A practice game changer: Impact of tenecteplase for acute ischemic stroke in a multicenter quality improvement project

Purpose Tenecteplase is a thrombolytic that is more fibrin specific, has a longer half-life, and is easier to administer than alteplase for acute ischemic stroke (AIS). This article outlines the pharmacy experience and perspective on implementation of tenecteplase as the treatment of choice for AIS. Summary Tenecteplase has been of increasing interest for AIS and is currently being studied in several clinical trials. Although it is not indicated by the Food and Drug Administration for AIS, several published studies and an update to stroke guidelines from the American Heart Association and American Stroke Association support its use in this setting. In January 2021, Cedars-Sinai Health System made the decision to add tenecteplase to the formulary for AIS in addition to keeping alteplase for patients who met the criterion of being outside the 4.5-hour window following stroke onset. Along with the added benefits of having tenecteplase on formulary come challenges of managing multiple thrombolytics for the same indication. Identifying key stakeholders and creating an interdisciplinary team are critical to ensure safe transitions. Conclusion Institutions can safely transition from alteplase to tenecteplase as a thrombolytic of choice for AIS.

Evaluation of a Medicaid performance improvement project to reduce high-dose opioid prescriptions

Background In 2015, Oregon’s Medicaid program implemented a performance improvement project to reduce high-dose opioid prescribing across its 16 coordinated care organizations (CCOs). The objective of this study was to evaluate the effect of that program on prescription opioid use and outcomes. Methods Using Medicaid claims data from 2014 to 2017, we conducted interrupted time-series analyses to examine changes in the prescription opioid use and overdose rates before (July 2014 to June 2015) and after (January 2016 to December 2017) implementation of Oregon’s high-dose policy initiative (July 2015 to December 2015). Prescribing outcomes were: 1) total opioid prescriptions 2) high-dose [> 90 morphine milligram equivalents per day] opioid prescriptions, and 3) proportion of opioid prescriptions that were high-dose. Opioid overdose outcomes included emergency department visits or hospitalizations that involved an opioid-related poisoning (total, heroin-involved, non-heroin involved). Analyses were performed at the state and CCO level. Results There was an immediate reduction in high dose opioid prescriptions after the program was implemented (− 1.55 prescription per 1000 enrollee; 95% CI − 2.26 to − 0.84; p < 0.01). Program implementation was also associated with an immediate drop (− 1.29 percentage points; 95% CI − 1.94 to − 0.64 percentage points; p < 0.01) and trend reduction (− 0.23 percentage point per month; 95% CI − 0.33 to − 0.14 percentage points; p < 0.01) in the monthly proportion of high-dose opioid prescriptions. The trend in total, heroin-involved, and non-heroin overdose rates increased significantly following implementation of the program. Conclusions Although Oregon’s high-dose opioid performance improvement project was associated with declines in high-dose opioid prescriptions, rates of opioid overdose did not decrease. Policy efforts to reduce opioid prescribing risks may not be sufficient to address the growing opioid crisis.

Assessing the Utility of an Outpatient Exercise Program for Children With Cystic Fibrosis: A Quality Improvement Project

Children with cystic fibrosis (CF) (cwCF) suffer from inadequate weight gain, failure to thrive, and muscle weakness. The latter may be secondary to disuse atrophy (muscle wasting or reduction in muscle size associated with reduced physical activity and inflammation). Handgrip strength (HGS) is a reliable surrogate for muscle strength and lean body mass. Data from our CF center have shown an association between low HGS and forced expiratory volume in 1 s (FEV1) in cwCF. High-intensity interval training (HIIT) improves physical strength. Therefore, we devised a project to assess implementing a HIIT exercise program in the home setting, in order to improve physical strength in cwCF with HGS ≤ 50th percentile. Patients were instructed to complete 3–5 sessions of HIIT exercises per week. Wilcoxon matched-pairs signed-rank tests were used to compare HGS, FEV1, and body mass index (BMI) percentile at baseline and at a follow-up clinic visit. Follow-up was limited due to the COVID pandemic. Adherence to the HIIT regimen was poor. A total of twenty-nine cwCF participated in the program. However, a total of 13 individuals reported some form of moderate activity at follow-up and therefore constituted our final study population. There was a statistically significant increase in absolute grip strength (AGS) and FEV1 for these individuals. Even though the home HIIT protocol was not followed, the project demonstrated that moderate physical activity in cwCF can lead to significant improvement in HGS and overall physical strength.

Multidisciplinary residential home intervention to improve outcomes for frail residents

Background Residential homes provide accommodation and assistance with personal care only and are not required to have registered nurses on site. However, their residents often have a combination of comorbidity, polypharmacy, frailty and mental-health conditions with poor access to healthcare to meet these needs. Integrated healthcare for older people is a key NHS priority in the Long-Term Plan and the Five-Year Forward View. We describe development and implementation of multi-disciplinary intervention to integrate healthcare and promote interprofessional education. Methods A multi-disciplinary residential home quality improvement project in two cycles by a team comprising senior and trainee general practitioners, trainees in geriatrics, psychiatry, pharmacist and residential home senior staff. The intervention was underpinned by the framework for enhanced health in care homes including Comprehensive Geriatric Assessment (CGA) and mental-health review. Each intervention session included an educational presentation by a team member consideration of each resident in a pre-evaluation multi-disciplinary discussion followed by a structured clinical assessment and discussion of proposed management. Results Three residential homes participated with a total 34 residents receiving intervention. In one residential home, there was a 75% reduction in admissions for those reviewed and a reduction in overall admission costs. Polypharmacy was reduced by an average of 2 medications per resident across the three sites. There was a 63% increase in cardio-pulmonary resuscitation decisions and 76% increase in advance care planning discussions. Conclusion This was an effective model for multi-disciplinary trainees working with a perceived impact on physical and mental health, and valuable opportunities for sharing learning.

The Introduction of An Intravenous Fluid Bundle to Improve the Prescribing of Intravenous Fluids Within a District General Hospital (Preprint)

BACKGROUND Intravenous (IV) fluids are some of the most commonly prescribed day-to-day drugs. Evidence suggests that such prescriptions are rarely ever done correctly despite the presence of clear guidelines (NICE CG174). This is believed to be due to lack of knowledge and experience, which often breeds confusion and places patients at increased risk of harm. It also incurs avoidable costs to hospitals. OBJECTIVE This quality improvement project (QIP) aims to ensure that IV fluid prescriptions are: safe, appropriate and adhere to evidence-based NICE guidance. The project’s aims will be achieved through implementing multiple interventions that are categorised under: educational, changing prescribing habits and raising awareness. METHODS Review and improve the prescribing process of “IV fluid prescribing” via three simultaneous approaches. Teaching sessions were delivered to all junior doctors in order to improve knowledge and awareness of appropriate IV fluid prescribing and promote familiarity with the current NICE IV fluid guidelines. This included a ‘feature session’ at our local hospital Grand Round. A point-of-care aide-memoire containing a summary of the information needed for correct prescription was designed and printed. This complimented the teaching sessions and supported good clinical practice. Using serial Plan-Do-Study-Act (PDSA) cycles, a novel “IV fluid bundle” was developed, fine-tuned and trialled on five wards, (three surgical, two medical). The aim of the bundle was to ensure that patients were clinically reviewed in order to assess their volaemic status in order that appropriate IV fluids could then be selected and prescribed safely. The impact of these interventions was assessed on the trial wards via a weekly point prevalence audit of the IV fluid bundles for the duration of the trial. Parameters looked at were: incidence of deranged U&E’s, incidence of AKI and the number of days between the latest U&E’s and the patient’s IV fluid prescription. RESULTS These interventions were assessed on trial wards via a weekly point prevalence audit of the new IV fluid prescription chart (bundle; IFB) for the duration of the trial. Parameters monitored were: incidence of deranged U&E’s, incidence of acute kidney injury (AKI) and the number of days between the latest U&E’s and the patient’s IV fluid prescription. Of all of the patients on the IV fluid bundle, 100% had a documented weight, review of both fluid status and balance. The incidence of deranged U&E’s decreased from 48% to 35%. Incidence of AKI decreased from 24% to 10%. The average number of days between the latest U&E’s and a fluid prescription decreased from 2.2 days to 0.6 day. CONCLUSIONS Prescribing IV fluids is a complex task that requires significant improvement both locally and nationally. With 85% uptake of the IFB, we were able to significantly improve all measured outcomes. Through carefully structured interventions geared towards tackling the confounding issues identified from previous audits and process mapping we have shown that prescribing IV fluids can be made safer.

AgMIP Regional Integrated Assessment of Agricultural Systems in Nioro, Senegal

The Agricultural Model Intercomparison and Improvement Project (AgMIP) developed protocol-based methods for Regional Integrated Assessment (RIA) of agricultural systems. These methods have been applied by teams of scientists working with regional and national stakeholders across Sub-Saharan Africa and South Asia. This paper describes the data sets that were used to implement the AgMIP RIA methods for the Nioro region of Senegal. The goal of the RIA is to assess the potential impacts of climate change on the principal agricultural system in the Senegal peanut basin comprised of peanut, millet, maize and other minor crops and livestock, and to assess adaptations of that system to climate change, under current as well as future climate and socio-economic conditions. The data sets include: the Representative Agricultural Pathways (RAPs) developed for Nioro from 2000-2050; climate data used to implement crop yield simulations; the data used to parameterize the Agricultural Production Systems sIMulator (APSIM) and the Decision Support System for Agrotechnology Transfer (DSSAT) crop models, which include historical climate data and future climate scenarios; and the data used to parameterize the Tradeoff Analysis Model for Multi-dimensional Impact Assessment (TOA-MD) economic simulation model. The analysis is structured around four AgMIP “core questions'' of climate impact assessment.

Associations between resources and practices of ILD centers and outcomes in patients with idiopathic pulmonary fibrosis: data from the IPF-PRO Registry

Background Performance benchmarks for the management of idiopathic pulmonary fibrosis (IPF) have not been established. We used data from the IPF-PRO Registry, an observational registry of patients with IPF managed at sites across the US, to examine associations between the characteristics of the enrolling sites and patient outcomes. Methods An online survey was used to collect information on the resources, operations, and self-assessment practices of IPF-PRO Registry sites that enrolled ≥ 10 patients. Site variability in 1-year event rates of clinically relevant outcomes, including death, death or lung transplant, and hospitalization, was assessed. Models were adjusted for differences in patient case mix by adjusting for known predictors of each outcome. We assessed whether site-level heterogeneity existed for each patient-level outcome, and if so, we investigated potential drivers of the heterogeneity. Results All 27 sites that enrolled ≥ 10 patients returned the questionnaire. Most sites were actively following > 100 patients with IPF (70.4%), had a lung transplant program (66.7%), and had a dedicated ILD nurse leader (77.8%). Substantial heterogeneity was observed in the event rates of clinically relevant outcomes across the sites. After controlling for patient case mix, there were no outcomes for which the site variance component was significantly different from 0, but the p-value for hospitalization was 0.052. Starting/completing an ILD-related quality improvement project in the previous 2 years was associated with a lower risk of hospitalization (HR 0.60 [95% CI 0.44, 0.82]; p = 0.001). Conclusions Analyses of data from patients with IPF managed at sites across the US found no site-specific characteristics or practices that were significantly associated with clinically relevant outcomes after adjusting for patient case mix. Trial registration ClinicalTrials.gov, NCT01915511. Registered 5 August 2013, https://clinicaltrials.gov/ct2/show/NCT01915511

Reducing Waiting Time in the General Pediatric Clinic at Al Wakra Hospital, Qatar

Background: Waiting times for clinic appointments constitute a key indicator of an outpatient department performance for access to care and patient satisfaction. This is particularly relevant for pediatric population. The Ministry of Public Health in Qatar set a waiting time of 28 days for patients to get new appointment in General Outpatient Department (GOPD). The current average waiting time to get a new appointment in the general pediatric clinic (GPC) at AWH is 57 days. Aim: Decrease the average waiting time to get a new clinic appointment from 57 days to 28 days by the end of December 2018, and to meet the national targets set by the Ministry of Public Health. Methodology: This is a Quality Improvement (QI) project using the Model for Improvement (MFI). The MFI framework is designed to support organizations answering fundamental questions before agreeing on drivers for change. The implementation of change was be facilitated by the Plan-Do-Study-Act (PDSA) cycles methodology. The QI project team performed a root cause analysis using the Ishikawa diagram and identified the key contributing factors to the long waiting times to get a new appointment. Twenty-seven PDSA cycle ramps were designed with support of predictive tool to test innovative changes in current operational processes in an attempt to improve waiting time in the general pediatric clinic at Al Wakra Hospital. Results: The monthly average number of referrals for GPC increased by 200% between the pre and post implementation periods. The average triage waiting time improved from 6 to 2.6 days in 2018 and the average become 1 day in 2019. Post-implementation the average waiting time for patients to get new appointment improved from 57 days to 28 days in 2018 and the average waiting time improved to 16 days in 2019. Conclusion: The quality improvement project for the AWH general pediatric clinic demonstrates significant improvement in waiting times for new appointments, the recommendation for the hospital leadership would be to rollout the improvement methodology to other clinics that suffer from similar challenges.

Care of Transgender Patients: A General Practice Quality Improvement Approach

Primary care must ensure high quality lifelong care is offered to trans and gender minority patients who are known to have poor health and adverse healthcare experiences. This quality improvement project aimed to interrogate and audit the data of trans and gender minority patients in one primary care population in England. A new data collection instrument was created examining pathways of care, assessments and interventions undertaken, monitoring, and complications. General practitioners identified a sample from the patient population and then performed an audit to examine against an established standard of care. No appropriate primary care audit standard was found. There was inconsistency between multiple UK gender identity clinics’ (GIC) individual recommended schedules of care and between specialty guidelines. Using an international, secondary care, evidence-informed guideline, it appeared that up to two-thirds of patients did not receive all recommended monitoring standards, largely due to inconsistencies between GIC and international guidance. It is imperative that an evidence-based primary care guideline is devised alongside measurable standards. Given the findings of long waits, high rates of medical complexity, and some undesired treatment outcomes (including a fifth of patients stopping hormones of whom more than half cited regret or detransition experiences), this small but population-based quality improvement approach should be replicated and expanded upon at scale.