Relationship between Treatment Plan Dosimetry, Toxicity, and Survival following Intensity-Modulated Radiotherapy, with or without Chemotherapy, for Stage III Inoperable Non-Small Cell Lung Cancer

Concurrent chemoradiotherapy (cCRT) is the preferred treatment for stage III NSCLC because surgery containing multimodality treatment is often not appropriate. Alternatives, often for less fit patients, include sequential CRT and RT alone. Many reports describing the relationship between overall survival (OS), toxicity, and dosimetry are based on clinical trials, with strict criteria for patient selection. We performed an institutional analysis to study the relationship between dosimetric parameters, toxicity, and OS in inoperable patients with stage III NSCLC treated with (hybrid) IMRT/VMAT-based techniques in routine clinical practice. Eligible patients had undergone treatment with radical intent using cCRT, sCRT, or RT alone, planned to a total dose ≥ 50 Gy delivered in ≥15 fractions. All analyses were performed for two patient groups, (1) cCRT (n = 64) and (2) sCRT/RT (n = 65). The toxicity rate differences between the two groups were not significant, and OS was 29 and 17 months, respectively. For sCRT/RT, no dosimetric factors were associated with OS, whereas for cCRT, PTV-volume, esophagus V50 Gy, and contralateral lung V5 Gy were associated. cCRT OS was significantly lower in patients with esophagitis ≥ G2. The overall rate of ≥G3 pneumonitis was low (3%), and the rate of high-grade esophagitis the OS in this real-world patient population was comparable to those reported in clinical trials. Based on this hypothesis-generating data, more aggressive esophageal sparing merits consideration. Institutional auditing and benchmarking of the planning strategy, dosimetry, and outcome have an important role to play in the continuous quality improvement process.

A Methodological Approach for Developing and Validating a Parsimonious and Robust Measurement Tool: The Academic E-Service Quality (ACEQUAL) Model

Nowadays, in the higher education sector, the quality measurement process of education-related services is assuming a crucial role to support focused and targeted improvement activities deeply centered on students’ needs/necessities. These are considered crucial factors for dealing with the current academic competitive context. Therefore, the quality measurement process has to be precise and accurate, namely the measurement model on which it is based has to be parsimonious and robust. The present work proposes an effective and easy-to-use methodological approach suitable for supporting the structuring of a measurement tool. Its effectiveness is shown with reference to the academic e-service provided at the University of Palermo. In particular, taking into account the students’ viewpoints and perspectives, a measurement model of the academic e-service quality is developed and validated, thus overcoming the lack of literature on the subject. Finally, a survey is conducted, and highlighted academic e-service quality shortcomings and criticalities are stressed and discussed. The outcomes of this study may be of interest to practitioners and researchers in the field, offering important suggestions on how to support the structuring of a measurement model, as well the data-driven service quality improvement process.

ECMO During a Pandemic: A COVID-19 Quality Improvement Process

Extracorporeal membrane oxygenation is a modified form of cardiopulmonary bypass and a complex adult critical care therapy. No evidence appears to exist on sustaining relevant quality nursing standards during a pandemic. The aim for this quality improvement process was to address nursing provision in real time related to extracorporeal membrane oxygenation in a pandemic, providing fundamentals for future readiness. The Ishikawa fishbone diagram and a Plan-Do-Study-Act cycle were methods used. Process changes included implementation of a communication algorithm, an alternative nursing care model, increased nursing staffing and leadership visibility, use of perfusion services for nursing task support, and minimized nursing documentation. Changes applied were successful. We recommend increasing nursing staffing volume and support resources, applying a communication algorithm, and minimizing documentation requirements. These strategies are generalizable to other clinical nursing areas in similar pandemics or disasters.

Exploration of a quality improvement process to standardised preoperative tests for a surgical procedure to reduce waste

BackgroundPreoperative tests are done to determine a patient’s fitness for anaesthesia and surgery.Local problemAlthough routine tests before surgery in the absence of specific clinical indications are not recommended, we observed high volumes of routine preoperative tests were performed in our institution. We describe a process to implement a standardised preoperative investigational approach to reduce unnecessary testing before surgeries.MethodsA series of six Plan-Do-Study-Act (PDSA) cycles was conducted for root cause analysis and process mapping, development of standardised tool (GRID), collection of baseline data, education and feedback, pilot testing and implementation and uptake of GRID.Root cause analysis revealed a lack of awareness of guidelines and a lack of a standardised tool to guide preoperative testing. We undertook a pilot quality improvement project to reduce unnecessary testing before knee and hip arthroplasty by developing and implementing a standardised tool (GRID) and engaging all stakeholders.InterventionsA clinical development team (CDT) was formed, including all the stakeholders. Our CDT focused on a continuous rapid cycle improvement strategy.ResultsAfter implementation of the tool in a subgroup of patients undergoing elective hip or knee arthroplasty, unnecessary coagulation tests (activated partial thromboplastin time and the international normalised ratio), electrolyte/renal panel tests and electrocardiograms were reduced by 81% (91%–17%), 81% (41%–7%) and 68% (35%–11%), respectively. No surgery was delayed or cancelled due to tests not performed before surgery.ConclusionsA standardised preoperative investigational approach based on patients’ medical conditions rather than routine testing can reduce unnecessary tests before surgery. Further, implementing guidelines is more complex than developing guidelines. Hence, continuous PDSA cycles are essential to evaluate the processes in a quality improvement project. It can take time to build teams and have shared goals; however, once this is achieved, the success of a quality improvement project is certain.

Evaluation of the System of Dispensation of Drugs in Intrahospital Services, of a Health Unit of Riobamba

Introduction: In Ecuador, many health institutions have not yet migrated to the Unit Dose Dispensation / Distribution System for Medications, which ensures the correct, safe and rational use of medications. Objective: The medication dispensing process in a Riobamba health unit was evaluated as part of the service quality improvement process. Methodology: Information was collected during three months of investigation, from the in-hospital services of hospitalization, intensive care unit, operating room and emergency. The instruments used for the evaluation corresponded to medical prescriptions, medication and medical device request sheets, medication return record sheets and labeling of boxes. Results: In the medical prescriptions as in the record sheets for the return of evaluated drugs, the main drawback was presented in the writing of the pharmaceutical form and the absence of mandatory data for the identification of the patient. In the total of the registers for the return of medications, the absence of the reason for the return of the medications was identified. The medication dispensing process was considered a critical point within the evaluation, since throughout the review period it was observed that the boxes did not have the minimum required labeling, for the correct identification of the patient. Conclusion: It was concluded that the dispensing system presented critical flaws, such as: deficiencies in the supply of medications, dispensing errors, lack of pharmacotherapeutic follow-up and little participation of the pharmaceutical professional. Keywords: dispensing, medication, medication error. Resumen Introducción: En Ecuador, muchas instituciones de salud aún no migran al Sistema de Dispensación/Distribución de Medicamentos por Dosis Unitaria, el cual asegura la correcta, segura y racional utilización de los medicamentos. Objetivo: Se evaluó el proceso de dispensación de medicamentos en una unidad de salud de Riobamba, como parte del proceso de mejoramiento en la calidad del servicio. Metodología: Se recolectó información durante tres meses de investigación, de los servicios de intrahospitalarios de hospitalización, unidad de cuidados intensivos, quirófano y emergencia. Los instrumentos utilizados para la evaluación correspondieron a recetas médicas, hojas de requerimiento de medicamentos y dispositivos médicos, hojas de registro de devolución de medicación y rotulación de cajetines. Resultados: En las recetas médicas como en las hojas de registro de devolución de medicamentos evaluadas, el principal inconveniente se presentó en la escritura de la forma farmacéutica y la ausencia de datos obligatorios para identificación del paciente. En el total de los registros de devolución de medicamentos, se identificó la inexistencia del motivo de la devolución de los medicamentos. El proceso de dispensación de medicación, se consideró un punto crítico dentro de la evaluación, ya que durante todo el período de revisión se observó que los cajetines no contaban con la rotulación mínima requerida, para la identificación correcta del paciente. Conclusión: Se concluyó que el sistema de dispensación presentaba fallas críticas, tales como: deficiencias en el suministro de medicamentos, errores de dispensación, falta de seguimiento farmacoterapéutico y la poca participación del profesional farmacéutico. Palabras clave: dispensación, medicamentos, error de medicación.

Gaussian Filtering Method to Remove Noise in Images

Capturing every moment is not taboo in this era. One way to capture the moment is to use a photo, but the results are often unsatisfactory. Noise, is one of the many causes of unsatisfactory results. Noise is a disturbance caused by digital data storage received by the image data receiver which can interfere with image quality. Noise can be caused by physical (optical) disturbances in the image capturing device, such as dust on the camera lens or due to improper processing. To get rid of this noise, you can use various methods, of which Gaussian Filtering is one of them. In this research, we will implement it using Matlab. The type of file used is a photo that has a jpg format and has noise above 75%. After doing image processing, it shows the results of the image which initially has noise and after the image quality improvement process is carried out, the image quality is clearer and the noise decreases.