported each month increased and texting became the predominant way for users to report trauma PIPS events. This increase in PIPS reporting did not appear to be accompanied by an increase in mortality and unplanned ICU readmissions. The PIPS team also improved the tracking and timely resolution of PIPS events and observed a decrease in time-to-loop closure with the implementation of the PIPS chatroom. Conclusions: The adoption of clinical texting as a way to report PIPS events was associated with increased reporting of such events and more timely resolution of concerns regarding patient safety and healthcare quality.Item Closer to or Farther away from an Ideal Model of Care? Lessons Learned from Geographic Cohorting(Springer, 2022-09) Kara, Areeba; Kashiwagi, Deanne; Burden, Marisha; Medicine, School of MedicineGeographic "cohorting," "co-location," "regionalization," or "localization" refers to the assignation of a hospitalist team to a specific inpatient unit. Its benefits may be related to the formation of a team and the additional interventions like interdisciplinary rounding that the enhanced proximity facilitates. However, cohorting is often adopted in isolation of the bundled approach within which it has proven beneficial. Cohorting may also be associated with unintended consequences such as increased interruptions and increased indirect care time. Institutions may increase patient loads in anticipation of the efficiency gained by cohorting-leading to further increases in interruptions and time away from the bedside. Fragmented attention and increases in indirect care may lead to a perception of increased workload, errors, and burnout. As hospital medicine evolves, there are lessons to be learned by studying cohorting. Institutions and inpatient units should work in synergy to shape the day-to-day work which directly affects patient and clinician outcomes-and ultimately culminates in the success or failure of the parent organization. Such synergy can manifest in workflow design and metric selection. Attention to workloads and adopting the principles of continuous quality improvement are also crucial to developing models of care that deliver excellent care.Item Coming back for more: factors linked to higher participation among Veterans with chronic pain in an innovative VA-YMCA wellness clinic(BMJ, 2024-01-29) Preddie, Alaina K.; Donnelly, Claire E.; Miech, Edward J.; Myers, Laura J.; Williams, Linda S.; Damush, Teresa M.; Medicine, School of MedicineIn 2019, the Indianapolis VA developed a Wellness Clinic in partnership with the Young Men's Christian Associations (YMCA) to comprehensively address Veterans' chronic pain. Our specific aims were twofold: (1) to evaluate the implementation of the Veterans Health Indiana (VHI) Wellness Clinic on patient utilisation and (2) to evaluate patient functioning.We conducted a mixed-methods evaluation, which included the extraction of VA administrative data to identify a patient cohort; the conduct of chart review to extract clinic utilisation, clinical outcomes collected during pain-related healthcare services and comorbidities; and semistructured interviews with Veteran patients who used the VHI Wellness Clinic in different patterns to identify challenges and facilitators to clinic utilisation. We applied configurational analysis to a Veteran sample who had their first visit to the VHI Wellness Clinic in March/April 2019 to pinpoint difference-making factors linked to Veterans' successful participation.The cohort included 312 Veterans (83% male), mean age of 55.4 years. The configurational model included six factors: participation in physical therapy, pain psychology or pain education sessions (22%); presence of any 'no-shows' (57% had 0); history of depression (39%) and clinic referral source (51% self-referred from primary care). The model consisted of four different pathways to successful participation, explaining 60% of cases in the higher-participation group with 86% consistency. Patient outcomes after clinic utilisation demonstrated a significant reduction in self-reported pain and pain catastrophising across time. Moreover, patients reported distance to clinic as both a facilitator and challenge.This mixed-methods analysis identified specific biopsychosocial factors and clinical services directly linked to higher Veteran participation in a new VA-YMCA Wellness Clinic. The VHI Wellness Clinic embedded within a YMCA facility is a feasible and efficacious healthcare delivery model for primary care patients experiencing chronic pain. Additional marketing to clinical providers for referrals and to patients to extend its reach is needed.Item Community-based in situ simulation: bringing simulation to the masses(BMC, 2019-12-21) Walsh, Barbara M.; Auerbach, Marc A.; Gawel, Marcie N.; Brown, Linda L.; Byrne, Bobbi J.; Calhoun, Aaron; Katz-Nelson, Jessica; Tay, Khoon-Yen; Whitfill, Travis; Kessler, David; Dudas, Robert; Nishisaki, Akira; Nadkarni, Vinay; Hamilton, Melinda; Pediatrics, School of MedicineSimulation-based methods are regularly used to train inter-professional groups of healthcare providers at academic medical centers (AMC). These techniques are used less frequently in community hospitals. Bringing in-situ simulation (ISS) from AMCs to community sites is an approach that holds promise for addressing this disparity. This type of programming allows academic center faculty to freely share their expertise with community site providers. By creating meaningful partnerships community-based ISS facilitates the communication of best practices, distribution of up to date policies, and education/training. It also provides an opportunity for system testing at the community sites. In this article, we illustrate the process of implementing an outreach ISS program at community sites by presenting four exemplar programs. Using these exemplars as a springboard for discussion, we outline key lessons learned discuss barriers we encountered, and provide a framework that can be used to create similar simulation programs and partnerships. It is our hope that this discussion will serve as a foundation for those wishing to implement community-based, outreach ISS.Item Core implementation strategies for improving cirrhosis care in the Veterans Health Administration(Wolters Kluwer, 2022) Yakovchenko, Vera; Morgan, Timothy R.; Miech, Edward J.; Neely, Brittney; Lamorte, Carolyn; Gibson, Sandra; Beste, Lauren A.; McCurdy, Heather; Scott, Dawn; Gonzalez, Rachel; Park, Angela; Powell, Byron J.; Bajaj, Jasmohan S.; Dominitz, Jason A.; Chartier, Maggie; Ross, David; Chinman, Matthew J.; Rogal, Shari S.; Emergency Medicine, School of MedicineBackground and aims: The Veterans Health Administration (VHA) provides care for more than 80,000 veterans with cirrhosis. This longitudinal, multimethod evaluation of a cirrhosis care quality improvement program aimed to (1) identify implementation strategies associated with evidence-based, guideline-concordant cirrhosis care over time, and (2) use qualitative interviews to operationalize strategies for a manualized intervention. Approach and results: VHA providers were surveyed annually about the use of 73 implementation strategies to improve cirrhosis care in fiscal years 2018 (FY18) and 2019 (FY19). Implementation strategies linked to guideline-concordant cirrhosis care were identified using bivariate statistics and comparative configurational methods. Semistructured interviews were conducted with 12 facilities in the highest quartile of cirrhosis care to specify the successful implementation strategies and their mechanisms of change. A total of 106 VHA facilities (82%) responded at least once over the 2-year period (FY18, n = 63; FY19, n = 100). Facilities reported using a median of 12 (interquartile range [IQR] 20) implementation strategies in FY18 and 10 (IQR 19) in FY19. Of the 73 strategies, 35 (48%) were positively correlated with provision of evidence-based cirrhosis care. Configurational analysis identified multiple strategy pathways directly linked to more guideline-concordant cirrhosis care. Across both methods, a subset of eight strategies was determined to be core to cirrhosis care improvement and specified using qualitative interviews. Conclusions: In a national cirrhosis care improvement initiative, a multimethod approach identified a core subset of successful implementation strategy combinations. This process of empirically identifying and specifying implementation strategies may be applicable to other implementation challenges in hepatology.Item Development of the Illinois Surgical Quality Improvement Collaborative (ISQIC): Implementing 21 Components to Catalyze Statewide Improvement in Surgical Care(Wolters Kluwer, 2023) Bilimoria, Karl Y.; McGee, Michael F.; Williams, Mark V.; Johnson, Julie K.; Halverson, Amy L.; O'Leary, Kevin J.; Farrell, Paula; Thomas, Juliana; Love, Remi; Kreutzer, Lindsey; Dahlke, Allison R.; D'Orazio, Brianna; Reinhart, Steven; Dienes, Katelyn; Schumacher, Mark; Shan, Ying; Quinn, Christopher; Prachand, Vivek N.; Sullivan, Susan; Cradock, Kimberly A.; Boyd, Kelsi; Hopkinson, William; Fairman, Colleen; Odell, David; Stulberg, Jonah J.; Barnard, Cindy; Holl, Jane; Merkow, Ryan P.; Yang, Anthony D.; Surgery, School of MedicineIntroduction: In 2014, 56 Illinois hospitals came together to form a unique learning collaborative, the Illinois Surgical Quality Improvement Collaborative (ISQIC). Our objectives are to provide an overview of the first three years of ISQIC focused on (1) how the collaborative was formed and funded, (2) the 21 strategies implemented to support quality improvement (QI), (3) collaborative sustainment, and (4) how the collaborative acts as a platform for innovative QI research. Methods: ISQIC includes 21 components to facilitate QI that target the hospital, the surgical QI team, and the peri-operative microsystem. The components were developed from available evidence, a detailed needs assessment of the hospitals, reviewing experiences from prior surgical and non-surgical QI Collaboratives, and interviews with QI experts. The components comprise 5 domains: guided implementation (e.g., mentors, coaches, statewide QI projects), education (e.g., process improvement (PI) curriculum), hospital- and surgeon-level comparative performance reports (e.g., process, outcomes, costs), networking (e.g., forums to share QI experiences and best practices), and funding (e.g., for the overall program, pilot grants, and bonus payments for improvement). Results: Through implementation of the 21 novel ISQIC components, hospitals were equipped to use their data to successfully implement QI initiatives and improve care. Formal (QI/PI) training, mentoring, and coaching were undertaken by the hospitals as they worked to implement solutions. Hospitals received funding for the program and were able to work together on statewide quality initiatives. Lessons learned at one hospital were shared with all participating hospitals through conferences, webinars, and toolkits to facilitate learning from each other with a common goal of making care better and safer for the surgical patient in Illinois. Over the first three years, surgical outcomes improved in Illinois. Discussion: The first three years of ISQIC improved care for surgical patients across Illinois and allowed hospitals to see the value of participating in a surgical QI learning collaborative without having to make the initial financial investment themselves. Given the strong support and buy-in from the hospitals, ISQIC has continued beyond the initial three years and continues to support QI across Illinois hospitals.Item Empowering telemetry technicians and enhancing communication to improve in-hospital cardiac arrest survival(BMJ, 2023) McCoy, Cody; Keshvani, Neil; Warsi, Maryam; Brown, L. Steven; Girod, Carlos; Chu, Eugene S.; Hegde, Anita A.; Medicine, School of MedicineDelays in treatment of in-hospital cardiac arrests (IHCAs) are associated with worsened survival. We sought to assess the impact of a bundled intervention on IHCA survival in patients on centralised telemetry. A retrospective quality improvement study was performed of a bundled intervention which incorporated (1) a telemetry hotline for telemetry technicians to reach nursing staff; (2) empowerment of telemetry technicians to directly activate the IHCA response team and (3) a standardised escalation system for automated critical alerts within the nursing mobile phone system. In the 4-year study period, there were 75 IHCAs, including 20 preintervention and 55 postintervention. Cox proportional hazard regression predicts postintervention individuals have a 74% reduced the risk of death (HR 0.26, 95% CI 0.08 to 0.84) during a code and a 55% reduced risk of death (HR 0.45, 95% CI 0.23 to 0.89) prior to hospital discharge. Overall code survival improved from 60.0% to 83.6% (p=0.031) with an improvement in ventricular tachycardia/ventricular fibrillation (VT/VF) code survival from 50.0% to 100.0% (p=0.035). There was no difference in non-telemetry code survival preintervention and postintervention (71.4% vs 71.3%, p=0.999). The bundled intervention, including improved communication between telemetry technicians and nurses as well as empowerment of telemetry technicians to directly activate the IHCA response team, may improve IHCA survival, specifically for VT/VF arrests.
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