817 A Proactive Feeding Regimen on Meeting Caloric Goals with Continuous Enteral Nutrition Support: A Quality Improvement Project

2020 ◽  
Vol 41 (Supplement_1) ◽  
pp. S247-S248
Author(s):  
Elizabeth Lu
Keyword(s):  
Quality Improvement ◽  
Enteral Nutrition ◽  
Total Body Surface Area ◽  
Quality Improvement Project ◽  
Nutrition Support ◽  
Burn Patients ◽  
Improvement Project ◽  
Impaired Wound Healing ◽  
Protocol Group ◽  
Increased Risk

Abstract Introduction Severe burn injuries are characterized by elevated metabolic demands. Numerous studies have documented iatrogenic underfeeding of critical care patients, which can lead to malnutrition, impaired wound healing, weakened immune response, and increased risk of infections. Enteral nutrition (EN) support is often utilized to help meet the increased caloric demands of burn patients. However, discrepancies between prescribed and delivered EN can occur due to frequent interruptions, delays initiating EN, gradual advancement of EN rate, and/or physician directed changes. The objective of this quality improvement project is to assess whether a proactive calculation of EN regimens can improve the provision of calories compared to a traditional calculation method. Methods A retrospective review of patients in a pediatric acute burn unit that received continuous EN for greater than three days was performed. The pre-protocol group consisted of patients from January 1st, 2017 to November 30th, 2017 who had continuous EN rates calculated by the dietitian based on 24 hours per day. This group was compared to patients from September 1st, 2018 to July 31st, 2019 who had EN rates calculated by the dietitian based on 23 hours per day (post-protocol group). Periods in which parenteral nutrition was administered or the EN regimen was prescribed in a non-continuous fashion were excluded. The primary outcome measure was the percentage of admissions in which patients met at least 85% of calorie estimations. This project was undertaken as a Quality Improvement initiative and, as such, was not formally supervised by an Institutional Review Board. Results A total of 132 patients (73 pre- and 59 post-protocol) from 134 separate inpatient admissions (73 pre- and 61 post-protocol) were identified. The average total body surface area burn was 40.9% (SD 18.8) vs. 49.4% (SD 19.8) and average age was 8.6 years (SD 5.9) vs. 7.9 years (SD 5.4) in the pre- and post-protocol groups, respectively. Continuous EN ran for an average of 20 hours a day (SD 2.2, median = 21) vs. 21 hours a day (SD 2.7, median = 22) in the pre- and post-protocol groups, respectively. The average number of days on continuous EN was comparable in both groups. The post-protocol group had 75% of admissions meet at least 85% of calorie estimations compared to the pre-protocol group with 52% of admissions having met the goal. Conclusions Due to the heightened metabolic demands of burn patients and the barriers to meeting caloric goals, it is important to minimize calorie deficits with EN support. Although a seemingly small change, calculating continuous EN rates based on 23 hours per day can yield improved caloric provisions compared to rates based on 24 hours per day. Applicability of Research to Practice A proactive approach to calculating continuous EN support should be considered to help decrease caloric deficits.

799 Free Transportation for Socioeconomically Disadvantaged Burn Patients: Quality Improvement Project

2020 ◽  
Vol 41 (Supplement_1) ◽  
pp. S236-S236
Author(s):  
Laura Perez ◽  
Rebecca Castro ◽  
Steven E Wolf ◽  
Jong Lee
Keyword(s):  
Emergency Department ◽  
Quality Improvement ◽  
Access To Care ◽  
Low Socioeconomic Status ◽  
Emergency Department Visits ◽  
Quality Improvement Project ◽  
Burn Patients ◽  
Socioeconomically Disadvantaged ◽  
Improvement Project ◽  
Transportation Program

Abstract Introduction Our Burn Center provides care to persons living in southeast area of our State. Patients residing in this area sometimes have low socioeconomic status (SES), and are often unable to return to burn clinic for continued care due to transportation barriers. Typically driving distance is over 80 miles involving ferry access, taking two or more hours each way. The aim of this quality improvement project was to examine the feasibility of a free transportation program for low SES patients who have barriers to transportation. Methods Our first step was to assess transportation needs. We started with a patient survey in clinic to determine if patients would be interested in free transportation and if the service would increase access to care. Survey with six questions was used to assess needs. Results We surveyed ten patients during burn clinic to determine if transportation would increase access to care. Nine patients responded positively and found transportation would be beneficial. One responded that he would not use it as he would use clinic appointment as opportunity to vacation in the area. Funding was secured from our School of Medicine. Community transportation providers were contacted and pricing was obtained. Transportation van was contracted with existing vender. Transportation is now available to patients with burn clinic appointments. We hope to expand to other clinics in the hospital in the future. The Transportation program will assist patients with access to care, compliance, decrease non-emergent Emergency Department visits and 30-day readmissions. Conclusions Transportation assistance for socioeconomically disadvantaged burn patients to follow up in clinic is needed. Nine out of ten patients surveyed were willing to use free transportation. We obtained funding to start a free transportation program once a month. This project began in October 2019. We have begun a once-a-month transportation assistance service to determine ridership and continued need. Twice monthly assistance may be needed and will be assessed over time. Our goal is ultimately to expand the program to include other clinics. Applicability of Research to Practice Free transportation program can assist patients with access to care, compliance, and decrease non-emergent Emergency Department visits and 30-day readmissions.

scholarly journals Quality improvement project to optimize enteral nutrition in a tertiary hospital's surgical ICU

Critical Care ◽  
2015 ◽  
Vol 19 (Suppl 1) ◽  
pp. P395 ◽  
Author(s):  
J Li ◽  
LY Koh ◽  
JH Yang ◽  
C Khoo ◽  
T Ter ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Enteral Nutrition ◽  
Quality Improvement Project ◽  
Improvement Project ◽  
Surgical Icu

13 Macronutrient Intake and Wound Healing in Critically Ill Burn Patients

2020 ◽  
Vol 41 (Supplement_1) ◽  
pp. S11-S12
Author(s):  
Sarah S Rupert ◽  
Beth A Shields ◽  
Brenda D Bustillos ◽  
Leopoldo C Cancio
Keyword(s):  
Wound Healing ◽  
Logistic Regression ◽  
Enteral Nutrition ◽  
Critically Ill ◽  
Univariate Analysis ◽  
Total Body Surface Area ◽  
Oral Intake ◽  
Nutrition Support ◽  
Burn Patients ◽  
Macronutrient Intake

Abstract Introduction Nutrition support is an important component of the care of the critically ill burn patient. The European Society for Parenteral and Enteral Nutrition recommends less than 35% of calories from fat and less than 60% from carbohydrate (CHO); however, favorable clinical outcomes have been found in randomized controlled trials when burn patients were given 12–27% fat and 46–65% CHO. These benefits include lower rates of pneumonia and mortality. The purpose of this research was to examine macronutrient intake of critically ill burn patients and the association with wound healing. Methods A retrospective study was approved by the Institutional Review Board and included patients admitted to our burn intensive care unit over an 11 year period who were ≥18 years of age, had ≥20% total body surface area burns. Subjects who required hospitalization for ≥8 days and required nutrition support were included in this analysis. Subjects who were admitted over a week after injury and those who underwent limb amputations were excluded. Caloric intake from CHO, fat, and protein was obtained from enteral nutrition, parenteral nutrition, and oral intake for the first eight days following hospitalization. Wound healing was defined as achieving < 10% TBSA open wound. Univariate analysis was used to identify factors significantly associated with wound healing. Variables found to be significant (p< 0.05) were subjected to logistic regression. Results A total of 309 patients (89% male) were included. Patients were 37 ± 17 years old and had 46 ± 18% TBSA burns. Wound healing was achieved by 77% of patients, with 26% mortality. Those who healed were significantly younger (34 ± 15 vs. 47 ± 19 years, p< 0.001), were taller (70 ± 3 vs. 68 ± 4 inches, p< 0.001), with smaller burns (44 ± 16% vs. 54 ± 20% TBSA, p< 0.001), predominantly male (92% vs. 77%, p< 0.001), received a higher amount of CHO (1166 ± 465 vs. 902 ± 494 kcals, p< 0.001), and received a higher amount of fat (455 ± 234 vs. 360 ± 220 kcals, p=0.003). After logistic regression, factors negatively associated with wound healing included increased age (p< 0.001), female gender (p=0.032), and larger burn size (p< 0.001); a positive association was seen with 8-day average calories from CHO (p=0.027). Conclusions This study identified several factors significantly associated with healing in burn patients; however, higher CHO intake was the only modifiable factor. Further research is needed to determine the optimal CHO intake to improve patient outcomes. Applicability of Research to Practice Consideration should be made for high-CHO enteral nutrition in critically ill burn patients.

scholarly journals Improving cardiometabolic screening on an inpatient psychiatric ward: a quality improvement project

BJPsych Open ◽  
2021 ◽  
Vol 7 (S1) ◽  
pp. S194-S194
Author(s):  
Harrison Howarth ◽  
Jonathan Pass ◽  
Fahel Ahmed ◽  
Sarah Wiethoff
Keyword(s):  
Mental Illness ◽  
Quality Improvement ◽  
General Population ◽  
Serious Mental Illness ◽  
Quality Improvement Project ◽  
Cardiometabolic Health ◽  
Improvement Project ◽  
Information Leaflets ◽  
Increased Risk ◽  
Cardiometabolic Screening

AimsPrimary aim: To increase the proportion of patients receiving a full cardiometabolic screen whilst on the ward to 75%.Secondary aims: To improve communication with GPs regarding cardiometabolic health, to improve the rates of intervention when abnormalities are found to 75%.BackgroundPeople with serious mental illness are known to have significantly increased risk of cardiometabolic syndrome than the general population. Estimates suggest there would be up to 12,000 fewer deaths from cardiovascular disease if people with serious mental illness had the same outcomes as the general population. People with serious mental illness die on average 20 years earlier than the general population due to preventable physical health problems.Whilst on the ward, we have an excellent opportunity to screen and treat patients with cardiometabolic risk factors, yet screens are often incomplete, not acted upon, or simply not carried out.MethodUsing the Plan-Do-Study-Act (PDSA) methodology, we trialed interventions to improve the cardiometabolic screening process on out 16 bed inpatient ward. Across 8 cycles, we set up a protocol to ensure all new patients received a full cardiometabolic screen during their admission reviews, engaged nursing staff with the process and managed inconsistencies with blood transportation and delivery. We also started using British Heart Foundation information leaflets, and treating patients in accordance with the Lester Tool: Positive Cardiometabolic Health Resource. We made design changes to the discharge summary template allowing for clear communication with GPs on discharge.ResultAt the end of 8 cycles, we had achieved 100% compliance with the full cardiometabolic screen (as defined by the Lester Tool) from a baseline of just 25%. We also improved intervention with identified abnormalities from a baseline of 0% to 100%.ConclusionImprovements in cardiometabolic screening and treatment were possible using the PDSA methodology. Given the success of this quality improvement project, we plan to introduce our methodology onto other wards in the trust.

scholarly journals Using quality improvement to standardise and enhance the use of the national early warning score (NEWS) in an old age psychiatry inpatient setting

BJPsych Open ◽  
2021 ◽  
Vol 7 (S1) ◽  
pp. S38-S39
Author(s):  
Fraser MacNicoll ◽  
Mong Sun Tung ◽  
Brion McGowan
Keyword(s):  
Quality Improvement ◽  
Old Age ◽  
Quality Improvement Project ◽  
Assessment Process ◽  
Early Warning Score ◽  
Post Intervention ◽  
Improvement Project ◽  
Physical Deterioration ◽  
Increased Risk ◽  
Old Age Psychiatry

AimsWithin an inpatient old-age psychiatry setting, there is an increased risk of acute physical deterioration secondary to age, comorbidities and reduced physiological reserve. Numerous recent clinical incidents highlighted late recognition of physical deterioration within this population. We assessed the use of the NEWS, a system for scoring physiological measurements, in an old-age psychiatry ward and subsequently attempted to improve performance of obtaining physical health observations in this cohort of patients.MethodRetrospective pre- and post- quality improvement study in a twenty bed Old Age Psychiatry Ward in East Lothian Community Hospital, Haddington, Scotland. Data were collected from 12th October – 16th November, 2020 (pre- period) and from 16th November 2020 to 15th February, 2021 (post- period). The primary process measure was ensuring all patients had at least one full set of physical observations at least once a week, or more frequent as deemed clinically appropriate. Secondary measures included ensuring NEWS scores were accurately calculated and improved documentation. This was tracked using a run chart. Improvement activities focused on increased awareness, effective training, key stakeholder buy-in and reviewing trust policy.ResultThe percentage of NEWS documented for all patients at least once a week improved from a mean of 28.7% (31/108) in the 6 weeks prior to intervention, to a mean of 71.4% (125/175) in the following 13 weeks. The minimum required physical observations required to accurately calculate a NEWS improved from 51.6% (16/31) pre-intervention to 95.2% (119/125) post-intervention and NEWS being calculated correctly increased from 80.6% (25/31) to 96% (120/125). Documentation of a reason why physical observations were not taken increased from 2.5% (2/77) to 62% (31/50) pre- and post- intervention respectively.ConclusionThis quality improvement project highlighted that recording of physical observations and use of NEWS was inadequate in this setting, increasing the risk of a delay in identification of acute physical deterioration and thus increase morbidity and mortality. Introducing simple measures and standardising the NEWS assessment process, along with senior nursing and medical oversight, greatly enhanced acquiring and recording of physical observations and NEWS scores. This quality improvement project has shown that practical solutions and staff education can increase efficacy and are hoping further input can consolidate the gains achieved and lead to continued improvements.

623 Procedural Pain Management in Burn Patients – A Quality Improvement Project

2021 ◽  
Vol 42 (Supplement_1) ◽  
pp. S167-S167
Author(s):  
Zachary Fleishhacker ◽  
Colette Galet ◽  
Lucy Wibbenmeyer
Keyword(s):  
Quality Improvement ◽  
Pain Control ◽  
Quality Improvement Project ◽  
Procedural Pain ◽  
Burn Patients ◽  
Improvement Project ◽  
Opioid Dose ◽  
Pain Scores ◽  
Post Procedure ◽  
Significant Difference

Abstract Introduction Achieving adequate burn pain control in patients is paramount as inadequate control can lead to PTSD, suicidal ideation, and depression. The pain accompanying hydrotherapy can be extreme and challenging to manage. The purpose of this quality improvement project was to assess our burn center’s current nurse-driven procedural pain control protocol during hydrotherapy. Methods Burn patients admitted from June to August 2020 who underwent hydrotherapy were observed during the procedure. Demographics, comorbidities, injury related data, and pain and sedation medication data were collected. Pain scores (1–10), patient and nurse satisfaction scores (1–10) were collected before, during, and after hydrotherapy. A single patient could be surveyed for up to three times. Paired t-tests and one-way ANOVA were performed to assess significant differences between pre- and post-procedure patient pain scores and satisfaction ratings across encounters, respectively. P < 0.05 was considered significant. Results Twenty-eight patients and 48 hydrotherapy events were surveyed. Patients were predominately male (23, 82.1%), middle aged (44.8 ± 19.6), and had a TBSA of 11.9 ± 10.5%. Analyzing only the first hydrotherapy sessions, time from initial opioid dose to hydrotherapy varied greatly as did the opioid morphine equivalent dose (OME) provided prior to hydrotherapy (Table 1). Only 13 (46.4%) subjects received versed during hydrotherapy. Pain scores post-procedure significantly increased compared to pre-procedure scores (5.39 vs. 6.32; p = 0.035). There was no significant difference in patients’ or nurse’s satisfaction scores regarding pain control nor with nurse’s rating of ease of procedure when comparing scores across the three encounters (Table 1). No adverse events (SaO2 < 92% or deep sedation RAS < 2) were observed across all encounters. Conclusions Our results suggest that procedural pain control during hydrotherapy, while safe, has opportunities for improvement. Pre-procedural medication timing remains imprecise and widely divergent. Satisfaction scores, while high, also have room for improvement. Finally, pre-procedural pain control is unacceptable (mean 5.39) and requires attention.

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