Blood Management Strategies to Reduce Transfusions after Elective Lower-Extremity Joint Arthroplasty Surgeries: One Tertiary Care Hospital's Early Experience with an Alternative Payment Model - a Total Joint 'Bundle

Blood ◽  
2016 ◽  
Vol 128 (22) ◽  
pp. 3854-3854
Author(s):  
Ankit J. Kansagra ◽  
Saurabh Dahiya ◽  
Chester Andrzejewski ◽  
Robert Krushell ◽  
Andrew Lehman ◽  
...  
Keyword(s):  
Lower Extremity ◽  
Conflicts Of Interest ◽  
Tertiary Care ◽  
Joint Arthroplasty ◽  
Blood Collection ◽  
Quality Improvement Initiative ◽  
Blood Management ◽  
Intervention Period ◽  
Post Intervention ◽  
Post Intervention Period

Abstract Background and objective: Blood loss associated with total lower-extremity joint arthroplasty (TJA) often results in postoperative anemia and need for red blood cell transfusions (RBCT). We report the results of a quality improvement initiative to improve blood management and decrease transfusions in patients undergoing TJA in one tertiary hospital. Methods: Pre and post analysis after the implementation of a multifaceted intervention which included preoperative assessment for anemia, use of tranexamic acid, discouragement of autologous pre-operative blood collection and institution of more restrictive RBCT protocols. The results were stratified into three periods: I - pre-interventional (01/01/2013 -09/30/2013); II - peri-interventional (10/01/2013 -04/30/2014); and III - post-interventional (05/01/2014 -12/31/2014). We used fractional logistic regression with robust standard errors and regression modeling was configured using a segmented, or "piecewise", approach in which slope coefficients in each period were estimated. Results: During the study period 2511 patients underwent surgery. Compared with the pre-intervention period, the total number of RBC units transfused decreased from a total of 587 in the pre- to 107 in the post-intervention period (81.8% decrease). The percentage of patients receiving transfusion declined from 36.7% in pre-implementation period to 8.8% to post-intervention period. Depending upon the costing methodology used, annualized savings in RBC expenditure between time period 1 and 3 ranged from a low of $108,000 using the acquisition cost per unit (~$225/unit) to $480,000 when using activity based costing (~$1000/unit). Mean length of stay (days) and 30-day readmission rates remained stable during the study period. Conclusions: A multidisciplinary approach with proactive involvement of all the interested parties can be successful and sustainable in reducing RBCT and its associated costs, in patients undergoing TJA. Disclosures No relevant conflicts of interest to declare.

Blood Management Strategies to Reduce Transfusions After Elective Lower-Extremity Joint Arthroplasty Surgeries: One Tertiary Care Hospital’s Early Experience With an Alternative Payment Model—a Total Joint “Bundle”

2017 ◽  
Vol 32 (6) ◽  
pp. 668-674 ◽  
Author(s):  
Ankit Kansagra ◽  
Chester Andrzejewski ◽  
Robert Krushell ◽  
Andrew Lehman ◽  
Jordan Greenbaum ◽  
...  
Keyword(s):  
Lower Extremity ◽  
Multidisciplinary Approach ◽  
Tertiary Care ◽  
Management Strategies ◽  
Joint Arthroplasty ◽  
Blood Collection ◽  
Quality Improvement Initiative ◽  
Activity Based Costing ◽  
Blood Management ◽  
Red Blood Cell Transfusions

Blood loss associated with lower-extremity total joint arthroplasty (TJA) often results in anemia and the need for red blood cell transfusions (RBCTs). This article reports on a quality improvement initiative aimed at improving blood management strategies in patients undergoing TJA. A multifaceted intervention (preoperative anemia assessment, use of tranexamic acid, discouragement of autologous preoperative blood collection, restrictive RBCT protocols) was implemented. The results were stratified into 3 intervention periods: 1, pre; 2, peri; and 3, post. Fractional logistic regression was used to describe differences between various intervention periods. During the study period, 2511 patients underwent TJA. Compared with the preintervention period, there was 81.8% decrease in total units of RBCT during the postintervention period. Using activity-based costing (~$1000/unit), the annualized saving in RBC expenditure was $480 000. A multidisciplinary approach can be successful and sustainable in reducing RBCT and its associated costs for patients undergoing TJA.

scholarly journals Improving decision making, communication and documentation regarding advance resuscitation decisions in a tertiary care hospital in Sri Lanka

2021 ◽  
Author(s):  
Shenal Appuhamy ◽  
Dinusha Hewage
Keyword(s):  
Sri Lanka ◽  
Health Care Professionals ◽  
Medical Records ◽  
Group Discussion ◽  
Tertiary Care ◽  
Junior Doctors ◽  
Care Hospital ◽  
Intervention Period ◽  
Post Intervention ◽  
Post Intervention Period

Abstract BACKGROUND Resuscitation decisions made in advance are especially important to prevent negative patient outcomes at end-of-life. We conducted a clinical audit to assess the current practice of these decisions in Sri Lanka and then introduced interventions to improve the same. MATERIALS AND METHODS An auditor-administered questionnaire developed through a focused group discussion among experts was used to analyze the medical records of deaths during a period of sixty days focusing on advance resuscitation decisions and factors affecting them. The junior doctors directly involved in the care of each patient were interviewed regarding their retrospective judgement about the most appropriate resuscitation decision, which was later compared with the decision of an expert panel, who decided on the most appropriate resuscitation decision based on the medical records of the patient. An educational session for doctors was then conducted to improve their knowledge about advance resuscitation decisions including the importance of meticulous documentation of such decisions. The outcome was assessed after sixty days following the introduction of the intervention using the same questionnaire. RESULTS There was a significant improvement in the number of documented advance resuscitation decisions from 4/40 (10%) to 17/38 (44.73%) (Z = 3.5, P = 0.0006), with a significant increase in DNACPR decisions from 4/40 (10%) to 14/38 (36.8%) (Z = 2.8, P = 0.005) following the intervention. Unsuccessful CPR attempts decreased significantly from 31/40 (77.5%) to 14/38 (36.8%) (Z = 3.6, P = 0.0003) in the post-intervention period. The resuscitation decisions suggested by junior doctors that matched with expert decision increased significantly for both interns ((from 11/40 (27.5%) to 22/38 (57.9%) (Z = 2.7, P = 0.0066)) and registrars ((18/40 (45%) to 27/38 (71.05%) (Z = 2.3, P = 0.0202)) in the post-intervention period. CONCLUSION Documentation and practice regarding advance resuscitation decisions is suboptimal in Sri Lanka. This can be improved by interventions targeting improving the knowledge about the concept and its proper documentation among health care professionals.

Impact of targeted bundles to reduce the nebulization time gap from prescription to administration among red triaged patients in emergency department: An quality improvement initiative

2021 ◽  
Author(s):  
Seema Sachdeva seema sachdeva ◽  
Akshay Kumar Akshay Kumar ◽  
Parveen Aggarwal Parveen Aggarwal
Keyword(s):  
Emergency Department ◽  
Tertiary Care ◽  
Signs And Symptoms ◽  
Fish Bone ◽  
Quality Improvement Initiative ◽  
Care Hospital ◽  
Analysis Model ◽  
Post Intervention ◽  
Targeted Interventions ◽  
Administration Time

Abstract BackgroundSevere exacerbation of asthma are potentially life-threatening and therefore require prompt care and frequent management. Important elements of early treatment includes recognition of early signs and symptoms of breathing difficulty and timely prescription and administration of therapeutic agents. A subsequent delay in receiving nebulization during an acute exacerbation of asthma can leads to cardiac arrest and even death. AimTo reduce the gap in administration of nebulization from its prescription time among red triaged patients by 50% from its baseline. Setting and designThis interventional study was conducted among red triaged patients in emergency department of tertiary care hospital, India . Material and MethodsBaseline information was collected during first 4 weeks to find gap in administration of nebulization from its prescription time. Fish bone analysis and process map were laid down to analyse the situation. The intervention using targeted bundles was done via 3 PDSA (PDSA1: indenting the nebulizers, PDSA 2: training of doctors and nurses, PDSA 3; introducing equipment checklist) to reduce the gap . A run chart using time series analysis model was used to compare the pre and post intervention nebulization gap. ResultsTotal 74 patients (30 in pre- intervention, 44 in post intervention) admitted in red triaged area were observed for nebulization gap from prescription to administration. Median time for nebulization gap before intervention was 46.5 minutes which reduced to 15 minutes in post intervention phase. ConclusionThis bundles of targeted interventions was successful to reduce the nebulization gap. Key words: nebulization gap, prescription time, administration time

Impact of Order-Set Modifications and Provider Education Following Guideline Updates on Broad-Spectrum Antibiotic Use in Patients Admitted With Community Acquired Pneumonia

2021 ◽  
pp. 001857872110557
Author(s):  
Jessica L. Colmerauer ◽  
Kristin E. Linder ◽  
Casey J. Dempsey ◽  
Joseph L. Kuti ◽  
David P. Nicolau ◽  
...  
Keyword(s):  
Broad Spectrum ◽  
Antibiotic Use ◽  
Community Acquired Pneumonia ◽  
Intervention Period ◽  
Provider Education ◽  
Broad Spectrum Antibiotic ◽  
Post Intervention ◽  
Post Intervention Period ◽  
Days Of Therapy ◽  
Order Set

Purpose: Following updates to the Infectious Diseases Society of America (IDSA) practice guidelines for the Diagnosis and Treatment of Adults with Community-acquired Pneumonia in 2019, Hartford HealthCare implemented changes to the community acquired pneumonia (CAP) order-set in August 2020 to reflect criteria for the prescribing of broad-spectrum antimicrobial therapy. The objective of the study was to evaluate changes in broad-spectrum antibiotic days of therapy (DOT) following these order-set updates with accompanying provider education. Methods: This was a multi-center, quasi-experimental, retrospective study of patients with a diagnosis of CAP from September 1, 2019 to October 31, 2019 (pre-intervention) and September 1, 2020 to October 31, 2020 (post-intervention). Patients were identified using ICD-10 codes (A48.1, J10.00-J18.9) indicating lower respiratory tract infection. Data collected included demographics, labs and vitals, radiographic, microbiological, and antibiotic data. The primary outcome was change in broad-spectrum antibiotic DOT, specifically anti-pseudomonal β-lactams and anti-MRSA antibiotics. Secondary outcomes included guideline-concordance of initial antibiotics, utilization of an order-set to prescribe antibiotics, and length of stay (LOS). Results: A total of 331 and 352 patients were included in the pre- and post-intervention cohorts, respectively. There were no differences in order-set usage (10% vs 11.3%, P = .642) between the pre- and post-intervention cohort, respectively. The overall duration of broad-spectrum therapy was a median of 2 days (IQR 0-8 days) in the pre-intervention period and 0 days (IQR 0-4 days) in the post-intervention period ( P < .001). Patients in whom the order-set was used in the post-intervention period were more likely to have guideline-concordant regimens ([36/40] 90% vs [190/312] 60.9%; P = .003). Hospital LOS was shorter in the post-intervention cohort (4.8 days [2.9-7.2 days] vs 5.3 days [IQR 3.5-8.5 days], P = .002). Conclusion: Implementation of an updated CAP order-set with accompanying provider education was associated with reduced use of broad-spectrum antibiotics. Opportunities to improve compliance and thus further increase guideline-concordant therapy require investigation.

scholarly journals 1154. Impact of Educational Feedback on Reducing Hospital-Onset Catheter-Associated Urinary tract Infections at an Academic Medical Center

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S412-S412
Author(s):  
Bhagyashri D Navalkele ◽  
Nora Truhett ◽  
Miranda Ward ◽  
Sheila Fletcher
Keyword(s):  
Infection Prevention ◽  
Medical Center ◽  
Academic Medical Center ◽  
Prevention Strategies ◽  
Intervention Period ◽  
Post Intervention ◽  
Frontline Staff ◽  
Post Intervention Period ◽  
Tract Infections ◽  
The Impact

Abstract Background High regulatory burden on hospital-onset (HO) infections has increased performance pressure on infection prevention programs. Despite the availability of comprehensive prevention guidelines, a major challenge has been communication with frontline staff to integrate appropriate prevention measures into practice. The objective of our study was to evaluate the impact of educational intervention on HO CAUTI rates and urinary catheter days. Methods At the University of Mississippi Medical Center, Infection prevention (IP) reports unit-based monthly HO infections via email to respective unit managers and ordering physician providers. Starting May 2018, IP assessed compliance to CAUTI prevention strategies per SHEA/IDSA practice recommendations (2014). HO CAUTI cases with noncompliance were labeled as “preventable” infections and educational justification was provided in the email report. No other interventions were introduced during the study period. CAUTI data were collected using ongoing surveillance per NHSN and used to calculate rates per 1,000 catheter days. One-way analysis of variance (ANOVA) was used to compare pre- and post-intervention data. Results Prior to intervention (July 2017–March 2018), HO CAUTI rate was 1.43 per 1,000 catheter days. In the post-intervention period (July 2018–March 2019), HO CAUTI rate decreased to 0.62 per 1,000 catheter days. Comparison of pre- and post-intervention rates showed a statistically significant reduction in HO CAUTIs (P = 0.04). The total number of catheter days reduced, but the difference was not statistically significant (8,604 vs. 7,583; P = 0.06). Of the 14 HO CAUTIs in post-intervention period, 64% (8/14) were reported preventable. The preventable causes included inappropriate urine culturing practice in asymptomatic patients (5) or as part of pan-culture without urinalysis (2), and lack of daily catheter assessment for necessity (1). Conclusion At our institute, regular educational feedback by IP to frontline staff resulted in a reduction of HO CAUTIs. Feedback measure improved accountability, awareness and engagement of frontline staff in practicing appropriate CAUTI prevention strategies. Disclosures All authors: No reported disclosures.

scholarly journals Enhanced infection control interventions reduced catheter-related bloodstream infections in the neonatal department of Hung Vuong Hospital, Vietnam, 2011–2012: a pre- and post-intervention study

2020 ◽  
Vol 9 (1) ◽  
Author(s):  
Hang Thi Phan ◽  
Thuan Huu Vo ◽  
Hang Thi Thuy Tran ◽  
Hanh Thi Ngoc Huynh ◽  
Hong Thi Thu Nguyen ◽  
...  
Keyword(s):  
Risk Factors ◽  
Intervention Study ◽  
Bloodstream Infections ◽  
Incidence Rates ◽  
Intervention Period ◽  
Intravenous Catheter ◽  
Aseptic Technique ◽  
Post Intervention ◽  
Post Intervention Period ◽  
Factors Associated

Abstract Background Catheter-related bloodstream infections (CR-BSI) cause high neonatal mortality and are related to inadequate aseptic technique during the care and maintenance of a catheter. The incidence of CR-BSI among neonates in Hung Vuong Hospital was higher than that of other neonatal care centres in Vietnam. Methods An 18-month pre- and post-intervention study was conducted over three 6-month periods to evaluate the effectiveness of the intervention for CR-BSI and to identify risk factors associated with CR-BSI. During the intervention period, we trained all nurses in the Department of Neonatology on BSI preventive practices, provided auditing and feedback about aseptic technique during catheter care and maintenance, and reorganised preparation of total parenteral nutrition. All neonates with intravenous catheter insertion ≥48 h in the pre- and post-intervention period were enrolled. A standardised questionnaire was used to collect data. Blood samples were collected for cultures. We used Poisson regression to calculate rate ratio (RR) and 95% confidence interval (CI) for CR-BSI incidence rates and logistic regression to identify risk factors associated with CR-BSI. Results Of 2225 neonates enrolled, 1027 were enrolled in the pre-intervention period, of which 53 CR-BSI cases occurred in 8399 catheter-days, and 1198 were enrolled in the post-intervention period, of which 32 CR-BSI cases occurred in 8324 catheter-days. Incidence rates of CR-BSI significantly decreased after the intervention (RR = 0.61, 95% CI 0.39–0.94). Days of hospitalisation, episodes of non-catheter–related hospital-acquired infections, and the proportion of deaths significantly decreased after the intervention (p < 0.01). The CR-BSI was associated with days of intravenous catheter (odds ratio [OR] = 1.05, 95% CI 1.03–1.08), use of endotracheal intubation (OR = 2.27, 95% CI 1.27–4.06), and intravenous injection (OR = 8.50, 95% CI 1.14–63.4). Conclusions The interventions significantly decreased the incidence rate of CR-BSI. Regular refresher training and auditing and feedback about aseptic technique during care and maintenance of catheters are critical to reducing CR-BSI.

SEC Scrutiny and the Evolution of Non-GAAP Reporting

2008 ◽  
Vol 83 (1) ◽  
pp. 157-184 ◽  
Author(s):  
Kalin Kolev ◽  
Carol A. Marquardt ◽  
Sarah E. McVay
Keyword(s):  
Securities And Exchange Commission ◽  
Unintended Consequences ◽  
Intervention Period ◽  
Post Intervention ◽  
Special Items ◽  
Post Intervention Period

We empirically examine the effects of intensified scrutiny over non-GAAP reporting on the quality of non-GAAP earnings exclusions. We find that, on average, exclusions are of higher quality (i.e., more transitory) following intervention by the Securities and Exchange Commission (SEC) into non-GAAP reporting. We further find that firms that stopped releasing non-GAAP earnings numbers after the SEC intervention had lower quality exclusions in the pre-intervention period. These results are consistent with the SEC's objectives of improving the quality of non-GAAP earnings figures. However, when we decompose total exclusions into special items and other exclusions, we find evidence that the quality of special items has decreased in the post-intervention period, which suggests that managers adapted to the new disclosure environment by shifting more recurring expenses into special items. This suggests that there may be unintended consequences arising from the heightened scrutiny over non-GAAP reporting.

The CDC Hemostasis and Thrombosis Centers (HTC) Pilot Sites: Data From the Pediatric Registry.

Blood ◽  
2009 ◽  
Vol 114 (22) ◽  
pp. 2990-2990
Author(s):  
Lisa A Michaels ◽  
Michele Beckman ◽  
Courtney Thornburg ◽  
Kristy Marquez ◽  
Roshni Kulkarni ◽  
...  
Keyword(s):  
Lower Extremity ◽  
Venous Thrombosis ◽  
Oral Anticoagulation ◽  
Conflicts Of Interest ◽  
Tertiary Care ◽  
Age Distribution ◽  
High Rate ◽  
Inpatient Setting ◽  
Anticoagulation Management ◽  
Recurrent Vte

Abstract Abstract 2990 Poster Board II-966 Background: Venous thrombosis (VTE) is a rare disorder in children, and its overall incidence, pathophysiology, and outcomes remain poorly defined. Registries and cohort studies including those from Canada, Germany, Colorado, and others have provided seminal observations on the incidence, age distribution, associated conditions, diagnostic modalities, location, and treatment patterns for children and have resulted in greater awareness and improvements in clinical practice. Methods: The Division of Blood Disorders of the Centers for Disease Control and Prevention (CDC) in collaboration with eight Thrombosis and Hemostasis Centers Patient Registry began in August 2003 to characterize clinical features, treatments, and services provided to the individuals referred. Results: As of March 2009, 316 children and adolescents from birth to 21 years were enrolled at six of the sites. About half of the patients (48%) were referred from the inpatient setting. Patients were predominantly of white (84%) or black (13%) race and median age was 15.6 years (newborn-21 years). Patients were stratified by age; 178 (56%) were adolescents (≥15 years), 75 (24%) age 7 to 14, 38 (12%) age 1 to 6. 25 (8%) were infants (<12 months). Gender distribution over the entire cohort was similar (54% female), however gender differed as age increased; 64% of infants were male decreasing to 42% in adolescents (p for trend=0.01). Site of thrombosis differed by age. In adolescents, 70% of VTE events occurred in the lower extremity, while cerebral sinus venous thrombosis (CSVT) was the most common site in infants (42%). Prevalence of lower extremity VTE increased with age (p for trend < .0001) while prevalence of CSVT (p<.0001) and abdominal VTE decreased with age (p=0.003). Pulmonary embolism (PE) was more common in the adolescent group (38%, p<.0001). Associated underlying conditions were found in 183 (58%) and also differed by age. Infection (16.8%) was the most common associated condition across all age groups, central venous lines (CVLs) were present in 11% and 4% had cancer. However among infants, CVL (32%), prematurity (24%) and infection (24%) were the most common while infection (10.1%) surgery (10.1%) and oral contraceptive use among females (23.1%) were concurrent for adolescents. Thrombophilia was identified in 86 (27%), of which antiphospholipid antibodies (APA) were the most common (15%). Recurrent VTE occurred in 46 (15%), of which 25 (54%) had one or more thrombophilic traits. No underlying cause or risk factor was found in 98 (31%). Most (85%) of the patients received anticoagulation treatment/management at the center. Low molecular weight heparin (LMWH) was the most commonly used therapy (54%), followed by oral anticoagulation (50%), unfractionated heparin (UFH) (12%), thrombolysis (4%), and embolectomy in 2%.Oral anticoagulation use increased with age (p<.0001). Discussion: These data represent one of the largest prospective cohorts of pediatric thrombosis published to date, and includes patients referred from the tertiary care inpatient, as well as the outpatient community. In contrast to earlier registry data, the pediatric thrombosis centers participating in this study are seeing a predominance of lower extremity VTE in adolescent females with acquired risk factors including oral contraceptives and APA, in addition to other underlying medical conditions. The study additionally documented a high rate of thrombus recurrence in children with thrombophilia and advances the debate on the value of routine thrombophilia testing in children with VTE. Although CVLs remain a substantial risk for VTE, their presence in this cohort was surprisingly low. This appears to result primarily from the rarity of CVL associated thrombosis in the adolescents and from the relatively low representation of children with cancer. The data confirm changes in anticoagulation management in favor of LMWH. Finally, the high proportion of pediatric patients with recurrent VTE highlights a need for outcome data to determine optimal methods for primary and secondary prevention of VTE and its sequellae. Disclosures: No relevant conflicts of interest to declare.

scholarly journals A Daytime Fast Track Improves Throughput in a Single Physician Coverage Emergency Department

CJEM ◽  
2015 ◽  
Vol 17 (6) ◽  
pp. 648-655 ◽  
Author(s):  
Julie Copeland ◽  
Andrew Gray
Keyword(s):  
Emergency Department ◽  
Fast Track ◽  
Community Hospital ◽  
Wait Time ◽  
Intervention Period ◽  
Post Intervention ◽  
Study Objective ◽  
Post Intervention Period ◽  
Left Without Being Seen ◽  
Physician Coverage

AbstractObjectivesFast tracks are one approach to reduce emergency department (ED) crowding. No studies have assessed the use of fast tracks in smaller hospitals with single physician coverage. Our study objective was to determine if implementation of an ED fast track in a single physician coverage setting would improve wait times for low-acuity patients without negatively impacting those of higher acuity.MethodsA daytime fast track opened in 2010 at Strathroy Middlesex General Hospital, a southwestern Ontario community hospital. Before and after intervention groups comprised of ED visits in 2009 and 2011 were compared. Pooled comparison of all Canadian Triage and Acuity Scale (CTAS) patients in each period, and between subgroups CTAS 2-5 comparisons were performed for: wait time (WT), length of stay (LOS), WTs that met national CTAS time guidelines (MNCTG), and proportion of patients that left without being seen (LWBS).ResultsWT and LOS were six minutes (88 min to 82 min, p=0.002) and 15 minutes (158 min to 143 min, p<0.001) lower, respectively, in the post-intervention period. Subgroup analysis showed CTAS 4 had the most pre- to post-intervention decrease in WT, of 13 minutes (98 min to 85 min, p<0.001). There was statistical improvement in MNCTG in the post-intervention period. No differences were found in outcome measures for higher-acuity patients or LWBS rates.ConclusionsImplementation of a fast track in a medium-volume community hospital with single physician coverage can improve patient throughput by decreasing WT and LOS without negatively impacting high-acuity patients. This may be clinically relevant, particularly for hospital administrators, given the improvement in meeting national WT standards we found post-intervention.

Sign in / Sign up

Export Citation Format

Share Document