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Project #22: Observation of Anti-Infective Use in Esophageal Perforations
Get PDFIntroduction: Esophageal perforations (EPs) are a tear of the esophageal mucosal and muscle layers, posing infection risks, due to gastric contents in the thoracic space. This rare disease state has many causes and has a mortality rate of 13.3%. Diagnosis is challenging due to vague symptoms, leading to delayed treatment Prognosis worsening significantly after 24 hours. Treatment involves surgery, endoscopy, and antibiotics. There is no standardized institutional or national guidance, highlighting the need to assess current practices.https://scholarlycommons.henryford.com/qualityexpo2024/1029/thumbnail.jp
Project #54: An Individualized Unit Based Approach to Utilizing Pressure Injury Prevention Strategies for Acute Care Nursing Staff
Get PDFHospital Acquired Pressure Injuries (HAPI) are a complex and important safety issue. They increase length of stay, readmission rates, costs , and mortality. Per NPIAP Pressure Injury (PI) Fact Sheet- 2019: Avg cost per patient for HAPIs: 151,700; 2.5 million patients develop PI and 60,000 die annually. At HFH Detroit, HAPI rates from Jan to Aug 2022 peaked to 6.5% (NDNQI* mean 2021 Q1 benchmark is 2.9%). Increased HAPI rate, high staff turnover, and supply chain challenges made evaluating PI prevention strategy implementation crucial. HFH Detroit Wound Care Team sought to decrease HAPI rate to the goal of 4% in 12 months. Approach/Plan: Wound care team developed an audit tool to measure compliance of: Current PI Prevention Strategies, Skin Assessment, Documentation on turning/positioning, and Appropriate layering under patients to prevent moisture skin damage. Audit also identified prevention supplies stocked and available on each unit. Data from the audit was used to: Develop education tailored to each units needs; Address supply stocking issues; Identify contributing factors that may increase HAPI rates; From Aug 2022-Jan 2023, 16 units were audited. Same units were re-audited from Nov 2023-Jan 2024.https://scholarlycommons.henryford.com/qualityexpo2024/1051/thumbnail.jp
Project #71: Creating a Pressure Injury Prevention (PIP) Rounding Team to Reduce Healthcare Acquired Pressure Injuries (HAPIs)
Get PDFProblem statement: Patients were lacking application of pressure injury prevention interventions leading to HAPIs: Newer staff who had less experience with wounds and wound prevention; Auditing showed few interventions in place and lack of Q2 hour turns. Improvement Statement: Implement a multidisciplinary PIP rounding team comprised of leaders, certified wound care nurses, HAPI & PIP committee members, skin champions, and new nursing staff monthly to provide education to staff, place interventions in real time to therefore reduce patient’s risk of HAPIs. The PIP rounding team was created to provide real time audits and interventions with opportunities to educate staff and place interventions in real time. The goal was to educate staff, increase compliance with PIP interventions to a goal of 85% placed within 1 year. The PIP team includes all levels of leadership, is multidisciplinary, held once a month for 3 hours, and has shown to help educate new staff members at Wyandotte. Education is provided by WOCNs, CNSs, and skin champions.https://scholarlycommons.henryford.com/qualityexpo2024/1065/thumbnail.jp
Project #11: Clinical Evaluation and Cost Impact of Sugammadex Utilization at Henry Ford Health Hospitals
Get PDFIntroduction: Sugammadex is a widely adopted neuromuscular reversal agent (NMBA) for rocuronium and vecuronium-induced paralysis. There is mixed evidence regarding the impact of sugammadex on PACU length of stay and time from NMBA reversal to operating room exit. Concerns excess usage could lead to higher overall costs with negligible benefits led to an exploration of use at Henry Ford Health (HFH). HFH policy indicates neostigmine/glycopyrrolate is the cost-effective standard of care for NMB reversal which is preferred over sugammadex, except in defined situations. This medication use evaluation conducted within HFH hospitals aims to: Assess the use of sugammadex in accordance with published policy; Evaluate the cost implications of sugammadex utilization.https://scholarlycommons.henryford.com/qualityexpo2024/1022/thumbnail.jp
Project #37: Outpatient Rehabilitation Fall Prevention: Working Towards a Safer Journey
Get PDFAim: Patient falls within the Rehab Services outpatient clinics are the primary safety event reported through the Henry Ford Health R/L process. According to the report from the American Physical Therapy Association from September 2023, The Economic Value of Physical Therapy in the United States the average cost savings for fall prevention programs is estimated to be $2144 per Episode of Care. For these reasons, fall reduction was set as a goal in the Rehab Services Line Strategic Plan. This project was developed to: Identify patients at higher risk for falls; Improved documentation of fall risk; Enhance communication of fall risk precautions; Improve R/L reporting documentation; and Minimize falls in our outpatient rehab clinics.https://scholarlycommons.henryford.com/qualityexpo2024/1039/thumbnail.jp
Project #41: Creating a Safe Space to Care and Heal in an Inpatient Psychiatric Hospital, Utilizing Welle and Empowering De-Escalation, a Hands Off Approach to Care
Get PDFIncidence of violence often occur in the psychiatric setting during physical management events which include: Physical hold, restraint or seclusion. At Kingswood Hospital the switch from CPI de-escalation and physical management to Welle De-escalation and physical management experienced interruptions and had observed opportunities for expansion, buy-in and development towards improved clinical care. In late 2021 incidence of patient reported abuse after physical holds led to investigation noting team members were not well trained in the correct use of welle techniques and current training did not include hands on training along with advanced welle techniques. Planning began to improve welle training, integrate welle language and focus on duress response with frequent debriefing and process improvement implementation using the PDCA cycle. Goal to reduce restraints, staff assaults, patient allegations of abuse, staff reports of feeling unsafe and improve BHT (behavioral health technician) retention and job security. Due to trauma of incidence of assault, abuse and restraint, goal will be continual reduction and PDCA cycles with continued growth and education to goal of zero harm.https://scholarlycommons.henryford.com/qualityexpo2024/1042/thumbnail.jp
Project #18: Improving Early Detection of Clostridioides difficile Infections Through Electronic Reports
Get PDFClostridioides difficile (C. difficile) is a serious infection, causing life-threatening diarrhea. Patients with C. difficile will have liquid, loose, mucous-like, or non-formed stools. The financial burden of C. difficile infection (CDI) is substantial, increasing costs up to an additional $32,000 during hospitalization. These patients can have complications leading to surgical intervention, longer length of stay, and are at risk for recurrent infection, which further adds to healthcare cost. Each year nearly 500,000 people in the United States develop CDI. Although C. difficile is historically classified as a hospital acquired condition, the incidence of community acquired CDI (CA-CDI) has increased. Classification of CDI is dependent upon hospital day. Positive stool samples collected within the first 3 calendar days of admission are classified as CA-CDI. Positive samples collected on calendar day 4 or after are hospital acquired CDI (HA-CDI). The institution had an existing nurse-driven C. difficile testing (CDT) protocol in place. According to the protocol, patients with mushy, loose, liquid/watery stool or clinical suspicion of C. difficile within 3 calendar days of admission are to be tested. Nurses can order CDT and isolation in the electronic medical record (EMR) without a provider co-signature. After calendar day 3, an automated C. difficile test-order hard-stop appears if patients received recent promotility agents, were tested in the last week, or previously tested positive during the admission.
Problem Statement: The surgical intensive care unit (SICU) at Henry Ford Hospital experienced low incidence of CDT during the first 3 calendar days of admission and high rates of HA-CDI in 2019 and 2020.
Improvement Statement: The goal was to use an electronic medical record (EMR) report to conduct early screening for patients on the SICU to improve capture of CA-CDI by at least 50% by the end of 2022.https://scholarlycommons.henryford.com/qualityexpo2024/1000/thumbnail.jp
US Liver Transplant Outcomes After Normothermic Regional Perfusion vs Standard Super Rapid Recovery
No full textIMPORTANCE: Normothermic regional perfusion (NRP) is an emerging recovery modality for transplantable allografts from controlled donation after circulatory death (cDCD) donors. In the US, only 11.4% of liver recipients who are transplanted from a deceased donor receive a cDCD liver. NRP has the potential to safely expand the US donor pool with improved transplant outcomes as compared with standard super rapid recovery (SRR).
OBJECTIVE: To assess outcomes of US liver transplants using controlled donation after circulatory death livers recovered with normothermic regional perfusion vs standard super rapid recovery.
DESIGN, SETTING, AND PARTICIPANTS: This was a retrospective, observational cohort study comparing liver transplant outcomes from cDCD donors recovered by NRP vs SRR. Outcomes of cDCD liver transplant from January 2017 to May 2023 were collated from 17 US transplant centers and included livers recovered by SRR and NRP (thoracoabdominal NRP [TA-NRP] and abdominal NRP [A-NRP]). Seven transplant centers used NRP, allowing for liver allografts to be transplanted at 17 centers; 10 centers imported livers recovered via NRP from other centers.
EXPOSURES: cDCD livers were recovered by either NRP or SRR.
MAIN OUTCOMES AND MEASURES: The primary outcome was ischemic cholangiopathy (IC). Secondary end points included primary nonfunction (PNF), early allograft dysfunction (EAD), biliary anastomotic strictures, posttransplant length of stay (LOS), and patient and graft survival.
RESULTS: A total of 242 cDCD livers were included in this study: 136 recovered by SRR and 106 recovered by NRP (TA-NRP, 79 and A-NRP, 27). Median (IQR) NRP and SRR donor age was 30.5 (22-44) years and 36 (27-49) years, respectively. Median (IQR) posttransplant LOS was significantly shorter in the NRP cohort (7 [5-11] days vs 10 [7-16] days; P \u3c .001). PNF occurred only in the SRR allografts group (n = 2). EAD was more common in the SRR cohort (123 of 136 [56.1%] vs 77 of 106 [36.4%]; P = .007). Biliary anastomotic strictures were increased 2.8-fold in SRR recipients (7 of 105 [6.7%] vs 30 of 134 [22.4%]; P = .001). Only SRR recipients had IC (0 vs 12 of 133 [9.0%]; P = .002); IC-free survival by Kaplan-Meier was significantly improved in NRP recipients. Patient and graft survival were comparable between cohorts.
CONCLUSION AND RELEVANCE: There was comparable patient and graft survival in liver transplant recipients of cDCD donors recovered by NRP vs SRR, with reduced rates of IC, biliary complications, and EAD in NRP recipients. The feasibility of A-NRP and TA-NRP implementation across multiple US transplant centers supports increasing adoption of NRP to improve organ use, access to transplant, and risk of wait-list mortality
Surgical and Interventional Management of Liver Metastasis
No full textColorectal cancer is one of the most common cancers diagnosed worldwide. While the incidence of colorectal cancer has been declining since the adoption of screening colonoscopy, the findings of liver metastasis are still found in up to 25% of patients at diagnosis. The management of liver metastasis has evolved over the past two to three decades, and survival rates have improved secondary to improved systemic therapy, surgical options, and local therapies. In this article, we aim to review the available surgical and ablative options for management of colorectal liver metastasis, as well as appropriate imaging and patient selection