Development of the Illinois Surgical Quality Improvement Collaborative (ISQIC): Implementing 21 Components to Catalyze Statewide Improvement in Surgical Care

INTRODUCTION

In 2014, 56 Illinois hospitals came together to form a unique learning collaborative, the Illinois Surgical Quality Improvement Collaborative (ISQIC). Our objectives are to provide an overview of the first three years of ISQIC focused on (1) how the collaborative was formed and funded, (2) the 21 strategies implemented to support quality improvement (QI), (3) collaborative sustainment, and (4) how the collaborative acts as a platform for innovative QI research.

METHODS

ISQIC includes 21 components to facilitate QI that target the hospital, the surgical QI team, and the peri-operative microsystem. The components were developed from available evidence, a detailed needs assessment of the hospitals, reviewing experiences from prior surgical and non-surgical QI Collaboratives, and interviews with QI experts. The components comprise 5 domains: guided implementation (e.g., mentors, coaches, statewide QI projects), education (e.g., process improvement (PI) curriculum), hospital- and surgeon-level comparative performance reports (e.g., process, outcomes, costs), networking (e.g., forums to share QI experiences and best practices), and funding (e.g., for the overall program, pilot grants, and bonus payments for improvement).

RESULTS

Through implementation of the 21 novel ISQIC components, hospitals were equipped to use their data to successfully implement QI initiatives and improve care. Formal (QI/PI) training, mentoring, and coaching were undertaken by the hospitals as they worked to implement solutions. Hospitals received funding for the program and were able to work together on statewide quality initiatives. Lessons learned at one hospital were shared with all participating hospitals through conferences, webinars, and toolkits to facilitate learning from each other with a common goal of making care better and safer for the surgical patient in Illinois. Over the first three years, surgical outcomes improved in Illinois.

DISCUSSION

The first three years of ISQIC improved care for surgical patients across Illinois and allowed hospitals to see the value of participating in a surgical QI learning collaborative without having to make the initial financial investment themselves. Given the strong support and buy-in from the hospitals, ISQIC has continued beyond the initial three years and continues to support QI across Illinois hospitals.

Diagnosis of cystic fibrosis in the Republic of Ireland: epidemiology and costs

There were four objectives in this study: (1) determine the incidence of cystic fibrosis (CF) in Ireland; (2) estimate the cost of diagnosing CF; (3) clarify the characteristics and outcomes of the nationwide diagnostic efforts and (4) identify disparities. Surveys were conducted to determine the number, methods, costs and outcomes for sweat tests in Ireland from 2001 through 2003. The results allowed us to determine that Ireland's CF incidence is the world's highest at 1:1353. The average cost for diagnosis was Euro 2663 per patient. Analyses of data in The Cystic Fibrosis Registry of Ireland revealed longer delays when diagnosis followed respiratory symptoms, rather than gastrointestinal signs, and also in girls compared to boys, particularly those presenting with respiratory symptoms. Although expenditures for diagnosing of CF in Ireland are relatively modest, the high incidence and age of diagnosis, as well as gender-related disparities, are sufficient to warrant investment in national newborn screening.

Determination of bending-induced strain in optical fibers by use of quantitative phase imaging

Quantitative phase microscopy with polarized light has been used to determine the change in refractive index introduced into an optical fiber when the fiber is bent through a constant radius of curvature. By obtaining phase images for two orthogonal directions of the polarization of the incident light, one can infer the induced axial strain profile within the fiber. Radii of curvature from 1 to 8 cm were considered, and in each case excellent agreement, within lambda/100, was obtained between experimental results and theory.

Genetic counseling and risk communication services of newborn screening programs

OBJECTIVES

Newborn screening test results labeled "positive" can have uncertain implications for parents, especially when false-positive results occur or when heterozygous infants are detected using molecular tests for sickle cell hemoglobinopathy or cystic fibrosis. This study surveyed communication services across state newborn screening programs.

METHODS

We surveyed newborn screening programs to identify current communication practices and the methods used for quality assessment. Two successive survey instruments with fixed-answer and free-answer questions were distributed to screening program follow-up coordinators or similar designated officials associated with 52 states and territories.

RESULTS

Replies from 46 respondents (89% response rate) revealed that regional newborn screening programs vary widely in their approaches to counseling. Of the 46 respondents, 35 (76%) answered that they "routinely" provide counseling services to families of affected infants. Depending on the disease, an average of approximately one-half that number provide counseling after false-positive results or for heterozygous infants. Most respondents advocate nondirective counseling more than direct advice. Most programs reported that counseling was usually done by subspecialist physicians or specially trained nurses and counselors. Respondents reported a perception that the "quality" of counseling by these professionals is better than counseling by primary care physicians. Few programs reported systems for assessing quality assurance of counseling.

CONCLUSIONS

Newborn screening programs in the United States vary widely with regard to counseling practices, and no best practices are currently evident. Few programs provide counseling quality assurance. Further study and advocacy is needed to optimize communication services, preferably before implementation of molecular tests arising as a result of the Human Genome Project.

Original research: enhancing power and educating: urban aboriginal family caregivers' perspectives of caring for a child who has chronic renal failure

The discovery of chronic renal failure in a child, and the meaning of this experience from the perspective of the child's family caregivers have previously not been described in the literature on aboriginal health. During the summer of 1995, a phenomenological approach was used to explore this phenomena with 10 urban aboriginal family caregivers. These caregivers were providing care for their children who were receiving health care services at the outpatient children's clinic or the transplant unit at one urban tertiary care hospital. The findings of this research have helped create the beginning of a nursing data base of knowledge about aboriginal family caregivers of children who have chronic renal failure. In this paper, three of the main themes: surviving; relocation; enhancing power; and five sub-themes: providing nutrition; getting involved; educating the caregivers; educating the community; and returning to traditional ways are described. Implications of the findings for health care providers of children who have renal failure and their family caregivers are discussed. Issues that need to be addressed to help meet the needs of aboriginal family caregivers are identified. These issues include communication strategies, culturally appropriate teaching methods, access to resources, and community development initiatives.

Confocal, two-photon laser-induced fluorescence technique for the detection of nitric oxide

We describe a confocal two-photon laser-induced fluorescence scheme for the detection of gaseous NO. Excitation from a simple YAG-pumped Coumarin 450 dye system near 452.6 nm was used to promote the two-photon NO(A (2)?(+), nu? = 0 ? X (2)?, nu? = 0) transition in the gamma(0, 0) band. Subsequent fluorescence detection in the range 200-300 nm permitted almost total rejection of elastic and geometric scatter of laser radiation for excellent signal/noise ratio characteristics. The goal of the research was to apply NO fluorescence to a relatively realistic limited optical access combustion environment. A confocal optical arrangement was demonstrated for single-point measurements of NO concentration in gas samples and in atmospheric-pressure flames. The technique is suitable for applications that offer only a single direction for optical access and when significant elastic scatter is present.

An institutionally funded program for educational research and development grants: it makes dollars and sense

Lack of funding for educational research and a paucity of researchers with academic credibility have been identified as the key issues facing the medical education research enterprise. The authors argue that institutionally supported programs for educational research and development grants can help to address these issues. This report (1) describes the general rationale for having such programs, (2) describes the development of such a program at the University of Wisconsin School of Medicine, and (3) reports the outcome of the first three cycles of awards. The program outcomes include 28 intramurally funded projects, a 200% increase in funds for educational research from local sources other than the medical school, two new grants funded from extramural sources, one peer-reviewed publication, three presentations at national meetings, and six presentations at local meetings. Such a program is an excellent mechanism for demonstrating the administration's support for educational efforts and also provides a way to factor peer review of educational efforts into the faculty promotion process. The authors argue that these two reasons alone are sufficient to justify the development of such programs, although the outcomes at the University of Wisconsin also show compelling added value.

Evaluation of criteria for chronic lung disease in surviving very low birth weight infants. Newborn Lung Project

Criteria in common use for the diagnosis of chronic lung disease of prematurity or bronchopulmonary dysplasia in the neonatal period have not been sufficiently compared and validated against indicators of later respiratory complications. In this study of all 680 infants < or = 1500 gm birth weight admitted to six perinatal centers August 1, 1988, to July 31, 1990, 524 were alive and had no major congenital anomalies at 5 years old. Of 419 who had given permission to release their names and addresses, 272 were located and participated in a follow-up study. The following diagnostic criteria for bronchopulmonary dysplasia and chronic lung disease of prematurity were used during the initial hospitalization: (1) use of supplemental oxygen on day 30 of life, (2) a comprehensive bronchopulmonary dysplasia severity score applied at 25 to 35 days of life developed by a clinician panel to adjust for practice variation in ventilatory support and blood gases, (3) use of supplemental oxygen on day 30 of life with radiographic evidence consistent with bronchopulmonary dysplasia between days 25 and 35 of life, (4) radiographic evidence consistent with bronchopulmonary dysplasia alone, and (5) use of supplemental oxygen at 36 weeks' postconceptional age. These criteria were assessed against use of bronchodilators or steroids during the first 2 years of life, diagnosis of asthma, and hospitalizations for respiratory causes up to age 5. Although all criteria were significantly associated with all the outcomes, radiographic evidence was most predictive. These results indicate that, during a period when 21% of neonates were exposed to antenatal steroids, 24% received surfactant and 9% received postnatal corticosteroids, radiographic evidence was more predictive of long-term respiratory outcome than other commonly used criteria.

Stability of the precorneal tear film in Chinese, African, Indian, and Caucasian eyes

The stability of the precorneal tear film was measured noninvasively in normal subjects from four diverse ethnic groups (Chinese, Africans, Indians, and Caucasians) all resident in the west of Scotland. Statistically significant differences were found to exist among the groups. The respective mean ( +/- SD) tear stabilities were: 9.8 s (3.9), 11.8 s (5.9), 16.4 s (6.9), and 19.9 s (8.3). Subjects were selected from an age range of 17 to 45 years.

The normal cell cycle activation program is exploited during the infection of quiescent B lymphocytes by Epstein-Barr virus

B lymphocytes in the peripheral circulation are maintained in a non-proliferative state. Antigen recognition stimulates limited proliferation, whereas infection with Epstein-Barr virus (EBV) results in continual proliferation and the outgrowth of immortal cell lines. Because it is not clear at which point in cell cycle the peripheral B lymphocytes are arrested, we characterized the expression of several cell cycle-associated genes in quiescent and stimulated cells. We show that the expression of four cell genes, cdc-2, cyclin E, CD23, and cyclin D2, are up-regulated approximately 100-fold as a result of EBV-mediated immortalization. Because these genes play a positive role in cell proliferation, we suggest that this regulatory switch contributes to controlling entry into the cell cycle. Transient stimulation of quiescent B lymphocytes with either a cocktail of anti-CD40, anti-IgM, and IL4, or EBV results in the rapid expression of the same four genes, suggesting that, after infection, EBV exploits the normal program of B-lymphocyte cell cycle activation.

Repeatability of measurements on human, rabbit, and bull sperm by computer-assisted sperm analysis when comparing individual fields and means of 12 fields

OBJECTIVE

To compare repeatability of measurements of human, rabbit, and bull sperm on two Hamilton Thorne Integrated Visual Optical System (IVOS) units, software version 10.

DESIGN

Semen samples from seven normal human subjects, six rabbits, and eight bulls were obtained at regular intervals. The samples were diluted, two chambers were filled, and 12 fields were recorded, using high resolution recorders. Computer-assisted sperm analysis (CASA) was performed nearly simultaneously with two Hamilton Thorne IVOS units.

SETTING

Reproduction Research Laboratories, Cornell University and Hamilton-Thorne Research, Beverly, Massachusetts.

RESULTS

Optimal settings were established for evaluating by CASA sperm from three species. Fifteen variables were analyzed. The correlation coefficients for most variables characterizing sperm motion and concentration, when means of 12 fields were calculated, were 0.95 to 1.00. There were too few hyperactive sperm to obtain a reliable correlation for human sperm (r = 0.63) and repeatability of elongation was lower only for human sperm (r = 0.75).

CONCLUSIONS

Two units of Hamilton Thorne IVOS, software version 10, were capable of providing nearly identical estimates of many CASA variables of human, rabbit, and bull sperm. Correlations for the paired estimates of many motion characteristics and sperm concentration usually exceeded 0.97.

Sleep apnea in end-stage renal disease patients on hemodialysis and continuous ambulatory peritoneal dialysis

Fifteen unselected end-stage renal disease patients (nine hemodialysis [HD] and six continuous ambulatory peritoneal dialysis [CAPD]) were randomly selected from four Sydney metropolitan dialysis centers for sleep assessment by full polysomnography. Four of six CAPD patients and eight of nine HD patients were found to have clinically significant obstructive sleep apnea. An additional 21 unselected patients (10 CAPD and 11 HD patients) were assessed using overnight home monitoring of nasal airflow and arterial oxygen saturation. Of these, 8 of the 11 HD and 7 of the 10 CAPD patients were found to have obstructive sleep apnea. These data confirm the high incidence of obstructive sleep apnea in the end-stage renal disease population at large. Screening for obstructive sleep apnea should become a routine part of the management of these patients.

Sleep apnea in CAPD

Sleep disturbances are common complaints of dialysis patients, and sleep studies have suggested that sleep apnea may occur frequently. We performed sleep studies on 18 stable continuous ambulatory peritoneal dialysis (CAPD) patients. Our results indicate that 6 of 18 patients (33%) had a respiratory disturbance index (RDI) greater than 15, which indicates severe sleep apnea. Twelve of 18 patients (67%) had an RDI greater than 5, indicating clinically significant sleep apnea. These results suggest that sleep apnea is common in CAPD patients. The impact of sleep apnea on the patients' quality of life remains to be determined.

The Need for Significant Reform: A Practice Driven Approach to Curriculum

The central theme of the curriculum revolution is the preparation of graduates with new and different perspectives and abilities who can function well in a rapidly changing health care environment. Discussions of approaches needed to prepare such graduates center on making substantive changes within the education system. Experience from a collaborative undergraduate nursing program reveal that revised structural and power relationships between nursing education and nursing practice are needed to support such fundamental changes in nursing curricula. This article explores structural and power relationship issues arising from implementing a practice-driven, phenomenological approach to a 4-year undergraduate nursing curriculum. The meaning of a practice-driven approach, the inherent benefits and risks, the outcomes and evaluation issues are included in the discussion. It is suggested that if learning to nurse is grounded in nursing practice as well as in nursing academia, then systems of nursing practice and of educating nurses must change.

Nuclear transfer in cattle: effect of nuclear donor cells, cytoplast age, co-culture, and embryo transfer

There are many factors affecting the efficiency of nuclear transfer technology. Some are evaluated here using our novel approach by enucleating oocytes at 20-22 hr after in vitro maturation (IVM), culturing the enucleated oocytes (cytoplasts) for 8-10 hr or 18-20 hr to gain activation competence and then conducting nuclear transfer. In the first experiment, we demonstrated that cumulus cell (CC) monolayer can support some cloned embryos to develop into morulae or blastocysts. Co-culture with CC and bovine oviduct epithelial cell (BOEC) monolayers resulted in no differences (P > 0.05) in supporting the development of cloned embryos (Experiment 2). When in vitro matured oocytes were enucleated at 22 hr after IVM followed by nuclear transfer 18-20 hr later, cleavage and morula or blastocyst development of the cloned embryos were similar to those resulting from the enucleated oocytes which had been matured in vivo (Experiment 3). Frozen embryos as nuclear donor cells worked equally well as fresh embryos for cloning in embryo development which was superior to IVF embryos (Experiment 4). However, fresh embryos resulted in a higher proportion (P < 0.05) of blastomere recovery than did frozen of IVF embryos. Finally, embryo transfer of cloned embryos from our procedure produced a viable calf, demonstrating the commercial value of this novel approach of the technology.

Kinetic modeling as a prescription aid in peritoneal dialysis

Methods for calculating fluid and mass removal in peritoneal dialysis are presented in order to aid clinicians in their care and management of patients and to assist them in their understanding of the physiological mechanisms which govern peritoneal transport. These methods are based on the Pyle-Popovich peritoneal mass transport model which encompasses both diffuse and convective transport as well as lymphatic flow and residual renal function. Algebraic solutions to the mass balance equations governing solute transport are provided. Since these solutions are expressed explicitly as functions of time, they are easily programmed for use on a personal computer or calculator. This offers considerable advantage over the more computer-intensive numerical solutions which had been previously required since one can now calculate both mass removal and changes in blood concentration at the end of an exchange without requiring any intermediate calculations. This computational advantage and the ability to model changes in blood concentration are shown to be of particular importance when modeling more dynamic therapies such as CCPD or Tidal peritoneal dialysis. Finally, the model and solutions, when assessed clinically among 5 patients on two separate occasions, resulted in predicted fluid and mass removals which were in high concordance with measured fluid and mass removals (concordance correlation coefficients in excess of 0.97). Our findings suggest that kinetic modeling can provide the kind of analytical tools necessary to guide clinicians in their care and management of peritoneal dialysis patients.

Development and validation of an index for scoring baseline respiratory disease in the very low birth weight neonate. Severity Index Development and Validation Panels and Newborn Lung Project

An accurate description of the population at risk for neonatal chronic lung disease is clearly of prime importance for comparative studies and the planning of interventions. Attempts to explain variations in chronic lung disease rates in such studies have been compromised by lack of a way of estimating the severity of the initial pulmonary disease as a risk factor. Therefore, a severity index was developed for use in very low birth weight (less than 1501 g) neonates. Special emphasis was placed on applicability of the index in the multicenter observational setting. Development followed a clinician panel approach, with the resulting index designed to capture clinical judgment of severity. The index was validated prospectively on neonates in a neonatal intensive care unit, and retrospectively using charts from nine hospitals nationwide. Correlations of the index with clinical judgment in the two samples were .95 and .93, respectively. In an additional validation the index combined with birth weight correctly predicted oxygen dependence status at 30 days in 36 of 42 neonates consecutively admitted to five neonatal intensive care units (P = .002). Birth weight and the severity index contributed about equally to the prediction, and therefore they seem to represent partly independent components of baseline propensity for prolonged oxygen dependence.

Paradigm case analysis and stimulated recall: strategies for developing clinical reasoning skills

Development of clinical reasoning skills was a major objective of a collaborative venture between a university school of nursing and a tertiary care teaching hospital. Two elective courses and an 8-month practicum were offered at the graduate level to students specializing in perinatal nursing. Through analysis of their own cases and those of clinical experts, students gained expertise in tracing the development of their decision-making skills. In the clinical practicum, where it was less feasible for the student and preceptor to withdraw from the clinical setting to discuss the decision-making process, "stimulated recall" was employed. This strategy uses segments of nurses' actual practice, on site, at the time of care delivery. In this way, the total context of the clinical reasoning process of nurses can be examined. In this paper, the two strategies are discussed with illustrations from the actual teaching/learning situations.

Neonatal screening for cystic fibrosis in Wisconsin

Primary care physicians have been very cooperative in referring screened patients to the two designated CF centers in Wisconsin--the University of Wisconsin Cystic Fibrosis Center, and the center at the Medical College of Wisconsin in Milwaukee--and their help has made this study possible. By 1990, we anticipate that meaningful clinical comparisons between the screened and control groups will be possible, and at that time we can begin to obtain some definitive answers concerning the benefits and potential risks of neonatal screening for cystic fibrosis. At this time, it would be premature to make a decision concerning the efficacy of screening for cystic fibrosis for the State of Wisconsin. It is very important that the study go to completion before making conclusive recommendations. We are eager to meticulously document the natural history of CF by following study patients for a long time. Answers to questions concerning rate of decline of the IRT value in true positives, psychosocial risks of screening to true positives, effect on future reproductive plans, and the cost effectiveness of the screening program will not be available for at least two more years. False positive IRT results seem to be related to perinatal asphyxia. We postulate the mechanism is ischemia in the pancreas related to hypoxia during the perinatal period leading to transient release of trypsin from the pancreas into the bloodstream. Decline of the IRT result over time is of great interest because a repeat blood sampling approach would hopefully eliminate several false positives.(ABSTRACT TRUNCATED AT 250 WORDS)

Epstein-Barr virus gene expression in P3HR1-superinfected Raji cells

The pattern of Epstein-Barr virus (EBV) RNAs expressed in Raji cells superinfected with P3HR1 EBV was examined. RNAs whose expression was of an immediate-early type (resistant to treatment of the cells with anisomycin) were identified. These RNAs, encoding the EBV reading frames BZLF1 and BRLF1, were probably expressed from defective virus within the P3HR1 preparation, and some of them were responsible for the induction of the EBV productive cycle in the Raji cells. The structures of the B95-8 RNAs equivalent to the anisomycin-resistant RNAs were determined. The RNA encoding the BZLF1 reading frame contained two splices which extended and modified the reading frame from that previously described.

Lifestyle counselling: the need for diagnostic clarity

Three approaches to changing lifestyle behaviours are hypothesized. The argument that diagnostic accuracy is essential for selection of appropriate nursing interventions is developed and illustrated with clinical examples. The diagnoses of information deficiency, information and behavioural control deficiency, and contextual awareness deficiency guide the interventions for the problem of obesity.

Questioning: an intervention for health promotion

In the health professions, questioning is traditionally viewed as a way of gathering information from a client as well as a way of developing the affective domain or how the client feels. The development of the cognitive domain, or how the client thinks, receives less attention. This article describes a clinical nursing approach using Bloom's Taxonomy to question clients' thinking behavior. Examples from nurses' files are used to clarify this approach.

Spliced RNA from the IR1-U2 region of Epstein-Barr virus: presence of an open reading frame for a repetitive polypeptide

We have constructed a cDNA library from the cytoplasmic RNAs of Raji cells, a Burkitt's lymphoma cell line latently infected with Epstein-Barr virus. We report here the characterization of a cDNA representing a spliced RNA transcribed from the IR1-U2 region of the viral genome. The cDNA is 1007 bp long. The 5' region contains three tandem repeats of two exons, 66 and 132 bp, which are transcribed from the IR1 repeats. The 3' region is formed from four exons transcribed from U2. An open reading frame extends from the 5' end to position 784, and includes the repeats. This reading frame presumably corresponds to the carboxy-terminal 261 amino acids of a polypeptide containing several repeats of a 66 amino acid sequence. Since it would be encoded by the IR1-U2 region of the viral genome, the putative polypeptide might be involved in the process of growth-transformation of B-lymphocytes.

Nursing interventions for health promotion

Selected nursing interventions for health promotion in well individuals are described. Over a two-year period, two clinical nurse specialists developed and used client record keeping, role playing, audio and video feedback, imagery, visual mapping and experimentation as health promotion interventions. Clinical examples and client outcomes are discussed. Health promoting interventions are clearly distinguished from disease prevention approaches as described in the literature.