Clinical spotlight intervention to accelerate translation of evidence-based practices in primary care.

Evidence-based medical practice is often slow to diffuse into widespread clinical practice. To accelerate translation of updated best practices into clinical care, we developed a quality improvement intervention called the 'Clinical Spotlight'. This programme was based on a knowledge translation model of four steps: education on evidence-based practices, using Lean for incorporation into patient care flow, support of implementation and sustainability, and measurement of outcomes.

Improving access to pre-exposure prophylaxis for HIV prescribing in a primary care setting.

Although emtricitabine-tenofovir was approved for HIV pre-exposure prophylaxis (PrEP) in 2012, use by persons at risk of acquiring HIV has been limited. Because many primary care providers lacked familiarity and comfort prescribing PrEP, at our institution PrEP prescribing was concentrated among the infectious disease specialists, effectively limiting access. This project sought to increase the number of patients receiving new prescriptions for PrEP.

Using Lean tools to improve the efficiency of awake fibreoptic intubation setup.

Background: Awake fibreoptic intubation is a complex advanced airway technique used by anaesthesiologists in the management of a difficult airway. The time to setup this important procedure can be significant which may dissuade its use by some providers. In our institution, the awake intubation setup process was highly variable and error prone.

Implementing screening for social determinants of health using the Core 5 screening tool.

Social determinants of health (SDOH) have been documented to underpin 80% of overall health and are being increasingly recognised as key factors in addressing tertiary health outcomes. Yet, despite the widespread acceptance of the association of SDOH with health outcomes, more than two-thirds of hospitals do not screen for social risk factors that indicate individual-level adverse SDOH. Such screening for social risk factors represents the first step in connecting patients with resources and documents the prevalence of social needs.

Feasibility and safety of a rapid-access transient ischemic attack clinic.

Background: In the United States, patients with transient ischemic attacks (TIAs) are commonly admitted to the hospital despite evidence that low-risk TIA patients achieve improved outcomes at lower costs at specialized rapid-access TIA clinics (RATCs).

Local Problem: All patients experiencing TIAs at a hospital system in the Pacific Northwest were being admitted to the hospital. This project aimed to implement an RATC to relocate care for low-risk TIA patients, showing feasibility and safety.

Opportunistic Screening of Patients for Hepatic Steatosis: Clinical Follow-Up and Diagnostic Yield.

Purpose: Hepatic steatosis is a common incidental finding on abdominal imaging that is not always reported or recognized as having clinical significance. Because of its association with liver disease, cirrhosis, and diabetes, the aim of this study was to bring attention to this finding and provide clinical guidance to referring clinicians by inserting standardized text into radiology reports of patients with incidentally detected hepatic steatosis.

Methods: Patients with incidentally discovered hepatic steatosis on abdominal ultrasound or CT had standard text inserted into the impression sections of their diagnostic imaging reports.

Association of Use of Contract Nurses With Hospitalized Patient Pressure Injuries and Falls.

Background: Hospital-acquired pressure injuries (HAPIs) and falls are outcomes sensitive to quality of nursing care. Use of contract (traveler) nurses varies among organizations, but there is little research on the effect of contract nurses on nurse-sensitive outcomes.

Objectives: To explore the relationship between use of contract nurses and two key nurse-sensitive outcomes, HAPIs and falls.

Reduction of early inpatient transfers and rapid response team calls after implementation of an emergency department intake huddle process.

Patients admitted to the hospital and requiring a subsequent transfer to a higher level of care have increased morbidity, mortality and length of stay compared with patients who do not require a transfer during their hospital stay. We identified that a high number of patients admitted to our intermediate care (IMC) unit required a rapid response team (RRT) call and an early (<24 hours) transfer to the intensive care unit (ICU). A quality improvement project was initiated with the goal to reduce subsequent early transfers to the ICU and RRT calls.

A multifaceted intervention to improve the quality of care for patients undergoing total joint arthroplasty.

Knee and hip arthroplasties vary in cost, quality and outcomes. We developed a Lean quality improvement intervention for knee and hip arthroplasty patients encompassing the recognition, readiness, restoration and recovery phases of care. The intervention included standardised, evidence-based pathways, shared decision making, patient and family member engagement, and transdisciplinary rounding, implemented successively through a series of rapid process improvement workshops.

Clinical Decision Support: Opportunity or Armageddon?

The objective of this article is to discuss clinical decision support (CDS) and the article by Palen and colleagues in this issue of . The Palen et al. study provides strong evidence to date that CDS can lead to improvement in imaging appropriateness scores.

Team-Based Medicine: Incorporating a Clinical Pharmacist into Pain and Opioid Practice Management.

Background: The Centers for Disease Control and Prevention (CDC) reports that death from opioids has increased by more than five times since 1999. In response, federal and state organizations have released guidelines recommending best practice standards to combat the opioid epidemic.

Objective: To evaluate the impact of a clinical pharmacist in a team-based care model on the adherence to best practice standards and access to care for management of patients prescribed chronic opioid therapy (COT).

The Relationship Between Medicare Outpatient Efficiency Measure OP8 and Lumbar MRI Utilization.

Introduction: Quality-based reporting and payment are predicated on using valid metrics. We sought to determine the relationship between widely used lumbar imaging quality metric OP8 and underlying quality as measured through actual utilization of lumbar MRI.

Methods: We performed a multi-institutional cross-sectional study using hospital-level billing data from a major commercial insurance company, including 23 Washington State hospitals from July 1, 2014, to June 30, 2015, with more than 25 eligible visits.

Early, Nurse-Directed Sepsis Care.

Unlabelled: : Background: Sepsis is one of the leading causes of hospital mortality and readmission. For the past 20 years, sepsis research has focused on best practices for treating patients with the most severe manifestations of sepsis, while the treatment of patients outside of critical care or ED settings, who have early or less severe signs and symptoms of sepsis, have received little attention.

Objective: The goal of this quality improvement (QI) initiative was to promote early recognition and treatment of sepsis through the establishment of a multidisciplinary, executive-led sepsis guiding team that leveraged nursing skills and expertise.

Effectiveness of a multi-component quality improvement intervention on rates of hyperglycaemia.

Purpose: To evaluate the effectiveness of a multifaceted, hospital-wide glycaemic control quality improvement programme.

Methods: The quality improvement intervention comprised three components, derived through root cause analysis: standardising and simplifying care (including evidence-based order sets), increasing visibility (through provider access to clinical data and direct feedback) and educational outreach (directed at the entire institution). Effectiveness was determined at a single urban acute care hospital through time-series analysis with statistical process control charts.

Meaningful use of the electronic patient portal - Virginia Mason's journey to create the perfect online patient experience.

We present a case study of Virginia Mason Medical Center's successful implementation of the online patient portal. The organization exceeded its Meaningful Use 2 View/Download/Transmit targets and national benchmarks, with over 70% of unique patient encounters being provided timely online access to their health information, over 50% viewing, downloading, and transmitting health information electronically, and potential cost savings to the institution. Key lessons learned in our implementation process were.

The Success and Failure of a Radiology Quality Metric: The Case of OP-10.

Purpose: Medical quality metrics can serve various functions, including promoting quality improvement efforts within a medical system, and providing a basis for comparing quality among institutions. OP-10, an imaging efficiency quality measure based on the number of CT scans of the abdomen performed both with and without contrast is broadly used and publically reported, but it has not been investigated in actual practice.

Methods: In this project, we report on both a successful quality improvement effort built around measurement of OP-10, and on the identified potential limitations of OP-10 itself for comparing among institutions.