Implementation of Veterans Affairs Primary Care Antimicrobial Stewardship Interventions For Asymptomatic Bacteriuria And Acute Respiratory Infections

Background Outpatient antimicrobial prescribing is an important target for antimicrobial stewardship (AMS) interventions to decrease antimicrobial resistance. The objective of this study was to design, implement, and evaluate the impact of AMS interventions focused on asymptomatic bacteriuria (ASB) and acute respiratory infections (ARIs) in the primary care setting. Methods This stepped-wedge trial evaluated the impact of multifaceted educational interventions to providers on adult patients presenting to primary care clinics for ARIs and ASB. The primary outcome was percentage of overall antibiotic prescriptions as a composite of prescriptions for ASB, acute bronchitis, upper respiratory infection not otherwise specified, uncomplicated sinusitis, and uncomplicated pharyngitis. Secondary outcomes were the individual components of the primary outcome; a composite safety endpoint of related hospital, emergency department, or primary care visits within 4 weeks; antibiotic selection appropriateness; and patient satisfaction surveys. Results A total of 887 patients were included (405 preintervention and 482 postintervention). After controlling for type I error using Bonferroni correction, the primary outcome was not significantly different between groups (56% vs 49%). There was a statistically significant decrease in prescriptions for acute bronchitis (20.99% vs 12.66%; P = .0003). Appropriateness of antibiotic prescriptions for uncomplicated sinusitis (odds ratio [OR], 4.96 [95% confidence interval {CI}, 1.79–13.75]; P = .0021) and pharyngitis (OR, 5.36 [95% CI, 1.93–14.90]; P = .0013) was improved in the postintervention vs the preintervention group. The composite safety outcome and patient satisfaction surveys did not differ between groups. Conclusions Multifaceted educational interventions targeting providers can improve antibiotic prescribing for indications rarely requiring antimicrobials without increasing re-visits or patient satisfaction surveys.

P-OGC05 The introduction of an Upper Gastrointestinal (UGI) specific menu can reduce the need for routine jejunostomy (JEJ) placement following UGI Cancer resection

Background Despite the fact that early oral feeding (EOF) after the surgical resection of oesophageal and gastric tumours is safe, and is associated with favourable early in-hospital outcomes, sooner return to physiological GI function and hospital discharge, there can still be some reluctance in establishing EOF. Concerns remain around risk of anastomotic leak, pneumonia, Naso-gastric tube (NGT) reinsertion, re-operation, readmissions and mortality. However, when utilising EOF, a reduction in length of stay, earlier removal of NGT and earlier initiation of soft diet can be observed. JEJ placement is beneficial however complications can arise and the optimal nutritional pathway remains debatable. Methods Patient satisfaction surveys were conducted amongst UGI Cancer patients following Cancer resection and analysed pre and post UGI menu development and staff training. Expert UGI Patient volunteers assisted in the UGI menu development through food tastings producing a new menu in collaboration with the catering department. The new menu was launched and an UGI snack box provided to the UGI Enhanced Recovery Unit (ERAS). Oral intake of Diet and Oral Nutritional Support was analysed for calorie and protein content post menu change, ward staff training and specialist UGI dietetic counselling. This was then compared with calculated minimum estimated nutritional requirements. Results Of the ten patients audited pre discharge: Remaining 1 patient achieved 51% of protein requirements, below the aim of 60%. No patient audited required supplementary Enteral feeding via JEJ or Naso-jejunal tube Patient satisfaction surveys were completed prior to catering staff training and menu revision, after the new menu was implemented. The results show a significant improvement in patient satisfaction following UGI menu implementation. Conclusions Specialist UGI RD support, UGI specific menu and Oral Nutritional Support can reduce the need for routine JEJ placement in favour of on an individual patient basis. Collaborative working between UGI Dietitians, Ward staff, Catering staff and Expert patients is required for UGI specific menu development to be effectual. This audit is limited to small numbers due to adapted operational procedures during the pandemic. This audit will be repeated on a larger scale to yield more meaningful data. Future audit will capture data on how many UGI patients went on to require enteral nutritional support with three months of discharge.

The evolution of the education module for men with metastatic prostate cancer (mPC) in the prostate cancer supportive care (PCSC) program.

279 Background: The PCSC Program was initiated in 2013 at the Vancouver Prostate Centre to provide a comprehensive program for patients and partners with prostate cancer. This program provides educational sessions (ES) and clinical services, including decision-making for primary therapy, sexual health, pelvic floor physiotherapy, hormone therapy, counseling, exercise, and nutrition for patients in BC, Canada. In 2016, the PCSC Program expanded to BC Cancer Victoria and in 2017 to other BC Cancer sites. In 2018, medical oncologists (MDs) in Victoria (JR, SP) developed an Education Module addressing treatment options for men with metastatic hormone sensitive (mHSPC) and metastatic castration resistant (mCRPC) disease. MDs delivered in-person ES in Victoria in 2018 and, in 2019, added a virtual platform (VP) option. From 3-5/2020, the ESs were on hold due to the COVID pandemic and parental leaves. In 6/2020, the ESs resumed only on VP, and the PCSC Oncology Nurse Practitioner (NP), NI, gave the presentations for the MDs on leave. In 10/2020, due to a changing standard of care for mHSPC, the PCSC team consolidated the two ESs into one. We report on the evolution of this Education Module in response to both the changing standard of care and the COVID pandemic. Methods: We prospectively collected attendance and patient characteristic metrics from all ES for men with mPC. We tracked presenter type (MD vs. NP) and prospectively collected anonymous patient satisfaction questionnaires. Results: From 1/2018 to 1/2021, 100 men registered for 27 ES; 81 men, 41 partners, and 2 family members actually attended. 48/75 (64%) men were white, 39/75 (52%) retired, and 56/75 (74.7%) married. 47 men attended 12 mHSPC ES, 13 men attended ten mCRPC ES, and 17 attended four consolidated ES. MDs presented 15 ES, and the NP presented 12 ES. Responses to questions on 70 satisfaction surveys were similar for MD vs. NP presenters. 9 responders to the recently added VP-specific questions said they agreed (4) or strongly agreed (5) that it was beneficial to watch the ES at home on a computer. The Table below shows attendance per site per year. Conclusions: The ESs for men with mPC were well-received. Although there was a VP option before COVID, attendance increased significantly after the lockdown as patients and providers became more familiar with VPs. Satisfaction surveys confirmed that an NP could deliver the ES rather than MD. Consolidation of the mHSPC and mCRPC ES reflected the changing standard of care and resulted in more efficient use of presenter time. Virtual delivery of the sessions provided greater access to those living in distant or remote areas of the province and those in lockdown during the COVID pandemic. [Table: see text]

An Advanced Nursing Directive for Children with Suspected Appendicitis: Protocol for a Quality Improvement Feasibility Study (Preprint)

BACKGROUND Pediatric appendicitis accounts for an estimated 7-10% of abdominal pain cases in the emergency department (ED). The diagnosis is time consuming, and the investigative process is dependent on physician assessment, resulting in delays in diagnosis and therapeutic management. The utility of an advanced nursing directive to expedite this process is unclear and needs further exploration. OBJECTIVE Our study aims to describe key components of ED flow in suspected appendicitis patients seen at a pediatric ED and pilot a directive that allows ED nurses to perform an order-set that includes blood work, urine tests, analgesics, fluids, and order an abdominal-pelvis ultrasound prior to physician assessment. METHODS This study involves conducting a retrospective chart review alongside a quality improvement initiative to compare key ED flow metrics before and after advanced nursing directive implementation. Primary outcome measures include median time from ED triage assessment to ultrasound completion, analgesia administration, bloodwork results, time to disposition (consult or discharge), alongside other key ED flow metrics for suspected appendicitis. Secondary outcomes will involve patient and caretaker satisfaction surveys. Descriptive statistics will be used to summarize the data. For differences in proportions, a χ2 test will be used. Student’s t-test will be used for continuous variables. A variable-controlled run chart will be performed to assess impact on ED flow metrics. Patient and family satisfaction surveys are administered immediately after the directive encounter and seven days afterwards. RESULTS There are currently 3900 patients who have been screened, 344 patients enrolled, and 90 patients who have received the medical directive since implementation in June 2020. Interim results on reduction of time to diagnostic and therapeutic ED flow parameters and satisfaction surveys are expected to be published in February 2022. The final study endpoint will be in June 2022. CONCLUSIONS This study proposes a novel protocol for improving the diagnosis and treatment of suspected pediatric appendicitis through implementation of an evidence-based advanced nursing directive. This model may provide a standardized, international pathway for management of common pediatric and adult emergencies.

Aprendizaje basado en problemas en el diseño de prácticas de laboratorio online

This communication describes the use of problem-based learning methodology for remote teaching of laboratory practices of Chemistry subjects in the Bachelor's Degree in Pharmacy. The virtualization was carried out using explanatory videos of each laboratory practice and questionnaires with queries and fictitious data equivalent to those the students would obtain in the laboratory to carry out the resolution of the laboratory practices. The contents were integrated into the virtual platform Blackboard Collaborate, where tutorials and remote support from the teacher were combined to solve the problems raised.The evaluation of the impact of this teaching methodology was carried out by comparing the marks with those obtained in the full presential model and questionnaires to the students. The degree of satisfaction was very high, 100% percentage of passing students as compared to the 70% obtained in the full presential model. It can be concluded that the introduction of problem-based learning methodologies increased the interest of the students, favoring the assimilation of knowledge, as is also demonstrated in the general improvement of grades, satisfaction surveys and a higher number of students passing the exams.

Achieving Continuous Improvement in CSSD Management through Performance Measurements using User Satisfaction Surveys and Interventions

ABSTRACT Introduction The objective of the study was to achieve continuous improvement in Central Sterile Supply Department (CSSD) management through performance measurements using user satisfaction surveys and interventions. Methods A brainstorming session was conducted with the multidisciplinary process improvement team in 2012 on the reasons for dissatisfaction with CSSD services. A baseline survey questionnaire was prepared to assess levels of dissatisfaction for key indicators and to establish target benchmarks for improvement. Charge nurses in the wards were chosen as respondents. The report was presented by the Quality Management Cell (QMC) to the steering committee in the presence of the CSSD managers. Solutions and support were offered to the team for improvement. Similar surveys were conducted in 2014, 2016, 2017, 2018, and 2019 to understand the impact of the changes implemented. Results The overall satisfaction of the respondents with the CSSD services increased from 54% in 2012 to 89% in 2019, which is statistically significant (95% Cl: −0.56 to −0.25) with p-value < 0.001. Conclusion This exercise helped to build a strong team and create a culture of openness in the CSSD. Improvement measures were data driven and other departments like Radiology and Laundry were motivated to embrace the idea of understanding their user perceptions. This study demonstrates the effectiveness of internal user satisfaction surveys as a valuable tool for continuous quality improvement. This exercise proved beyond doubt that regular monitoring improves quality of services.

Cross-cultural comparability of customer satisfaction measurement – the case of mobile phone service providers

Purpose Customers from different cultures might have different expectations and perceptions of quality, leading to different levels of satisfaction. Together with the construct and measurement equivalence issues of cross-cultural surveys, this raises the question of the comparability of customer satisfaction measurements across countries. The purpose of this study is to evaluate the survey method of anchoring vignettes as a tool for improving the comparability of customer satisfaction measurements across countries and to shed some light on cultural influences on customer satisfaction measurements. Design/methodology/approach Based on the models of American Customer Satisfaction Index and European Performance Satisfaction Index, the authors designed and conducted a survey using the method of anchoring vignettes to measure and compare customer satisfaction with mobile phone services in four countries – Costa Rica, Poland, Sweden and Thailand. The survey was carried out with young adults aged 20–30 years, who were mostly university students. Findings This study demonstrates how anchoring vignettes can be used to mitigate cultural bias in customer satisfaction surveys and to improve both construct and measurement equivalence of the questionnaire. The results show that different conclusions on cross-cultural benchmarking of customer satisfaction would be drawn when using a traditional survey compared to the anchoring vignettes method. Originality/value This paper evaluates the survey method of anchoring vignettes as a potential quantitative research method for studying customer satisfaction across countries. The results also contribute to customer satisfaction research as these shed some light onto how culture influences customer satisfaction measurements. The practical implication for firms and managers is that allocating resources among different countries based on traditional customer satisfaction surveys may be misleading.