Assessing Adherence to Audiologic Parameters of Care for Children With Cleft Palate: A Quality Improvement Initiative

2021 ◽  
pp. 105566562110295
Author(s):  
Ursula M. Findlen ◽  
Jonathan Grischkan ◽  
Sandra Alston ◽  
Lauren Durinka ◽  
Adriane Baylis
Keyword(s):  
Quality Improvement ◽  
Cleft Palate ◽  
Cleft Lip ◽  
Quality Improvement Initiative ◽  
Evidence Based ◽  
Team Communication ◽  
Care Protocol ◽  
Management Protocol ◽  
Key Drivers

Objective: To evaluate and increase adherence to an evidence-based audiologic management protocol for children with cleft palate. Design: Prospective, multidisciplinary quality improvement initiative. Setting: Tertiary pediatric hospital. Patients, Participants: Children with cleft palate (with or without cleft lip) between the ages of 0 and 5 years (n = 205). Interventions: A multidisciplinary team identified key drivers for nonadherence to recommended audiological follow-up and implemented interventions to improve adherence. Key drivers included provider practices and preferences, clinic logistics and flow, and patient/family awareness and education. Several interventions were implemented between 2016 and 2020, including developing an evidence-based audiologic protocol, maximizing access to audiologic clinic visits across multiple departments, cleft team education, and improved team communication. Main Outcome Measure(s): Completion of recommended audiologic assessment at 5 separate care milestones. Results: After implementation of interventions between 2016 and 2020, adherence to recommended audiologic follow-up increased from 59% to 84%. Analysis of individual care milestones revealed that increased access to audiologic testing during team clinics resulted in the largest increase in adherence to recommended follow-up. Additionally, cause-effect analysis revealed that nonadherence due to provider-related causes decreased over the project period to a greater extent than patient/family-related causes. Conclusions: Implementation of an evidence-based audiologic care protocol and improvements in access to early hearing care are feasible in a high-volume multidisciplinary cleft clinic. Adherence to recommended audiologic management can be improved by establishing strategies to improve access to care, team member and family education, and enhanced team communication.

Phonological Profile of Patients With Velopharyngeal Dysfunction and Palatal Anomalies

2021 ◽  
pp. 1-15
Author(s):  
Ariela Nachmani ◽  
Muhamed Masalha ◽  
Firas Kassem
Keyword(s):  
Cleft Palate ◽  
Cleft Lip ◽  
Cleft Lip And Palate ◽  
Age Groups ◽  
Phonological Process ◽  
Phonological Processes ◽  
Process Error ◽  
Submucous Cleft Palate ◽  
Different Types

Purpose This purpose of this study was to assess the frequency and types of phonological process errors in patients with velopharyngeal dysfunction (VPD) and the different types of palatal anomalies. Method A total of 808 nonsyndromic patients with VPD, who underwent follow-up at the Center for Cleft Palate and Craniofacial Anomalies, from 2000 to 2016 were included. Patients were stratified into four age groups and five subphenotypes of palatal anomalies: cleft lip and palate (CLP), cleft palate (CP), submucous cleft palate (SMCP), occult submucous cleft palate (OSMCP), and non-CP. Phonological processes were compared among groups. Results The 808 patients ranged in age from 3 to 29 years, and 439 (54.3%) were male. Overall, 262/808 patients (32.4%) had phonological process errors; 80 (59.7%) ages 3–4 years, 98 (40, 0%) ages 4.1–6 years, 48 (24.7%) 6.1–9 years, and 36 (15.3%) 9.1–29 years. Devoicing was the most prevalent phonological process error, found in 97 patients (12%), followed by cluster reduction in 82 (10.1%), fronting in 66 (8.2%), stopping in 45 (5.6%), final consonant deletion in 43 (5.3%), backing in 30 (3.7%), and syllable deletion and onset deletion in 13 (1.6%) patients. No differences were found in devoicing errors between palatal anomalies, even with increasing age. Phonological processes were found in 61/138 (44.20%) with CP, 46/118 (38.1%) with SMCP, 61/188 (32.4%) with non-CP, 70/268 (26.1%) with OSMCP, and 25/96 (26.2%) with CLP. Phonological process errors were most frequent with CP and least with OSMCP ( p = .001). Conclusions Phonological process errors in nonsyndromic VPD patients remained relatively high in all age groups up to adulthood, regardless of the type of palatal anomaly. Our findings regarding the phonological skills of patients with palatal anomalies can help clarify the etiology of speech and sound disorders in VPD patients, and contribute to general phonetic and phonological studies.

A quality improvement project to reduce restrictive interventions in a mental health service

2021 ◽  
pp. 1-12
Author(s):  
Darren Savarimuthu ◽  
Katja Jung
Keyword(s):  
Mental Health ◽  
Quality Improvement ◽  
Positive Impact ◽  
Essential Elements ◽  
Quality Improvement Project ◽  
Psychiatric Ward ◽  
Quality Improvement Initiative ◽  
Successful Implementation ◽  
Evidence Based ◽  
Improvement Project

Background/aims This article describes a quality improvement project that aimed to reduce restrictive interventions on an acute psychiatric ward. In light of a service level agreement and based on a trust-wide target, the purpose of the project was to reduce restrictive interventions by 20% within a period of 6 months. It was also anticipated that a least restrictive environment could have a positive impact on patient experience. Methods Three evidence-based interventions were introduced to the ward during the quality improvement project. These included positive behaviour support, the Safewards model and the productive ward initiative. Results There was a 63% reduction in restrictive interventions over a 6-month period through the successful implementation of a series of evidence-based interventions to manage behaviours that challenge on the mental health ward. Conclusions The project identified collaborative team working, staff training and adequate resources as essential elements in the success of the quality improvement initiative. However, co-production was found to be crucially significant in bringing sustainable changes in ward environment and in addressing restrictive practices.

Treatment of Asymmetric Velopharyngeal Insufficiency with Skewed Pharyngeal Flap

1994 ◽  
Vol 31 (4) ◽  
pp. 287-294 ◽  
Author(s):  
Ravelo V. Argamaso ◽  
Gerald J. Levandowski ◽  
Karen J. Golding-Kushner ◽  
Robert J. Shprintzen
Keyword(s):  
Cleft Palate ◽  
Cleft Lip ◽  
Tumor Resection ◽  
Velocardiofacial Syndrome ◽  
Velopharyngeal Insufficiency ◽  
Lateral Pharyngeal Wall ◽  
Pharyngeal Wall ◽  
Wall Movement ◽  
Hypernasal Speech

Twenty-two patients, with hypernasal speech and asymmetric velopharyngeal insufficiency (VPI) identified preoperatively by multi-view videofluoroscopy and nasopharyngoscopy, were managed with superiorly based pharyngeal flaps skewed to the side with reduced lateral pharyngeal wall movement. Patient age ranged from 5 to 58 years. The etiology of the VPI included cleft palate with or without cleft lip, neurogenic VPI, velocardiofacial syndrome, tumor resection or latrogenic causes, submucous cleft palate, neurofibromatosis, and hemifacial microsomia. Follow-up, at 1 year and thereafter, showed resolution of VPI in all but two patients. An auxiliary flap to augment the primary flap was added on the side of diminished lateral pharyngeal wall motion which corrected the residual VPI. Three patients developed hyponasality. One was a child whose symptoms improved with time and growth. Two were adults, but the hyponasal resonance was mild and required no further Intervention. The advantage of skewing flaps is that at least one port functions adequately for ease in respiration and for drainage of secretions, thus reducing the risk of nasal obstruction. One open port also allows access for nasoendotracheal intubation should anesthetic be required for future operations.

Results of a Regional Effort to Improve Warfarin Management

2016 ◽  
Vol 51 (5) ◽  
pp. 373-379 ◽  
Author(s):  
Adam J. Rose ◽  
Angela Park ◽  
Christopher Gillespie ◽  
Carol Van Deusen Lukas ◽  
Al Ozonoff ◽  
...  
Keyword(s):  
Quality Improvement ◽  
New England ◽  
Audit And Feedback ◽  
Quality Improvement Initiative ◽  
Veterans Health ◽  
Health Administration ◽  
Process Of Care ◽  
Processes Of Care ◽  
Anticoagulation Control

Background: Improved anticoagulation control with warfarin reduces adverse events and represents a target for quality improvement. No previous study has described an effort to improve anticoagulation control across a health system. Objective: To describe the results of an effort to improve anticoagulation control in the New England region of the Veterans Health Administration (VA). Methods: Our intervention encompassed 8 VA sites managing warfarin for more than 5000 patients in New England (Veterans Integrated Service Network 1 [VISN 1]). We provided sites with a system to measure processes of care, along with targeted audit and feedback. We focused on processes of care associated with site-level anticoagulation control, including prompt follow-up after out-of-range international normalized ratio (INR) values, minimizing loss to follow-up, and use of guideline-concordant INR target ranges. We used a difference-in-differences (DID) model to examine changes in anticoagulation control, measured as percentage time in therapeutic range (TTR), as well as process measures and compared VISN 1 sites with 116 VA sites located outside VISN 1. Results: VISN 1 sites improved on TTR, our main indicator of quality, from 66.4% to 69.2%, whereas sites outside VISN 1 improved from 65.9% to 66.4% (DID 2.3%, P < 0.001). Improvement in TTR correlated strongly with the extent of improvement on process-of-care measures, which varied widely across VISN 1 sites. Conclusions: A regional quality improvement initiative, using performance measurement with audit and feedback, improved TTR by 2.3% more than control sites, which is a clinically important difference. Improving relevant processes of care can improve outcomes for patients receiving warfarin.

scholarly journals Evidence-based development of a nephrotoxic medication list to screen for acute kidney injury risk in hospitalized children

2019 ◽  
Vol 76 (22) ◽  
pp. 1869-1874 ◽  
Author(s):  
Elizabeth Goswami ◽  
Richard K Ogden ◽  
William E Bennett ◽  
Stuart L Goldstein ◽  
Richard Hackbarth ◽  
...  
Keyword(s):  
Acute Kidney Injury ◽  
Quality Improvement ◽  
Injury Risk ◽  
Kidney Injury ◽  
Quality Improvement Initiative ◽  
Evidence Based ◽  
Hospitalized Children ◽  
Consensus Definition ◽  
Medication Exposure ◽  
Definition Of

Abstract Purpose Medications are commonly associated with acute kidney injury (AKI). However, in both clinical practice and research, consideration of specific medications as nephrotoxic varies widely. The Nephrotoxic Injury Negated by Just-in-time Action quality improvement collaborative was formed to focus on prevention or reduction of nephrotoxic medication-associated AKI in noncritically ill hospitalized children. However, there were discrepancies among institutions as to which medications should be considered nephrotoxic. The collaborative convened a Nephrotoxic Medication (NTMx) Subcommittee to develop a consensus for the classification of nephrotoxic medications. Summary The NTMx Subcommittee initially included pediatric nephrologists, a pharmacist, and a pediatric intensivist. The committee reviewed NTMx lists from the collaborative and identified changes from the initial NTMx list. The NTMx Subcommittee conducted a literature review of the disputed medications and assigned an evidence grade based on the reported association with nephrotoxicity and the quality of the data. The association between medication exposure and AKI was also determined using administrative data from the Pediatric Health Information Systems database. The NTMx Subcommittee then came to a majority consensus regarding which medications should be included on the list. The subcommittee’s recommendations were presented to the larger collaborative for approval, and consensus was achieved. The list continues to be reviewed and updated annually. Conclusion Formation of a multicenter quality-improvement initiative exposed current limitations as to which medications are considered nephrotoxic in clinical and research settings and presented an opportunity to approach this problem using an evidence-based process. A consensus definition of nephrotoxic-medication exposure was achieved.

Change in Readmissions and Follow-up Visits as Part of a Heart Failure Readmission Quality Improvement Initiative

2013 ◽  
Vol 126 (11) ◽  
pp. 989-994.e1 ◽  
Author(s):  
Jason Ryan ◽  
Sangwook Kang ◽  
Steven Dolacky ◽  
Joseph Ingrassia ◽  
Raj Ganeshan
Keyword(s):  
Heart Failure ◽  
Quality Improvement ◽  
Quality Improvement Initiative

Long-Term Otologic and Audiometric Outcomes in Patients with Cleft Palate

2017 ◽  
Vol 157 (4) ◽  
pp. 676-682 ◽  
Author(s):  
Terence E. Imbery ◽  
Lindsay B. Sobin ◽  
Emily Commesso ◽  
Lindsey Koester ◽  
Sherard A. Tatum ◽  
...  
Keyword(s):  
Cleft Palate ◽  
Cleft Lip ◽  
Cleft Lip And Palate ◽  
Medical Center ◽  
Academic Medical Center ◽  
Case Series ◽  
Closure Rate ◽  
Pressure Equalization

Objective Describe longitudinal audiometric and otologic outcomes in patients with cleft palates. Study Design Case series with chart review. Setting Single academic medical center. Methods Charts of 564 patients with a diagnosis of cleft palate (59% syndromic etiology, 41% nonsyndromic) from 1998 to 2014 were reviewed. Patients without at least 1 audiometric follow-up were excluded from analysis. Patient demographics, surgeries, audiometric tests, and otologic data were recorded for 352 patients. Results Forty-five percent had isolated cleft palates, 34% had unilateral cleft lip and palate, and 21% had bilateral cleft lip and palate. Patients were followed for a mean of 50.3 months with a mean of 3.2 separate audiograms performed. Patients received a mean of 2.93 pressure equalization tubes. Increased number of pressure equalization tubes was not associated with incidence of cholesteatoma, which was identified in only 4 patients. Nine patients underwent eventual tympanoplasty with an 89% closure rate. Analysis of mean air-bone gap by cleft type did not reveal significant differences ( P = .08), but conductive losses and abnormal tympanometry persisted into teenage years. Conclusions Patients with cleft palates have eustachian tube dysfunction, which, in our cohort, resulted in persistent conductive hearing loss, highlighting the importance of long-term follow-up. Cholesteatoma incidence was low and not associated with number of tubes, which at our institution were placed prophylactically. Tympanoplasty was successful in those with persistent perforations.

Implementation of a checklist before colonoscopy: a quality improvement initiative

Endoscopy ◽  
2017 ◽  
Vol 50 (03) ◽  
pp. 203-210 ◽  
Author(s):  
Omar Kherad ◽  
Sophie Restellini ◽  
Charles Ménard ◽  
Myriam Martel ◽  
Alan Barkun
Keyword(s):  
Quality Improvement ◽  
Positive Impact ◽  
Quality Improvement Intervention ◽  
Quality Improvement Initiative ◽  
Team Communication ◽  
Intervention Period ◽  
Retrospective Audit ◽  
Safety Outcomes ◽  
Checklist Implementation ◽  
Improvement Intervention

Abstract Background and study aims Checklists can prevent errors and have a positive impact on patient morbidity and mortality in different surgical settings, and possibly also in gastrointestinal endoscopy. The aims of this study were to reinforce commitment in safety culture and better communication among team members in endoscopy, and to prove the feasibility of successful checklist adoption before colonoscopy. Patients and methods The study involved a pre – post quality improvement intervention involving all consecutive patients undergoing a colonoscopy at a single academic endoscopy unit. The first part of the study was a retrospective audit, carried out over a 3-month period (July to September 2016). A checklist developed through a formal validation process was implemented during the intervention period (October to December 2016). Primary outcomes were changes in patient and team satisfaction after the quality improvement intervention, using validated 5-point scale questionnaires. Secondary outcomes included successful procedure completion rates and safety outcomes. Results During the baseline and comparative intervention period, 1317 and 1141 colonoscopies, respectively, were performed. Overall, checklists were fully completed by nurses and physicians for 791 patients (69.3 %). Mean overall patient satisfaction was high at baseline and did not differ following the quality improvement intervention (4.66 vs. 4.63; P  = 0.5). Perception of team communication and teamwork was improved after checklist implementation. Comparative analyses of per-procedure and safety outcomes did not differ between the pre- and post-checklist implementation. Conclusion Adoption of an endoscopy checklist before colonoscopy is feasible, and significantly increases perception of team communication and teamwork. Additional studies are needed to assess the generalizability of these results to complex endoscopic procedures and to characterize any improvement in patient safety outcomes.

Cleft Palate Rehabilitation: Interim Strategies in Indonesia

1994 ◽  
Vol 31 (4) ◽  
pp. 316-320 ◽  
Author(s):  
Doris Schreiber Willcox
Keyword(s):  
Cleft Palate ◽  
Cleft Lip ◽  
Cleft Lip And Palate ◽  
Frequent Feeding ◽  
Speech Therapists

The following is a discussion of the formidable obstacles to cleft palate rehabilitation in Indonesia, including frequent feeding deaths, lack of timely surgery, lack of speech therapists, and lack of follow-up opportunities. It describes the work of a remarkable group of Indonesian professionals who, along with a few interested Western associates, are searching for ways to provide treatment and care for needy patients with cleft lip and palate. It details the various strategies being attempted to overcome some of these obstacles.

A multicenter quality improvement initiative on the impact of pharmacists’ postdischarge follow-up to reduce medication-related acute care episodes

2020 ◽  
Vol 77 (12) ◽  
pp. 938-942
Author(s):  
Lydia Noh ◽  
Kristina Heimerl ◽  
Rita Shane
Keyword(s):  
Quality Improvement ◽  
High Risk ◽  
Acute Care ◽  
Academic Medical Centers ◽  
Quality Improvement Initiative ◽  
Medical Centers ◽  
Academic Medical ◽  
Risk Patients ◽  
The Impact

Abstract Purpose This multicenter quality improvement initiative aims to measure and quantify pharmacists’ impact on reducing medication-related acute care episodes (MACEs) for high-risk patients at an increased risk for readmission due to drug-related problems (DRPs). Methods This was a prospective, multicenter quality improvement initiative conducted at 9 academic medical centers. Each participant implemented a standardized methodology for evaluating MACE likelihood to demonstrate the impact of pharmacist postdischarge follow-up (PDFU). The primary outcome was MACEs prevented, and the secondary outcome was DRPs identified and resolved by pharmacists. During PDFU, pharmacists were responsible for identification and resolution of DRPs, and cases were reviewed by physicians to confirm whether potential MACEs were prevented. Results A total of 840 patients were contacted by 9 participating academic medical centers during a 6-week data collection period. Of these, 328 cases were identified as MACEs prevented during PDFU by pharmacists, and physician reviewers confirmed that pharmacist identification of DRPs during PDFU prevented 27.9% of readmissions. Pharmacist identified 959 DRPs, 2.8% (27) of which were identified as potentially life threatening. Potentially serious or significant DRPs made up 56.6% (543) of the DRPs, and 40.6% (389) were identified as having a low capacity for harm. Conclusion The results demonstrate that PDFU of high-risk patients reduces DRPs and prevents MACEs based on physician confirmation. Implementation of MACE methodology provides health-system pharmacy departments the ability to demonstrate pharmacists’ value in transitions of care and assist in expanding pharmacist services.

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