Solving the Pervasive Problem of Protocol Non-Compliance in MRI using an Open-Source tool mrQA.

Pooling data across diverse sources acquired by multisite consortia requires compliance with a predefined reference protocol i.e., ensuring different sites and scanners for a given project have used identical or compatible MR physics parameter values. Traditionally, this has been an arduous and manual process due to difficulties in working with the complicated DICOM standard and lack of resources allocated towards protocol compliance. Moreover, issues of protocol compliance is often overlooked for lack of realization that parameter values are routinely improvised/modified locally at various sites. The inconsistencies in acquisition protocols can reduce SNR, statistical power, and in the worst case, may invalidate the results altogether. An open-source tool, mrQA was developed to automatically assess protocol compliance on standard dataset formats such as DICOM and BIDS, and to study the patterns of non-compliance in over 20 open neuroimaging datasets, including the large ABCD study. The results demonstrate that the lack of compliance is rather pervasive. The frequent sources of non-compliance include but are not limited to deviations in Repetition Time, Echo Time, Flip Angle, and Phase Encoding Direction. It was also observed that GE and Philips scanners exhibited higher rates of non-compliance relative to the Siemens scanners in the ABCD dataset. Continuous monitoring for protocol compliance is strongly recommended before any pre/post-processing, ideally right after the acquisition, to avoid the silent propagation of severe/subtle issues. Although, this study focuses on neuroimaging datasets, the proposed tool mrQA can work with any DICOM-based datasets.

Implementing Change: Sustaining Enhanced Recovery After Surgery Protocols in Pediatric Surgery Using Iterative Assessments.

INTRODUCTION: While Enhanced Recovery After Surgery (ERAS) protocols are becoming more common in pediatric surgery, there is still little published about protocol compliance and sustainability. METHODS: This is a prospective observational study to evaluate the compliance of an ERAS protocol for pectus repair at a large academic children's hospital. Our primary outcome was overall protocol compliance at 1-y postimplementation of the ERAS protocol. Our comparison group included all pectus repairs for 2 y before protocol implementation. RESULTS: Overall protocol compliance at 12 mo was 89%. Of the 16 pectus repairs included in the ERAS protocol group, 94% (n = 15) and 94% (n = 15) received preoperative acetaminophen and gabapentin, respectively, which was significantly greater than the historical control group (P < 0.001). For the intraoperative components analyzed, only the intrathecal morphine was significantly different than historical controls (100% versus 49%, P < 0.001). Postoperatively, the time from operating room to return to normal diet was shorter for the ERAS group (0.53 d versus 1.16 d, P < 0.001). There was no significant difference in readmission rates between the two groups. CONCLUSIONS: ERAS protocol compliance varies based on phase of care. Solutions to sustain protocols depend on the institution and the patient population. However, the utilization of implementation science fundamentals was invaluable in this study to identify and address areas for improvement in protocol compliance. Other institutions may adapt these strategies to improve protocol compliance at their centers.

Lessons Learned From a Systematic, Hospital-Wide Implementation of the ABCDEF Bundle: A Survey Evaluation.

Objective: We recently reported the first part of a study testing the impact of data literacy training on "assessing pain, spontaneous awakening and breathing trials, choice of analgesia and sedation, delirium monitoring/management, early exercise/mobility, and family and patient empowerment" [ABCDEF [A-F]) compliance. The purpose of the current study, part 2, was to evaluate the effectiveness of the implementation approach by surveying clinical staff to examine staff knowledge, skill, motivation, and organizational resources. DESIGN: The Clark and Estes Gap Analysis framework was used to study knowledge, motivation, and organization (KMO) influences. Assumed influences identified in the literature were used to design the A-F bundle implementation strategies. The influences were validated against a survey distributed to the ICU interprofessional team. SETTING: Single-center study was conducted in eight adult ICUs in a quaternary academic medical center. SUBJECTS: Interprofessional ICU clinical team. INTERVENTIONS: A quantitative survey was sent to 386 participants to evaluate the implementation design postimplementation. An exploratory factor analysis was performed to understand the relationship between the KMO influences and the questions posed to validate the influence. Descriptive statistics were used to identify strengths needed to sustain performance and weaknesses that required improvement to increase A-F bundle adherence. MEASUREMENT AND RESULTS: The survey received an 83% response rate. The exploratory factor analysis confirmed that 38 of 42 questions had a strong relationship to the KMO influences, validating the survey's utility in evaluating the effectiveness of implementation design. A total of 12 KMO influences were identified, 8 were categorized as a strength and 4 as a weakness of the implementation. CONCLUSIONS: Our study used an evidence-based gap analysis framework to demonstrate key implementation approaches needed to increase A-F bundle compliance. The following drivers were recommended as essential methods required for successful protocol implementation: data literacy training and performance monitoring, organizational support, value proposition, multidisciplinary collaboration, and interprofessional teamwork activities. We believe the learning generated in this two-part study is applicable to implementation design beyond the A-F bundle.

A Self-Sustaining Antibiotic Prophylaxis Program to Reduce Surgical Site Infections.

Background: Our multi-institutional healthcare system had a higher-than-expected surgical site infection (SSI) rate. We aimed to improve our peri-operative antibiotic administration process. Gap analysis identified three opportunities for process improvement: standardized antibiotic selection, standardized second-line antibiotic agents for patients with allergies, and feedback regarding antibiotic administration compliance. Hypothesis: Implementation of a multifaceted quality improvement initiative including a near-real-time pre-operative antibiotic compliance feedback tool will improve compliance with antibiotic administration protocols, subsequently lowering SSI rate. Methods: A compliance feedback tool designed to provide monthly reports to all anesthesia and surgical personnel was implemented at two facilities, in September 2017 and December 2018. Internal case data were tracked for antibiotic compliance through June 2021, and these data were merged with American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) data at the case level to provide process and outcome measures for SSIs. Implementation success was evaluated by comparing protocol compliance and risk-adjusted rates of superficial and deep SSI before and after the quality improvement implementation. Results: A total of 20,385 patients were included in this study; 11,548 patients in the pre-implementation and 8,837 in the post-implementation groups. Baseline patient and operative characteristics were similar between groups, except the post-implementation group had a higher median expected SSI rate (2.2% vs. 1.6%). Post-implementation, antibiotic protocol compliance increased from 86.3% to 97.6%, and superficial and deep SSIs decreased from 2.8% to 1.9% (p < 0.001). The odds of superficial and deep SSI in patients in the post-implementation group was 0.69 (0.57, 0.83) times the odds of superficial and deep SSI in pre-implementation patients while adjusting for age, gender, diabetes mellitus, American Society of Anesthesiologists Physical Status (ASA) classification, wound class, smoking, and chronic obstructive pulmonary disease (COPD). Observed-to-expected ratios of superficial and deep SSI decreased from 0.82 to 0.48 after the intervention. Conclusions: Surgical antibiotic prophylaxis standardization and providing near-real-time individualized feedback resulted in sustained improvement in peri-operative antibiotic compliance rates and reduced superficial and deep SSIs.

Have the UK Pediatric Trauma Protocols resulted in a reduction in chest computed tomography imaging for children presenting with major blunt trauma?

Objectives: To observe variation in imaging requests after publication of the Royal College of Radiologists UK Paediatric Trauma Protocols in 2014, recommending limited use of thoracic computed tomography (CT) to appropriately clinically risk stratified children. Method: A retrospective observational study using data from the Trauma Audit & Research Network in the United Kingdom, for children (0-16 years of age) for the years 2012-2021. Percentages were calculated to facilitate comparison between year groups (under 1 year of age, 1-10 years of age, 11-15 years of age), and CT imaging categories reviewed: (1) whole-body CT (WBCT); (2) abdominopelvic CT (CTAP) with chest radiograph (CXR); (3) chest, abdomen, and pelvic CT (CTCAP) with CXR; (4) CTCAP without CXR; and (5) other imaging. Results: Increased use of the recommended protocol (CXR with CTAP) was observed after guidance publication but was not sustained: infants under 1 year old, 0.0% in 2012, 7% in 2017, 0.0% in 2021; 1-10-year-olds, 4% in 2012, 13.9% in 2017, 5.5% in 2021; 11-15-year-olds, 7.1% in 2012, 10.2% in 2017, 6.6% in 2021. Requests for WBCT increased from 2012-2021 (all age groups, 2.4%, 2012, to 5.3%, 2021) and requests for CTCAP were consistently at a higher level than that of the recommended protocol. Conclusion: The increased use of CXR with CTAP after publication of the guidelines, was not sustained with a decreasing trend observed from ∼2017, raising concern for the ionizing radiation burden in this population.

Assessment of Emergency Medical Services Personnel Compliance with Escalating Airway Algorithm Protocol.

Introduction: When emergency medical services (EMS) personnel respond to emergencies, the decisions they make often can mean life or death for the patient. This is especially true in the case of advanced airway management. Protocols are set in place to ensure that the least invasive airway management techniques are used initially before more invasive techniques. The purpose of this study was to determine how often EMS personnel followed this protocol, while adequately achieving the goals of appropriate oxygenation and ventilation. Methods: This retrospective chart review was approved by the Institutional Review Board of the University of Kansas Medical Center. The authors reviewed the Wichita/Sedgewick County EMS system for cases during 2017 in which patients required airway support. We examined de-identified data to determine if invasive methods were applied in sequence. Cohen's kappa coefficient (κ) and immersion-crystallization approach were used to analyze the data. Results: A total of 279 cases were identified in which EMS personnel used advanced airway management techniques. In 90% (n = 251) of cases, less invasive techniques were not used prior to more invasive techniques and in 80% (n = 222) of cases, the more invasive technique was used alone. A dirty airway was the most common reason for the EMS personnel's choice of using more invasive approaches in achieving the goals of appropriate oxygenation and ventilation. Conclusions: Our data showed that EMS personnel in Sedgwick County/Wichita, Kansas often deviated from the advanced airway management protocols when caring for patients in need of respiratory intervention. Dirty airway was the main reason for using a more invasive approach in achieving the goals of appropriate oxygenation and ventilation. It is important to understand reasons why deviations in protocol were occurring to ensure that current protocols, documentation, and training practices are effective in producing the best possible patient outcomes.

Effect of an educational intervention on compliance with care bundle items to prevent ventilator-associated pneumonia.

OBJECTIVES: We aimed to evaluate the effectiveness of our ventilator-associated pneumonia prevention bundle implemented by education of the nursing staff, and to describe the tendency of knowledge retention. RESEARCH METHODOLOGY: A prospective, before-and-after study was performed. The ventilator-associated pneumonia prevention bundle was implemented through a single educational intervention of the nursing staff. The risk of ventilator-associated pneumonia over time was estimated using a Cox proportional cause-specific hazard model. Compliance to preventive measures was assessed at three time-points: before education, at three months and 12 months after education. SETTING: A 29-bed mixed medical-surgical intensive care unit. MAIN OUTCOME MEASURES: Ventilator-associate pneumonia incidence densities, the risk of ventilator-associated pneumonia, and compliance to preventive measures in the pre-implementation and post-implementation periods. RESULTS: We analyzed the data of 251 patients. The incidence density of pneumonia decreased from 29.3/1000 to 15.3/1000 ventilator-days after the implementation of the prevention program. Patients in the post-implementation period had significantly lower risk to develop pneumonia (hazard ratio 0.34, 95 % confidence interval 0.19-0.61, p = 0.001). At 3 months of implementation, a significant improvement was detected to all the individual bundle components. Complete compliance increased from 16.2 % to 62.2 % (p < 0.001). Compliance with bundle components decreased to baseline levels after 12 months of implementation apart from head-of-bed elevation. CONCLUSION: This study supports existing evidence that educational interventions improve compliance. The gained knowledge was well translated into clinical practice reflected by the decreasing ventilator-associated pneumonia rate. It may be assumed that a refresher educational session within 12 months after implementation is needed.

Effect of evidence-based nursing management of protocol compliance in anticancer drug clinical trial.

Objective: This study aimed to construct evidence-based anticancer drug clinical trial nursing management norms to ensure the safety and quality of clinical trial nursing. Methods: This before-after study was carried out to complete the evidence implementation in a cancer hospital in Shanghai, China. Seven review indicators were developed and reviewed in one phase I clinical trial center and two oncology wards. The corresponding evidence-based intervention program was formulated, and the completion rate of good clinical practice certification, protocol training, delegation of duties, qualification rate of administration, sampling and document recording in anticancer drug clinical trials before and after implementation were compared. Results: After implementation, the completion rate of protocol training, delegation of duties, and the qualification rate of document recording were significantly higher than those of the baseline review, whereas the completion rate of good clinical practice certification and the qualification rate of sampling did not significantly differ from those observed at the baseline review. There was no administration or infusion device-related protocol deviation during the baseline and post reviews. Conclusions: Anticancer drug clinical trial nursing management norms and relevant standard operating procedures were constructed. The results showed that the implementation of this intervention improved the standardization of nurse qualification procedures and the nursing original document recording in anticancer drug clinical trials, and nursing-related protocol deviation could be reduced to a certain extent.

Assessment of pre-anesthesia machine check and airway equipment preparedness: A cross-sectional study.

Background: Anesthesia Equipment malfunction is one of the most common factors contributing to intraoperative surgical patient morbidity and mortality. It is impossible to give anesthesia without proper anesthesia machine checks and airway equipment preparation. Therefore, all anesthesia professionals should make sure that the anesthetic machine and equipment are working correctly. Method: An institutional-based prospective observational study was conducted at the University Comprehensive Specialized Hospital, Operation rooms, from April 10, 2020 to May 10, 2020. About 90 anesthetists were working regularly in the operation theater both emergency and elective patients. Those include; 26 Msc holders, 17 MSc students, 7 BSc anesthetists, and 40 graduating BSc students. These descriptive data were presented with frequency, percentage, and table. Result: The overall compliance rate was 87%. Whereas; 12.46% of clinicians have not met the standard. Out of standards that were not performed, 25.81% were not available from the setup. Conclusion: The result shows that there was poor compliance with anesthesia machine check and equipment preparation before anesthesia in the operation theater according.

Critical impact of radiotherapy protocol compliance and quality in the treatment of retroperitoneal sarcomas: Results from the EORTC 62092-22092 STRASS trial.

BACKGROUND: The European Organization for Research and Treatment of Cancer 22092-62092 STRASS trial failed to demonstrate the superiority of neoadjuvant radiotherapy (RT) over surgery alone in patients with retroperitoneal sarcoma. Therefore, an RT quality-assurance program was added to the study protocol to detect and correct RT deviations. The authors report results from the trial RT quality-assurance program and its potential effect on patient outcomes. METHODS: To evaluate the effect of RT compliance on survival outcomes, a composite end point was created. It combined the information related to planning target volume coverage, target delineation, total dose received, and overall treatment time into 2 groups: non-RT-compliant (NRC) for patients who had unacceptable deviation(s) in any of the previous categories and RT-compliant (RC) otherwise. Abdominal recurrence-free survival (ARFS) and overall survival were compared between the 2 groups using a Cox proportional hazard model adjusted for known prognostic factors. RESULTS: Thirty-six of 125 patients (28.8%) were classified as NRC, and the remaining 89 patients (71.2%) were classified as RC. The 3-year ARFS rate was 66.8% (95% confidence interval [CI], 55.8%-75.7%) and 49.8% (95% CI, 32.7%-64.8%) for the RC and NRC groups, respectively (adjusted hazard ratio, 2.32; 95% CI, 1.25-4.32; P = .008). Local recurrence after macroscopic complete resection occurred in 13 of 89 patients (14.6%) versus 2 of 36 patients (5.6%) in the RC and NRC groups, respectively. CONCLUSIONS: The current analysis suggests a significant benefit in terms of ARFS in favor of the RC group. This association did not translate into less local relapses after complete resection in the RC group. Multidisciplinary collaboration and review of cases are critical to avoid geographic misses, especially for rare tumors like retroperitoneal sarcoma.

Improving ABCDEF Bundle Compliance and Clinical Outcomes in the ICU: Randomized Control Trial to Assess the Impact of Performance Measurement, Feedback, and Data Literacy Training.

OBJECTIVES: Describe the effects of data literacy training and continuous performance reports on ICU staff compliance with the 6-element ICU quality bundle approach known as the ABCDEF (A-F) bundle and patient outcomes. DESIGN: Stepped-wedge cluster randomized trial conducted during an institutional A-F bundle implementation program. SETTING: Single-center study conducted in eight adult ICUs. PATIENTS: Adult patients admitted for at least 24 hours, not undergoing active withdrawal of life support or palliative care. INTERVENTIONS: Four ICUs in the intervention group received bundle-related staff education, data literacy training, and weekly bundle performance reports during the 12-month study period. The four ICUs in the nonintervention group received none of these interventions. Bundle compliance and patient outcomes were tracked, including ICU and hospital mortality, transfer and discharge, discharge disposition, mechanical ventilation, and ICU delirium. MEASUREMENT AND RESULTS: In the intervention group, staff education alone increased bundle compliance from 9% to 16% (p < 0.0001); data literacy training further increased compliance from 16% to 21% (p = 0.03). This improvement was sustained throughout the study period including the onset of the COVID-19 pandemic and was greater than improvement in the nonintervention group (p < 0.001). Full A-F bundle compliance was associated with a lower likelihood of next-day ICU and hospital mortality, discharge to a facility other than home, and was associated with a higher likelihood of next-day extubation in patients. Next-day ICU and hospital discharge likelihood decreased, and delirium frequency was not affected. CONCLUSIONS: This is the first study demonstrating that the combination of staff education, data literacy training, and access to performance data improves A-F bundle compliance, sustains performance, and improves ICU patient outcomes (ICU and hospital mortality, mechanical ventilation duration, and home discharge rates). In contrast to previous studies, increased bundle compliance did not hasten ICU or hospital discharges or reduce delirium frequency in patients.

Structured and shared MRI staging lexicon and report of rectal cancer: A consensus proposal by the French Radiology Group (GRERCAR) and Surgical Group (GRECCAR) for rectal cancer.

PURPOSE: To develop French guidelines by experts to standardize data acquisition, image interpretation, and reporting in rectal cancer staging with magnetic resonance imaging (MRI). MATERIALS AND METHODS: Evidence-based data and opinions of experts of GRERCAR (Groupe de REcherche en Radiologie sur le CAncer du Rectum [i.e., Rectal Cancer Imaging Research Group]) and GRECCAR (Groupe de REcherche en Chirurgie sur le CAncer du Rectum [i.e., Rectal Cancer Surgery Research Group]) were combined using the RAND-UCLA Appropriateness Method to attain consensus guidelines. Experts scoring of reporting template and protocol for data acquisition were collected; responses were analyzed and classified as "Recommended" versus "Not recommended" (when ≥ 80% consensus among experts) or uncertain (when < 80% consensus among experts). RESULTS: Consensus regarding patient preparation, MRI sequences, staging and reporting was attained using the RAND-UCLA Appropriateness Method. A consensus was reached for each reporting template item among the experts. Tailored MRI protocol and standardized report were proposed. CONCLUSION: These consensus recommendations should be used as a guide for rectal cancer staging with MRI.

Estrategias para fomentar la higiene de manos en la atención ambulatoria / Interventions aimed to improve clinical handwashing in an outpatient setting

Introducción: se realizó un análisis de la evidencia disponible sobre intervenciones orientadas a mejorar la adherencia al lavado de manos, para generar recomendaciones para los centros de atención en salud ambulatoria.Materiales y métodos: se realizó una búsqueda en Pubmed, Embase y Epistemonikos, y en las referencias de guías sobre el tema, seleccionando aquellos estudios no observacionales en que se realizaran intervenciones para aumentar la adherencia al lavado de manos en atención en salud. Se clasificaron las estrategias descritas según tipo de intervención, y se evaluaron según su efectividad en mejorar la adherencia al lavado de manos y el seguimiento en el tiempo.Resultados: se seleccionaron 34 estudios experimentales prospectivos, que se clasificaron en 10 grupos según el tipo de intervención realizada, y se evaluaron según efectividad y seguimiento en una escala del I al VII. 24 de 34 estudios mostraron un aumento estadísticamente significativo de la adherencia al lavado de manos mayor al 15% desde el basal o en comparación al grupo control, correspondiendo en su mayoría a estrategias multimodales y de feedback. Discusión: las intervenciones más efectivas para mejorar la adherencia al lavado de manos fueron las que incluían abordajes multimodales y las que incluían feedback. Se hace urgente generar mayor evidencia sobre esta temática en el contexto de atención ambulatoria.

Introduction: To analyze the available evidence on interventions aimed at improving adherence to handwashing, to generate re-commendations for outpatient health care centers. Methods: A search was made in Pubmed, Embase and Epistemonikos, and in the references of guides on the subject, selecting those non-observational studies in which interventions were carried out to increase adherence to handwashing in health care. The strategies described were classified according to the type of intervention, and evaluated according to their effectiveness in improving adherence to handwashing, and its follow-up time afterward. Results: 34 prospective experimental studies were selected, which were classified into 10 groups according to the type of intervention performed, and were evaluated according to effectiveness and follow-up on a scale from I to VII. 24 of 34 studies showed a statistically significant increase in handwashing adherence greater than 15% from baseline or compared to the control group, corresponding mostly to multimodal and feedback strategies. Discussion: The most effective interventions to improve adherence to handwashing were those that included multimodal approaches and the ones that included feedback. It is urgent to generate more evidence on the subject in the context of ambulatory care.

Protocolo de profilaxis antibiótica preoperatoria para pacientes ortopédicos del Hospital México: un análisis de cumplimiento / Hospital Mexico’s preoperative antibiotic prophylaxis protocol for orthopedic patients: a compliance analysis

Objetivo: Analizar el cumplimiento en la prescripción de la profilaxisantibiótica prequirúrgica, según el protocolo establecido por el Programade Optimización de Antibióticos y el Servicio de Ortopedia del HospitalMéxico, Caja Costarricense del Seguro Social, ubicado en San José,Costa Rica, de febrero a marzo de 2019. Desde la instauración del protocolo en 2018 no se ha realizado una evaluación de su cumplimiento nise ha determinado la tasa de infección del sitio quirúrgico.Método: Estudio observacional retrospectivo; se identificaron lospacientes hospitalizados en el Servicio de Ortopedia desde el 1 defebrero al 31 de marzo de 2019. Se accedió al expediente digitalde cada paciente, se caracterizó la profilaxis antibiótica prescrita y seanalizó el cumplimiento según el protocolo vigente. Se estimó la tasade infección de sitio quirúrgico. Se realizó un análisis descriptivo de lapoblación.Resultados: El estudio incluyó 110 expedientes clínicos. Los antibióticos más prescritos fueron clindamicina y gentamicina de manera concomitante. El cumplimiento de la prescripción de profilaxis antibiótica oscilóentre 89,1% y 100% para los criterios considerados en el protocolo,exceptuando dosis y antibiótico al alta (14,3 y 65,8%, respectivamente). (AU)

Objective: To analyze compliance with a prescribed pre-surgical antibiotic prophylaxis protocol established by the Antimicrobial StewardshipProgram team and the Orthopedics Department of Hospital Mexico, apublic hospital located in Costa Rica, from February to March 2019. Noassessments of compliance with the protocol had been conducted sinceits introduction in 2018, nor had variations in surgical site infection ratesbeen determined.Method: This is a retrospective observational study that extended fromFebruary 1st to March 31st, 2019. We identified patients hospitalizedduring the study period in the hospital’s Orthopedics Department. Wereviewed each patient’s medical record to record their prescribed antibiotic prophylaxis. Following an analysis of the overall compliance with theprotocol, we made an estimation of the surgical site infection rate as wellas a descriptive analysis of the studied population.Results: The study included 110 clinical records. The most frequentlyprescribed antibiotics were clindamycin and gentamicin. Compliancewith the protocol ranged between 89.1% and 100% across the differentcriteria, except for dosing appropriateness and prescription of antibioticsat discharge (14.3% and 65.8%, respectively). The most common noncompliance factor was gentamicin´s dosing. The surgical site infection ratewas 5%. (AU)

Assessment of Non-Routine Events and Significant Physiological Disturbances during Emergency Department Evaluation after Pediatric Head Trauma.

Outcomes following pediatric traumatic brain injury (TBI) are dependent on initial injury severity and prevention of secondary injury. Hypoxia, hypotension, and hyperventilation following TBI are associated with increased mortality. The purpose of this study was to determine the association of non-routine events (NREs) during the initial resuscitation phase with these physiological disturbances. We conducted a video review of pediatric trauma resuscitations of patients with suspected TBI and Glasgow Coma Scale (GCS) scores <13. NREs were rated as "momentary" if task progression was delayed by <1 min and "moderate" if delayed by >1 min. Vital sign monitor data were used to identify periods of significant physiological disturbances. We calculated the association between the rate of overall and moderate NREs per case and the proportion of cases with abnormal vital signs using multi-variate linear regression, controlling for GCS score and need for intubation. Among 26 resuscitations, 604 NREs were identified with a median of 23 (interquartile range [IQR] 17-27.8, range 5-44) per case. Moderate delay NREs occurred in 19 resuscitations (n = 32, median 1 NRE/resuscitation, IQR 0.3-1, range 0-5). Oxygen desaturation and respiratory depression were associated with a greater rate of moderate NREs (p = 0.008, p < 0.001, respectively). We observed no association between duration of hypotension, desaturation, and respiratory depression and overall NRE rate. NREs are common in the initial resuscitation of children with moderate to severe TBI. Episodes of hypoxia and respiratory depression are associated with NREs that cause a moderate delay in task progression. Conformance with resuscitation guidelines is needed to prevent physiological events associated with adverse outcomes following pediatric TBI.

Q-Bot: automatic DICOM metadata monitoring for the next level of quality management in nuclear medicine.

BACKGROUND: Regular and precise inspection of the realization of the local nuclear medicine standard operation procedures (SOPs) is very complex and time-consuming, especially when large amount of patient data is obtained from a wide scale of different scan procedures on a daily basis. DICOM metadata comprise a complete set of data related to the patient and the imaging procedure, and consequently all information necessary to evaluate the compliance with the actual SOP. METHODS: Q-Bot, an automatic DICOM metadata monitoring tool which is capable to verify SOP conformities, was tested for 11 months at two nuclear medicine departments. Relevant parameters, such as patient ID, patient mass and height, injected activity, and uptake time, were investigated in the case of adult 18F-FDG whole-body PET/CT and 99mTc-MDP gamma camera bone scans on a daily basis. Q-Bot automatically inspected the actual SOP compliance of these relevant DICOM parameters. Q-Bot graphical user interface (GUI) provided a summary of the outliers in a table format to be investigated by a dedicated technologist. In addition, information related to the error handling was also collected for retrospective analysis of long-term tendencies. RESULTS: In total, 6702 PET/CT and 2502 gamma camera scans were inspected, from which 8581 were confirmed as valid patient study without errors. Discrepancies related to the lack of a parameter, not appropriate format, or improper scan procedures were found in 623 cases, and 156 out of these were corrected before the medical reading and reporting. SOP non-conformities explored with Q-Bot were found to be non-correctable in 467 cases. Systematic errors to our practice turned out to be the manual radiopharmaceutical injection, the allowance to use both SI and non-SI units, and the clear definition of decimal point symbol to use. CONCLUSION: The daily evaluation of Q-Bot results provided early detection of errors and consequently ensured the minimization of error propagation. Integration of a QM software that inspects protocol compliance at a nuclear medicine department provides significant support to detect non-conformities for technologists, and much higher confidence in image quality for physicians.

Technical Note: A standardized automation framework for monitoring institutional radiotherapy protocol compliance.

PURPOSE: To establish a framework for the standardization of monitoring radiotherapy protocol compliance. METHODS: An automated protocol compliance tool was developed using best practice in software design and a flexible framework to easily adapt to changing institutional standards. The Eclipse scripting environment was used to develop the application with the scripting application programing interface (API) and direct data extraction from ARIA. For each institutional protocol, external validation was specified in a JavaScript Object Notation (JSON) file that stores protocol specific constraints and evaluates compliance of the data from Eclipse and Aria. This tool was applied prospectively to a cohort of prostate cancer patients undergoing radiotherapy with a prescription regimen of 60 Gy in 20 fractions. RESULTS: The prospective evaluation was performed on 58 prostate cancer patients. For this cohort, the mean (standard deviation) pass rate is 92.3% (6.1%). The overall fail rate is 6.0% (5.8%); the percentage of these failures is in 2.6% in Patient Assessment, 0% in Simulation, and 97.4% in Treatment Planning. CONCLUSIONS: A protocol compliance application is developed and implemented in a standard radiotherapy information system. The application functionality is demonstrated on a cohort of 58 patients undergoing prostate radiotherapy, which highlights the utility of assessing adherence to institutional protocols. A unified method must be available for the community to ensure consistency in compliance reporting.

ERAS protocol compliance impact on functional recovery in colorectal surgery. / Impacto del grado de cumplimiento de un protocolo ERAS en la recuperación funcional después de cirugía colorrectal.

INTRODUCTION: Compliance to ERAS protocols is a process quality measure that is associated to better outcomes. The main objective of this study is to analyze the association between protocol compliance, surgical stress and functional recovery. The secondary objective is to identify independent factors associated to functional recovery. METHODS: A prospective observational single-centre study was performed. Patients who had scheduled colorectal surgery within an ERAS program from January 2017 to June 2018 were included. We analysed the relationship between protocol compliance percentage and surgical stress (defined by C reactive protein [CRP] blood levels on postoperative 3rd day), and functional recovery (defined by the proportion of patients who meet the discharge criteria on the 5th PO day or before). Multivariate analysis was performed to asses independent factor associated to functional recovery. RESULTS: 313 were included. For every additional percentage point of compliance to the protocol 3rd day C reactive protein plasmatic level decreases 1,46 mg/dL and increases 7% the probability to meet the discharge criteria (p < 0.001 both). Independent factors associated to functional recovery were ASA III-IV (OR 0.26; 0.14-0.48), surgical CR-POSSUM score (OR 0.68; 0.57-0.83), early mobilization (OR 4.22; 1.43-12.4) and removal of urinary catheter (OR 3.35; 1.79-6.27), p < 0,001 each of them. CONCLUSION: Better compliance to ERAS protocol in colorectal surgery decreases surgical stress and accelerates functional recovery.

Use of electronic medical record templates improves quality of care for patients with infantile spasms.

BACKGROUND: Infantile spasms (IS) is a neurologic disorder of childhood where time to treatment may affect long-term outcomes. Due to the clinical complexity of IS, care can be delayed. OBJECTIVE: To determine if the use of electronic medical record templates (EMRTs) improved care quality in patients treated for IS. METHOD: Records of patients newly diagnosed with IS were retrospectively reviewed both before and after creation of an EMRT for the workup and treatment of IS. Quality of care measures reviewed included delays in treatment plan, medication administration, obtaining neurodiagnostic studies and discharge. The need for repeat neurodiagnostic studies was also assessed. Resident physicians were surveyed regarding template ease of use and functionality. RESULTS: Of 17 patients with IS, 7 received template-based care and 10 did not. Patients in the non-template group had more delays in treatment (p = 0.010), delay in medication administration (p = 0.10), delay in diagnostic studies (p = 0.01) and delay in discharge (p = 0.39). Neurodiagnostic studies needed to be repeated in 5 out of 10 patients in the non-template group and none of the 7 patients in the template group (p = 0.04). Surveyed resident physicians reported improved coordination in care, avoidance of delays in discharge and improved ability to predict side effects of treatment with template use. CONCLUSION: In a single centre, the use of protocolised EMRTs decreased treatment delays and the need for repeated invasive procedures in patients with newly diagnosed IS and was reported as easy to use by resident physicians. IMPLICATIONS: The use of protocolised EMRTs may improve the quality of patient care in IS and other rare diseases.

The effect of compliance with a perioperative goal-directed therapy protocol on outcomes after high-risk surgery: a before-after study.

Perioperative goal-directed therapy is considered to improve patient outcomes after high-risk surgery. The association of compliance with perioperative goal-directed therapy protocols and postoperative outcomes is unclear. The purpose of this study is to determine the effect of protocol compliance on postoperative outcomes following high-risk surgery, after implementation of a perioperative goal-directed therapy protocol. Through a before-after study design, patients undergoing elective high-risk surgery before (before-group) and after implementation of a perioperative goal-directed therapy protocol (after-group) were included. Perioperative goal-directed therapy in the after-group consisted of optimized stroke volume variation or stroke volume index and optimized cardiac index. Additionally, the association of protocol compliance with postoperative complications when using perioperative goal-directed therapy was assessed. High protocol compliance was defined as ≥ 85% of the procedure time spent within the individual targets. The difference in complications during the first 30 postoperative days before and after implementation of the protocol was assessed. In the before-group, 214 patients were included and 193 patients in the after-group. The number of complications was higher in the before-group compared to the after-group (n = 414 vs. 282; p = 0.031). In the after-group, patients with high protocol compliance for stroke volume variation or stroke volume index had less complications compared to patients with low protocol compliance for stroke volume variation or stroke volume index (n = 187 vs. 90; p = 0.01). Protocol compliance by the attending clinicians is essential and should be monitored to facilitate an improvement in postoperative outcomes desired by the implementation of perioperative goal-directed therapy protocols.