Quality Improvement in Hematopoietic Stem Cell Transplant and Cellular Therapy: Using the Model for Improvement to impact Outcomes.

Quality improvement and quality assurance form a complementary and independent relationship. Quality assurance measures compliance against industry standards using audits, whereas quality improvement is a continuous process focused on processes and systems that can improve care. The Model for Improvement is a robust quality improvement tool that transplant and cellular therapy teams can use to redesign healthcare processes. The Model for Improvement uses several components addressed in sequence to organize and critically evaluate improvement activities. Unlike other health sciences clinical research, quality improvement projects, and research are based on dynamic hypotheses that develop into observable, serial tests of change with continuous collection and feedback of performance data to stakeholders.

A pragmatic multi-institutional approach to understanding transplant-associated thrombotic microangiopathy after stem cell transplant.

Transplant-associated thrombotic microangiopathy (TA-TMA) is a severe complication of hematopoietic stem cell transplantation (HSCT). A single-center prospective screening study has shown that the incidence of TA-TMA is much higher than prior retrospective studies that did not systematically screen. These data have not been replicated in a multicenter study. Our objective was to determine the incidence and risk factors for TA-TMA and compare outcomes of pediatric HSCT patients with and without TA-TMA. Patients were prospectively screened for TA-TMA at participating centers using a simple to implement and inexpensive strategy from the start of the preparative regimen through day +100. TA-TMA was diagnosed if ≥4 of 7 laboratory/clinical markers diagnostic for TA-TMA were present concurrently or if tissue histology showed TA-TMA. A total of 614 patients (359 males; 58%) received prospective TA-TMA screening at 13 pediatric centers. TA-TMA was diagnosed in 98 patients (16%) at a median of 22 days (interquartile range, 14-44) posttransplant. Patients with TA-TMA had significantly increased bloodstream infections (38% [37/98] vs 21% [107/51], P ≤ .001), mean total hospitalization days (68; 95% confidence interval [CI], 63-74 vs 43; 95% CI, 41-45; P ≤ .001), and number of days spent in the intensive care unit (10.1; 95% CI, 6.4-14; vs 1.6; 95% CI, 1.1-2.2; P ≤ .001) in the first 100 days after HSCT compared with patients without TA-TMA. Overall survival was significantly higher in patients without TA-TMA (93%; 490/516) compared with patients with TA-TMA (78%; 76/98) (P ≤ .001). These data support the need for systematic screening for TA-TMA and demonstrate the feasibility and efficacy of an easy to implement strategy to do so.

Central venous catheter dressing durability: an evaluation.

BACKGROUND: Skin organisms at the insertion site are frequently implicated in central venous catheter blood stream infections (CVC BSIs) yet few studies have compared the durability of CVC dressings in critically ill patients. AIMS: To undertake an evaluation of the durability and associated costs of different CVC dressings. METHODS: Dressing duration was captured prospectively using a pro forma on four different dressings on five critical care units over a 12-month period. Staff received training on CVC dressing evidence-based practices and a 'how to guide' was implemented. FINDINGS: A total of 1229 CVC dressings were observed from 590 CVCs. One dressing had a median (IQR) duration of 68.5 h (range, 32-105 h) compared to a median duration of 43.5, 46.0 and 40.5 h for the other dressings (P <0.001). The mean time to change a CVC dressing was 13.5 min and the cost of a dressing change was in the range of £1.97-4.97. During the 12-month study period we observed a downward trend in CVC BSIs. DISCUSSION: Despite few dressings remaining adherent for 7 days, the low rates of CVC BSI observed suggests good dressing practices. CONCLUSIONS: One dressing appeared more durable than the others, although it was still below the recommended standard and more expensive.

Room novelty, sex, scopolamine and their interactions as determinants of general activity and rearing, and light-dark preferences in rats.

Male and female rats were assessed for effects of scopolamine on general activity, rearing and light-dark preferences when tested in either a familiar or a novel room. Males but not females reared more often when tested in the familiar rather than novel room, and the response was increased by scopolamine for all rats combined. Whereas scopolamine increased general activity for females (but not males) in the familiar room, it decreased the response for males (but not females) in the novel room. Females crossed more often between the dark and light sides of a light-dark box and, when treated with saline but not drug, spent more time in the light side than males. Scopolamine reduced the amount of time spent in the light side for females only. While the results were discussed mainly in terms of sex differences in fearfulness, their principal value was in demonstrating the effectiveness of room novelty and sex in determining levels of the behaviors recorded, and drug responsiveness.