Cohort study of impact on length of stay of individual enhanced recovery after surgery protocol components

ObjectiveThe goal of this study was to explore which enhanced recovery after surgery (ERAS) bundle items were most associated with decreased length of stay after surgery, most likely associated with decreased length of stay after surgery.DesignA cohort study.SettingLarge tertiary academic medical centre.ParticipantsThe study included 1318 women undergoing hysterectomy as part of our ERAS pathway between 1 February 2018 and 30 January 2020 and a matched historical cohort of all hysterectomies performed at our institution between 3 October 2016 and 30 January 2018 (n=1063).InterventionThe addition of ERAS to perioperative care.This is a cohort study of all patients undergoing hysterectomy at an academic medical centre after ERAS implementation on 1 February 2018. Compliance and outcomes after ERAS roll out were monitored and managed by a centralised team. Descriptive statistics, multivariate regression, interrupted time series analysis were used as indicated.Main outcome measuresImpact of ERAS process measure adherence on length of stay.ResultsAfter initiation of ERAS pathway, 1318 women underwent hysterectomy. There were more open surgeries after ERAS implementation, but cohorts were otherwise balanced. The impact of process measure adherence on length of stay varied based on surgical approach (minimally invasive vs open). For open surgery, compliance with intraoperative antiemetics (−30%, 95% CI −18% to 40%) and decreased postoperative fluid administration (−12%, 95% CI −1% to 21%) were significantly associated with reduced length of stay. For minimally invasive surgery, ambulation within 8 hours of surgery was associated with reduced length of stay (−53%, 95% CI −55% to 52%).ConclusionsWhile adherence to overall ERAS protocols decreases length of stay, the specific components of the bundle most significantly impacting this outcome remain elusive. Our data identify early ambulation, use of antiemetics and decreasing postoperative fluid administration to be associated with decreased length of stay.

Implementation of a Quality Improvement Role for Unlicensed Assistive Personnel and Effects on Infection Prevention

Background: Care bundles comprise evidence-based practices and interventions that are easily and consistently implemented while improving patient outcomes. As patient acuity and task overload continue to increase, infection prevention bundle and process measure compliance and data collection may become a lower priority for registered nurses (RNs). In early 2019, a certified nursing assistant (CNA) began full-time quality liaison work on a 53-bed inpatient adult oncology unit at UNC Medical Center to provide targeted compliance data collection and to correct deficits in real time when possible and within the appropriate scope of practice. Methods: The quality liaison CNA is highly motivated, with a relevant clinical background and effective communication skills. After conducting a gap analysis, the unit developed specific responsibilities for several areas of quality improvement, including infection prevention. In addition to rounding on all patients daily, the quality liaison (1) performs direct patient care tasks like Foley catheter care, (2) conducts patient education on topics such as chlorhexidine gluconate treatments, (3) performs all relevant process measure audits, and (4) easily relays missed or needed care to RNs with a door sign created as part of this initiative. High-risk findings, such as a loose central-line dressing, prompt immediate communication to the RN, with follow-up and escalation when necessary. Results: Patients and staff received the quality liaison well, and the increased attention to care bundle components and auditing ensured consistent, evidence-based care along with accurate and reliable data collection. Compared to the previous calendar year, the number of central-line audits on the unit increased by >1,400 by the end of 2019. Patient outcomes improved, and during 1 fiscal year, the unit achieved rate reductions between 40% and 55% for central-line–associated bloodstream infections, catheter-associated urinary tract infections, and healthcare-associated C. difficile infections. Staffing and logistical challenges imposed by the COVID-19 global pandemic have hampered this work because the quality liaison was redeployed to direct patient care intermittently. Correspondingly, from July to October 2020, the same infection rates increased between 30% and 353%. Conclusions: Having a designated quality liaison is an effective means to achieving quality improvements while remaining an integral member of the patient care team. As staffing has improved on this unit, the quality liaison has refocused efforts, and infection rates are beginning to improve. Given the success of the quality liaison role in improving quality outcomes on this unit, the hospital is exploring expansion of this model to additional units.Funding: NoDisclosures: None

Measuring Implementation of Antibiotic Stewardship in Critical Access Hospitals Using the NHSN Annual Facility Survey

Background: Critical access hospitals (CAHs) serving rural communities have numerous limitations regarding resources, infrastructure, and staffing to support antibiotic stewardship programs (ASPs) and related quality improvement activities. The Federal Office of Rural Health Policy (FORHP) established the Medicare Beneficiary Quality Improvement Project (MBQIP) to provide CAHs with specialized technical assistance in quality improvement data collection and reporting to drive improvements in the quality of care and to reduce barriers to establishing ASPs. In 2016, FORHP developed an antibiotic stewardship process measure in partnership with the CDC to assess progress on implementing ASPs and to optimize hospital quality improvement practices related to antibiotic use. This is the first measure to be successfully implemented and reported at a national level to improve the judicious use of antibiotics in hospitals. Methods: A process measure was developed to assess adherence to the 7 core elements of a successful hospital ASP (ie, leadership, accountability, drug expertise, action, tracking, reporting, and education), as defined by CDC guidelines. Implementation was accomplished through CAH participation in the NHSN Annual Facility Survey (AFS). Responses were analyzed to assess fidelity to each core element, to identify trends, and to benchmark measure reporting among 1,350 CAHs across the United States. Responses were mapped to 7 core element categories, and the total number of positive responses were matched to each core element for a specific survey year to track progress. Overall, the measure assessed progress in meeting all 7 core elements, as well as program robustness in the number of actions implemented and the amount of data tracked and reported at each hospital. NHSN reports were generated to tailor technical assistance activities and to assist hospitals with measure uptake and reporting. Results: CAH participation in the NHSN significantly increased from 2014 to 2018 (83% response rate). From 2014 through 2018, reporting of the new antibiotic stewardship measure consistently increased. CAHs that met all core elements increased from 18% (2014) to 73% (2018). Performance-based benchmarks enabled hospital comparisons and the establishment of reporting goals. Conclusions: This study highlights viable approaches to measuring antibiotic stewardship at a national level to drive improvements in care at hospitals of any size. The implementation of the antibiotic stewardship measure across CAHs demonstrates the impact of federal programs like MBQIP for hospitals that are building capacity for quality improvement. For the first time, CAHs were able to measure and compare their implementation of ASPs to other hospitals at the state and national level.Funding: NoneDisclosures: None

LO37: Reducing hemolysis of coagulation blood samples in the emergency department

Background: Hemolysis of blood samples is the leading cause of specimen rejection from hospital laboratories. It contributes to delays in patient care and disposition decisions. Coagulation tests (prothrombin time/international normalized ratio [PT/INR] and activated partial thromboplastin time [aPTT]) are especially problematic for hemolysis in our academic hospital, with at least one sample rejected daily from the emergency department (ED). Aim Statement: We aimed to decrease the monthly rate of hemolyzed coagulation blood samples sent from the ED from a rate of 2.9% (53/1,857) to the best practice benchmark of less than 2% by September 1st, 2019. Measures & Design: Our outcome measure was the rate of hemolyzed coagulation blood samples. Our process measure was the rate of coagulation blood tests sent per 100 ED visits. Our balancing measure was the number of incident reports by clinicians when expected coagulation testing did not occur. We used monthly data for our Statistical Process Control (SPC) charts, as well as Chi square and Mann-Whitney U tests for our before-and-after evaluation. Using the Model for Improvement to develop our project's framework, we used direct observation, broad stakeholder engagement, and process mapping to identify root causes. We enlisted nursing champions to develop our Plan-Do-Study-Act (PDSA) cycles/interventions: 1) educating nurses on hemolysis and coagulation testing; 2) redesigning the peripheral intravenous and blood work supply carts to encourage best practice; and 3) removing PT/INR and aPTT from automatic inclusion in our electronic chest pain bloodwork panel. Evaluation/Results: The average rate of hemolysis remained unchanged from baseline (2.9%, p = 0.83). The average rate of coagulation testing sent per 100 ED visits decreased from 41.5 to 28.8 (absolute decrease 12.7 per 100, p < 0.05), avoiding $4,277 in monthly laboratory costs. The SPC chart of our process measure showed special cause variation with greater than eight points below the centerline. Discussion/Impact: Our project reduced coagulation testing, without changing hemolysis rates. Buy-in from frontline nurses was integral to the project's early success, prior to implementing our electronic approach – a solution ranked higher on the hierarchy of intervention effectiveness – to help sustainability. This resource stewardship project will now be spread to a nearby institution by utilizing similar approaches.

Experimental Optimization of Nimonic 263 Laser Cutting Using a Particle Swarm Approach

This paper presents an experimental study carried out on Nimonic 263 alloy sheets to determine the optimal combination of laser cutting control factors (assisted gas pressure, beam focus position, laser power, and cutting speed), with respect to multiple characteristics of the cut area. With the aim of designing laser cutting parameters that satisfy the specifications of multiple responses, an advanced multiresponse optimization methodology was used. After the processing of experimental data to develop the process measure using statistical methods, the functional relationship between cutting parameters and the process measure was determined by artificial neural networks (ANNs). Using the trained ANN model, particle swarm optimization (PSO) was employed to find the optimal values of laser cutting parameters. Since the effectiveness of PSO could be affected by its parameter tuning, the settings of PSO algorithm-specific parameters were analyzed in detail. The optimal laser cutting parameters proposed by PSO were implemented in the validation run, showing the superior cut characteristics produced by the optimized parameters and proving the efficacy of the suggested approach in practice. In particular, it is demonstrated that the quality of the Nimonic 263 cut area and the microstructure were significantly improved, as well as the mechanical characteristics.