Reducing Central Line-Associated Bloodstream Infections in a Burn Intensive Care Unit: Using a Business Framework for Quality Improvement.

Central line-associated bloodstream infections (CLABSIs) pose a unique risk in burn patients, with rates of infection 2-3 times that of other Intensive Care Unit (ICU) populations. Here we present a detailed account of our experience in reducing CLABSI rates utilizing a business framework called the Four Disciplines of Execution (4DX). The Burn ICU CLABSI rate had risen to the 90th percentile nationally when compared to other burn units on the National Healthcare Safety Network. We applied the 4DX framework. This is a four-step method which includes creating a Wildly Important Goal, establishing measurable and accomplishable process measures, creating a scoreboard, and using a weekly meeting to provide accountability. Process changes included both physician and nursing practices. The physicians changed the criteria for when to order blood cultures, as well as requiring attending approval for cultures. The nurses engaged in a peer-observation practice improvement for "scrub the hub" and line dressing conditions and improved their own expertise for peripheral IV placement. The multidisciplinary team initiated a daily review of line indications to ensure removal as soon as possible. Overall, the CLABSI rate decreased from 7.39 infections per 1000 line days to 2.29 infections per 1000 line days over 1 year. We subsequently achieved over 635 days without a CLABSI. In conclusion, the 4DX was a successful quality improvement technique in our healthcare context. Because of the simplicity of implementation, we think it is broadly applicable in the healthcare setting.

Using a Business Model (the 4 Disciplines of Execution) to Improve Consistency, Efficiency, and Length of Stay in Microvascular Autologous Breast Reconstruction.

BACKGROUND: Autologous free tissue transfer is a common method of breast reconstruction in the United States, but it involves many care teams and can incur a large cost on an institution. The consistency and efficiency of performing these procedures can be improved with a method called the 4 disciplines of execution (4DX). METHODS: Patients that underwent autologous breast reconstruction between 2015 and 2020 were included. Midway through the collection period, several preoperative and intraoperative interventions were implemented using the 4DX. Then, 2 cohorts of patients were analyzed for differences in operative times, length of stay (LOS), and major complications. RESULTS: Thirty-two total patients were included. The median operative time before interventions were implemented was 828 minutes, and the median operative time after interventions was 619 minutes (P < 0.05). The median LOS in days before interventions was 5 days, and the median LOS after interventions was 3 days (P < 0.05). There were no statistically significant differences in complications before or after the interventions. CONCLUSIONS: The 4DX successfully improved consistency and efficiency in the process of performing autologous breast reconstruction at our institution, as evidenced by a faster median operative time and shorter patient LOS in the hospital.

Development of a Clinical Decision Support System to Predict Unplanned Cancer Readmissions.

Unplanned 30-day cancer readmissions are an important outcome of cancer hospitalization and can significantly raise mortality rates and costs for both the patient and the hospital. This paper aimed to develop a predictive model using machine learning and electronic health records to predict unplanned 30-day cancer readmissions and further develop it as a clinical decision support system. The three-stage study design followed the 2022 AMIA Artificial Intelligence Evaluation Showcase. In the first stage, the technical performance of the model was determined (81% of AUROC) and contributing factors were identified. In the second stage, the technical feasibility and workflow considerations of using such a predictive model were explored through semi-structured interviews. In the third stage, a decision tree analysis and a cost estimation showed that the model can reduce unplanned readmissions significantly if timely action is taken and that preventing a single readmission may significantly reduce costs.

Platelet aggregation inhibitors from Philippine marine invertebrate samples screened in a new microplate assay.

A new microplate assay for Ca(2+)-induced platelet aggregation as detected by Giemsa dye was used to screen marine invertebrate samples from the Philippines for inhibitors of human platelet aggregation. Out of 261 crude methanol extracts of marine sponges and tunicates, 25 inhibited aggregation at 2 mg/ml. Inhibition of agonist-induced aggregation in an aggregometer was used to confirm results of the microplate assay and to determine the specific mode of inhibition of 2 samples. The marine sponge Xestospongia sp. yielded a xestospongin/araguspongine-type molecule that inhibited collagen-induced aggregation by 87% at 2 micro g/ml, and epinephrine-induced aggregation by 78% at 20 micro g/ml, while the marine sponge Aplysina sp. yielded 5,6-dibromotryptamine, which inhibited epinephrine-induced aggregation by 51% at 20 micro g/ml. In this study we have found that the microplate assay is a simple, inexpensive, yet useful preliminary tool to qualitatively screen a large number of marine samples for antiplatelet aggregation activity.