Project COALESCE—An Example of Academic Institutions as Conveners of Community-Clinic Partnerships to Improve Cancer Screening Access

In Virginia, 56% of colorectal cancers (CRC) are diagnosed late, making it one of three enduring CRC mortality hotspots in the US. Cervical cancer (CCa) exhibits a similar pattern, with 48% late-stage diagnosis. Mortality for these cancers is worse for non-Latinx/e(nL)-Black people relative to nL-White people in Virginia, but preventable with equitable screening access and timely diagnostic follow-up. However, structural barriers, such as fractured referral systems and extended time between medical visits, remain. Because Federally Qualified Health Centers (FQHCs) care for a large proportion of racial and ethnic minorities, and underserved communities, regardless of ability to pay, they are ideal partners to tackle structural barriers to cancer screenings. We piloted a quality improvement initiative at five FQHCs in southcentral Virginia to identify and address structural, race-related barriers to CRC, as well as CCa screening and diagnostic follow-up using evidence-based approaches. Uniquely, FQHCs were paired with local community organizations in a didactic partnership, to elevate the community’s voice while together, increase support, acceptance, uptake, and intervention sustainability. We report on project development, and share preliminary data within the context of project goals, namely, to increase cancer screenings by 5–10%, improve knowledge and diagnostic follow-up processes, and build longitudinal partnerships.

Oral Care in Acute Stroke

Purpose: Stroke impacts independent activities, particularly personal care such as oral hygiene. Existing guidelines lack details about how to provide effective oral care. This study explores the frequency of oral care based on staff adherence to oral care policies. Method: As part of a quality improvement initiative, we conducted a retrospective chart review of 30 consecutive stroke admissions to an acute care hospital. Patients with primary intracerebral hemorrhage or ischemic stroke were eligible. Sources of information included a decision support database and an electronic chart review. Data collection included length of hospitalization, stroke type, presence of infections, oral mechanism exam, dysphagia evaluations, and daily personal care provision by nursing staff (e.g., oral care and bathing). Results: Twenty-seven patients met the inclusion criteria. They had a mean age of 74 years, and 52% were men. Most had supratentorial stroke (86%) with comparable frequencies of right (48%) and left (52%) hemisphere lesions. In over half of the cases, provision of oral care was not documented at any point during the patients' hospitalization ( Mdn = 128 hr). Pericare and bathing were about twice and 4 times more frequent than oral care, respectively. Conclusions: Oral care after stroke is challenging. Existing oral care recommendations from stroke guidelines lack sufficient detail and warrant reconsideration for optimal and routine implementation particularly in acute settings. Education around oral care and associated protocols are necessary to advance oral care practices and improve stroke recovery.

Variation in Family Involvement on Rounds Between English-Speaking and Spanish-Speaking Families

BACKGROUND: Family-centered rounds (FCR) is the standard of care in inpatient pediatrics. Results of studies have revealed that Spanish-speaking families can experience communication challenges and decreased empowerment on rounds. In our study, we aim to identify variation in FCR practices for Spanish-speaking compared to English-speaking families and factors contributing to these disparities. METHODS: This is a cross-sectional observational study performed by secondary analysis of a quality improvement initiative conducted at a quaternary children’s hospital. Data were collected from June 2019 to March 2020 by using observational audits. Encounters were analyzed to compare key elements of FCR (including rounds location, elicitation of family questions, involvement in discharge planning) for English-speaking and Spanish-speaking families. Multivariable logistic regression was used to compare family involvement in FCR. A sensitivity analysis was conducted to evaluate unmeasured confounding. RESULTS: Rounding encounters included 394 families (261 English-speaking and 133 Spanish-speaking). Fewer Spanish-speaking families were included in the medical team’s discussion on rounds (64.7% vs 76.3%, P = .017), were asked about questions at the start of rounds (44.4% vs 56.3%, P = .025), or were involved in discussion of discharge criteria (72.2% vs 82.8%, P = .018) when compared to English-speaking families. These differences were magnified for resident teams rounding with subspecialists. The finding of decreased family involvement in the discussion on rounds persisted after adjusting for patient age and team type. CONCLUSIONS: Spanish-speaking families were less likely to be involved in FCR compared to English-speaking families. Further investigation is needed to explore the root causes of this practice variation and to develop interventions to address disparities.

Quality Initiative to Reduce Extrauterine Growth Restriction in Very Low Birth Weight Infants

BACKGROUND: We report a statewide quality improvement initiative aimed to decrease the incidence of extrauterine growth restriction among very low birth weight infants cared for in Tennessee NICUs. METHODS: The cohort consisted of infants born appropriate for gestational age between May 2016 and December 2018 from 9 NICUs across Tennessee. The infants were 23 to 32 weeks gestation and 500 to 1499 g birth weight. The process measures were the hours of life (HOL) when parenteral protein and intravenous lipid emulsion were initiated, the number of days to first enteral feeding, and attainment of full enteral caloric intake (110–130 kcal/kg per day). The primary outcome was extrauterine growth restriction, defined as weight <10th percentile for weight at 36 weeks postmenstrual age. Statistical process control charts and the Shewhart control rules were used to find special cause variation. RESULTS: Although special cause variation was not indicated in the primary outcome measure, it was indicated for the reduction in specific process measures: HOL when parenteral protein was initiated, HOL when intravenous lipid emulsion was initiated, and the number of days to attainment of full enteral caloric intake (among the hospitals considered regional perinatal centers). CONCLUSIONS: A statewide quality improvement initiative led to earlier initiation of parenteral and enteral nutrition and improved awareness of the importance of postnatal nutrition.

Using Quality Improvement Methodology to Increase Communication of Discharge Criteria on Rounds

OBJECTIVE: Clear communication about discharge criteria with families and the interprofessional team is essential for efficient transitions of care. Our aim was to increase the percentage of pediatric hospital medicine patient- and family-centered rounds (PFCR) that included discharge criteria discussion from a baseline mean of 32% to 75% over 1 year. METHODS: We used the Model for Improvement to conduct a quality improvement initiative at a tertiary pediatric academic medical center. Interventions tested included (1) rationale sharing, (2) PFCR checklist modification, (3) electronic discharge SmartForms, (4) data audit and feedback and (5) discharge criteria standardization. The outcome measure was the percentage of observed PFCR with discharge criteria discussed. Process measure was the percentage of PHM patients with criteria documented. Balancing measures were rounds length, length of stay, and readmission rates. Statistical process control charts assessed the impact of interventions. RESULTS: We observed 700 PFCR (68 baseline PFCR from July to August 2019 and 632 intervention period PFCR from November 2019 to June 2021). At baseline, discharge was discussed during 32% of PFCR. After rationale sharing, checklist modification, and criteria standardization, this increased to 90%, indicating special cause variation. The improvement has been sustained for 10 months. At baseline, there was no centralized location to document discharge criteria. After development of the SmartForm, 21% of patients had criteria documented. After criteria standardization for common diagnoses, this increased to 71%. Rounds length, length of stay, and readmission rates remained unchanged. CONCLUSION: Using quality improvement methodology, we successfully increased verbal discussions of discharge criteria during PFCR without prolonging rounds length.

Automated intra-operative SMS message updates: a quality improvement initiative to relieve caregivers’ worries (Preprint)

BACKGROUND Undergoing a surgical procedure is anxiety provoking for patients and their caregivers. During the intra-operative period, caregivers seek out informational updates from healthcare professionals, a situation complicated by COVID-19 health measures that require caregivers to wait outside the hospital. SMS-based communication that allows caregivers to follow their loved ones through surgery has shown promise in relieving anxiety and improving satisfaction with overall care. This form of communication is also well accepted by healthcare professionals and may be effective at relieving staff burden. OBJECTIVE Here we describe a quality improvement initiative of a standardized and integrated intra-operative SMS-based system to improve communication between surgical teams and caregivers. The main goal was to reduce caregiver anxiety; secondary goals included improving satisfaction with care and not increasing staff burden. METHODS A large tertiary care hospital offered the SMS service to caregivers who were waiting for loved ones undergoing surgery. SMS messages were integrated into the clinical information system software and sent at key points during the surgical journey to phone numbers provided by caregivers. A satisfaction survey was sent to caregivers one business day after surgery. Data were collected between Feb 16th and July 14th 2021. RESULTS Of the 8,129 surgeries scheduled, caregivers waiting for 6,149 surgeries (76%) agreed to receive SMS messages. A total of 34,129 messages were sent. The satisfaction survey was completed by 2,088/6,149 or 34 % of caregivers. Satisfaction with messages was high, with the majority of respondents reporting the messages received were adequate (71%), clear (74%), informative (72%) and met their needs (60%). Receiving text messages reduced caregiver anxiety (score 8.5 out of 10) and the overall satisfaction score was high (4.5 out of 5). Technical errors were reported by 111 caregivers. Suggestions for improvements included having messages sent more often, providing greater patient detail and being offered in other languages. CONCLUSIONS This digital health initiative provided SMS messages that were standardized and systematically sent to caregivers waiting for their loved ones undergoing surgery. This in turn decreased caregiver anxiety, with no additional burden to staff. In creating digital healthcare innovations, what patients and their families find useful and appreciated will ultimately determine uptake. Thus, caregiver feedback will inform future iterations of this initiative.

Impact of a pilot multimodal intervention to decrease antibiotic use for respiratory infections in a geriatric clinic

Background: More than 80% of antibiotics are prescribed in the outpatient setting, of which 30% are inappropriate. The National Action Plan for Combating Antimicrobial Resistance called for a 50% decrease in outpatient antibiotic use by 2020. Inappropriate antibiotics are associated with adverse reactions and Clostridioides difficile infection, especially among older adults. Study design: Before and after study. Methods: We performed a quality improvement initiative at the University of Colorado Seniors Clinic. Providers received education on antibiotic guidelines, electronic antibiotic order sets were introduced with standardized stop dates. Antibiotic use data were collected for 6 months before and 6 months after the intervention, from December to May to avoid seasonal variation. Descriptive statistics and linear mixed-effects regression models were used for this comparison. Results: Total antibiotic prescriptions for acute respiratory conditions decreased from 137 prescriptions before the intervention (December 1, 2017, to May 31, 2018) to 112 prescriptions after the intervention (December 1, 2018, to May 31, 2019), driven primarily by decreases in antibiotic prescriptions for pneumonia, sinusitis, and bronchitis. Prescriptions for broad-spectrum antibiotics declined following the intervention including decreases in levofloxacin from 12 (9%) to 3 (3%) and amoxicillin-clavulanate from 15 (12%) to 7 (7%). We detected significant reductions in prescribed antibiotic durations (days) after the intervention for sinusitis (estimate, −2.0; 95% CI, −3.1 to −1.0; P = .0003), pharyngitis (estimate, −2.5; 95% CI, −4.6 to −0.5; P = .018), and otitis (−3.2; 95% CI, −5.2 to −1.3; P = .008). Conclusions: Low-cost interventions were initially successful in changing patterns of antibiotic use and decreasing overall antibiotic prescribing among older patients in the outpatient setting. Long-term follow-up studies are needed to determine the sustainability and clinical impact of these interventions.