789 Best of both worlds: a hybrid simulation-based junior trainee mock code curriculum with complementary asynchronous e-learning modules

Introduction Delirium is a recognised complication in the peri-operative period amongst older surgical patients. Delirium is defined as an acute fluctuating confusional state with a 4AT score ≥ 4. Our aim was to improve delirium recognition on arrival to the acute surgical receiving unit and throughout admission in patients aged ≥65 years. Methods Initial data was collected by reviewing medical notes of general surgical patients aged ≥65 years. Data collected included; age, 4AT within 24-hours of admission, 4AT during admission, and a documented delirium diagnosis. PDSA (plan, do, study, act) cycles including delirium teaching sessions for foundation doctors, and subsequent distribution of lanyard cards with the 4AT for easy use in the clinical environment, were completed. Results Our patients’ ages ranged from 65 to 91 years and included emergency and elective general surgery patients. Initial data showed that 39% of patients aged ≥65 years had a documented 4AT within 24-hours of admission. After our first intervention, 4AT within 24-hours of admission increased to 46% and remained at 46% after our second intervention. 33% of patients aged ≥65 years within our general surgical wards had a documented 4AT score at the time of delirium diagnosis. This improved to 45% of patients after our first PDSA cycle. 44% of patients with delirium had operative intervention. Conclusion Our aim of achieving 50% of patients aged ≥65 years having a documented 4AT within 24-hours of admission was not met, despite two PDSA cycles. There was a small improvement in delirium recognition. Delirium is prevalent and within our organisation, further improvement work to promote using the 4AT with PDSA cycles is planned.

Introduction Delirium is a common neuropsychiatric syndrome in patients over the age of 65 presenting to medical admissions units yet remains under-diagnosed despite significant associated mortality and morbidity. Our trust's delirium screening tool incorporates a four-step approach, with completion of validated 4AT test warranted in all those over 65 years of age admitted with increased confusion or social withdrawal. Our aim was to measure current uptake of this delirium screening and introduce measures to improve practice. Method We retrospectively collected data from medical records of patients on two Geriatric inpatient wards (42 patients) at the Leicester Royal Infirmary, to determine whether appropriate delirium screening was taking place for at-risk patients on admission. We then introduced two PDSA (plan, do, study, act) cycles: 1. teaching at departmental weekly educational meetings with sending electronic communications to all doctors in medicine highlighting importance of delirium screening; and 2. displaying posters on all admissions wards. A third cycle was planned involving visiting wards to raise awareness, however this was interrupted by the COVID pandemic. Results Initial baseline results showed only 5% (1 of 18) of at-risk patients were fully screened for delirium. Following our first intervention, this increased to 13% (3 of 23). Second intervention involving display of posters led to an increase to 44% (8 of 18) of at-risk patients being screened. Proportions of dementia were comparable across PDSA cycles. Conclusions Education, raising awareness, and display of reminder posters can improve delirium screening uptake of at-risk patients on admission to medical admission units, despite growing pressures associated with the COVID pandemic. Further interventions are planned to improve and maintain awareness and uptake of delirium screening.

AimsPhysical health monitoring is paramount to optimal care for psychiatric patients. Blood tests and ECGs are invaluable tests throughout a patient's care. At baseline, they aid investigation of potential organic causes of psychiatric presentations and provide organ and electrolyte status before starting medication. Common psychotropic medications carry physical health risks: bloods and ECGs aid in monitoring potential side effects of prescribed medication.In this local Tier 4 inpatient unit, anecdotal observation revealed completion of these basic investigations was noted to be suboptimal.This project aimed to improve timely completion of baseline (within 72 hours of admission) and monitoring (within one week of due date) bloods and ECGS.MethodThis project was completed within a 12-bed child and adolescent inpatient unit. Using Plan Do Study Act (PDSA) methodology, the multidisciplinary team collated driver diagrams to identify potential areas for intervention. Following baseline analysis, colleague communication was considered key. Consequently, a chart for bloods and ECG completion was created.Each monthly PDSA cycle included the following consecutive interventions: PDSA cycle 1: chart implementationPDSA cycle 2: chart simplification and font size increasePDSA cycle 3: allocated change in team leader for this cyclePDSA cycle 4: Blood request pocket in officePDSA cycle 5: chart simplification through removal of datesPDSA cycle 6: ECG pocketPDSA cycle 7: box on handover listResultMonthly investigations and admission numbers are unpredictable and inconsistent in this cohort: relevant case numbers per PDSA ranged from zero to ten. The results were presented as percentages to allow for direct comparison between cycles.Baseline and results of each consecutive PDSA cycle described above were as follows (N/A represents a cycle where no investigations were required):Admission bloods were completed within 72 hours in 50%, 100%, 50%, 80%, N/A, 100%, 100%, 100%Admission ECG was completed within 72 hours in 30%, 66%, 50%, 70%, N/A, 100%, 100%, 100%Monitoring bloods were completed within one week of due date in 25%, 33%, 0%, 80%, 100%, 100%, 100%, 100%Monitoring ECG was completed within one week of due date in 0%, 0%, N/A, 66%, 100%, 66%, N/A 100%ConclusionThrough close multidisciplinary collaboration and chart implementation, completion of bloods and ECGs improved. Low patient numbers per PDSA cycle resulted in large changes in percentage results, limiting the significance of these findings. Wider implementation of the chart within local Trust inpatient wards is considered.

240 Background: Hypoglycemia has been observed in children receiving Acute Lymphoblastic Leukemia (ALL) therapy. It affects patients’ outcome. The current quality initiative was piloted at two of the St Jude affiliate clinics. Each month about 10% of children with ALL develop hypoglycemia in those two clinics. Methods: Data was collected for the eight months prior to intervention. Root Cause Analysis (RCA) using fish bone diagram, and Pareto chart to find out the most likely causes of hypoglycemia. Prolonged hours of fasting for procedures, giving 6MP at night on empty stomach, seem to further prolong hours of fasting, and lack of awareness of the new 6MP administration guidelines were the top likely causes. Interventions based on RCA: Developed Hypoglycemia educational brochure addressing causes and prevention of hypoglycemia for care givers followed by knowledge assessment tool, in addition two educational sessions for staff. Plan, Do, Study, Act (PDSA) was used to guide implementation. 4 PDSA cycles were done. Results: Combined monthly average number of ALL patients seen in both centers was 43 (range 38-51) patients with monthly average of 94 (range 71-141) blood glucose samples drawn from them. Process Measure 1: % care givers received hypoglycemia education after 1st cycle was 16.3% which increased to 88% after PDSA cycle # 4. Process Measure 2: % of caregivers scored above 75% in the knowledge of morning hypoglycemia after education were 78%. Outcome Measure: At the end of intervention the average monthly patients with hypoglycemia decreased from 9.4% to 7.8% representing 17% reduction. Hypoglycemic episodes dropped from 6% to 4.2%, showing 30% reduction in hypoglycemic episodes. More reduction in hypoglycemic episodes was observed in clinic 1 (68%) compared to 22% reduction in clinic 2. Conclusions: Using quality improvement methodology in implementing hypoglycemia education led to drop in hypoglycemia episodes among children on ALL therapy. Despite using similar approach, yet one of the two clinics showed higher improvement compared to the other. This may reflect the possible impact of local institutional factors on implementation.

BackgroundDelirium is a common hospital presentation among the elderly population. Chronicity of this condition necessitates that relatives and carers have better access to information. Patient information leaflets offer a simple...

Background Skin and soft tissue infections (SSTIs) are the second most common diagnosis leading to pediatric antibiotic prescriptions in the outpatient setting after respiratory diagnoses. Children with SSTIs often receive > 7 days of antibiotics, although current guidelines recommend 5-7 days for most diagnoses. At Children’s Mercy Hospital (CMH) urgent care clinics (UCC), only 58% patients received the recommended 5-7 days of antibiotics. We aimed to increase the percentage of patients receiving 5-7 days of oral antibiotics for SSTIs from 58% to 75% by December 31st, 2021. Methods We formed a multidisciplinary team in April 2020. A provider survey assessed factors influencing prescribing habits. We completed cause-and-effect analyses and developed a driver diagram (Figure 1). Interventions were chosen based on the potential for highest impact and lowest effort. Our first Plan-Do-Study-Act (PDSA) cycle provided an update on current guidelines for UCC providers. The second PDSA cycle updated prescription sentences in the electronic health record (EHR) and organized them from shortest to longest duration. The third PDSA cycle provided a project update via email to UCC providers. Our outcome measure is the percentage of patients receiving 5-7 days of antibiotics for SSTIs. Process measure is the number of updated prescriptions used. Balancing measure is the number of patients returning for SSTI within 14 days of their visit. Results are displayed using a run chart. Results After initiation of the project in April 2020, the percentage of patients receiving 5-7 days of antibiotics increased to 68% (Figure 2). This percentage increased to our goal of 75% after the 1st PDSA cycle (October-December 2020), 80% following the second PDSA cycle in February 2021, and 90% following the third PDSA cycle in April 2021. There was no change in balancing measure numbers. Run Chart Conclusion Prior to our project, only 58% of children seen in CMH UCCs for SSTIs received the recommended antibiotic duration. By addressing the primary drivers uncovered through QI methodology, we surpassed our goal of 75%. Additional PDSA cycles are planned along with expansion to other departments. This work will allow us to expand antibiotic stewardship efforts to other infectious diagnoses as well. Disclosures Brian R. Lee, PhD, MPH , Merck (Grant/Research Support)Pfizer (Grant/Research Support)

The purpose of this study was to determine the characteristics of academic Pediatric Emergency Medicine (PEM) faculty, the workload of these physicians, and the perceived effect this workload has had or will have on job satisfaction. A self-administered, seven-page, closed-end survey was used. participants were PEM departments with PEM Fellowship Training Programs. Surveys were completed by 37 PEM departments (84%). The average number of faculty per department was 7.33. Ninety-three percent of the faculty were board certified in Pediatrics, Emergency Medicine, or both. Only 15% of the faculty had an academic rank of associate or full professor. Fifty-four percent of the faculty had less than five years' experience. Average patient census per department was 43,400 per year. Physicians without administrative titles averaged 30 clinician hours per week. Attending physicians covered 85 to 100% of the overnight shifts in 17 programs (52%). Clinical workload was believed to be excessive in 17 programs (46%), with total number of hours given as the most common reason for this excess. In nine of these 17 programs, excess clinical workload had resulted in physician "burnout." Physicians from only eight programs (22%) believed they could practice PEM after 50 years of age. Shift work and overnight shifts were given as the most common reason. Stressed physician groups were significantly associated with programs whose attending physicians covered > or = 85% of the night shifts (P < 0.04) and reported excessive clinical workload (P < 0.002). Job satisfaction perceived by PEM faculty appears to be dependent on addressing the clinical workload and the adverse effects of overnight and shift work.

Introduction Bowel care is an important part of care for older people. This quality improvement project (QIP) was carried out on the Older Person’s Assessment Unit at Arrowe Park Hospital which is a 24 bed acute frailty unit. Locally we found inadequate documentation of stool charts. This had the potential to cause problems related to constipation such as pain, increased use of catheters, delirium, bowel obstruction, thereby increasing length of hospital stay. Our aim was that all our patients would have a completed stool chart. Method Three Plan Do Study Act (PDSA) cycles were designed with input from the medical team, ward charge nurse and QIP lead. The first intervention was to discuss the importance of stool charts at board round. The second intervention included displaying a Bristol stool chart poster. The final intervention involved discussion with the clinical support workers and notices were displayed. Baseline audit data was collected and the audit repeated following each intervention. 12 patients were selected per cycle using alternate even and odd bed numbers. Data included if the amount, colour and stool type had been documented on the chart or the notes. Data was collected and presented using Google Sheets and Slides. Results Baseline data showed 40% of patients had a completed stool chart. Following the first intervention this improved to 50%. Data collected in PDSA cycle 2 showed the worst results with 25% of charts documented. After the final intervention stool charts were completed for 42% of patients. This information was less frequently documented in the notes. Staff experience and workload were likely factors affecting documentation. Conclusion The first intervention of active discussion with the multi-disciplinary team was most effective. Passive interventions such as displaying a poster was much less effective. There remains room for improvement and further PDSA cycles are planned.

289 Background: The Swedish Cancer Institute (SCI) is committed to holistic care and recognizes immunizations are an essential component to quality outcomes. In 2022 the SCI was selected to participate in the Specialty Societies Advancing Adult Immunization (SSAAI) project supported by the Centers for Disease Control and Prevention (CDC) with a goal of incorporating the CDC Standards for Adult Immunization Practice into medical oncology clinical care. The CDC Standards for Adult Immunization Practice are assess, recommend, administer or refer, and document. Recognizing immunization status is not routinely assessed, this quality initiative aimed to increase assessment of immunization status in medical oncology across 7 network clinics on 4 campuses to above 50 % by the end of 2023. Methods: All team members completed the ASCO Quality Training Program. The Plan Do Study Act (PDSA) framework was selected. Assessment was defined as having completed the Immunization Activity Record within the Epic Medical Record system, which includes reconciliation with the Washington state immunization registry. Data was initially abstracted manually to determine the baseline assessment rate until an automated method was developed. A Fishbone diagram determined the top barrier was the lack of awareness about this functionality and lack of training around the task. A workflow diagram and standard operating procedure were implemented. Clinic staff were trained on the new workflow when rooming patients. A small pilot with one clinic of solid tumor medical oncology clinics was completed. Patients included were on active treatment and seen face to face within the clinic. The standardized process and tools were refined, and problem areas addressed. The work was then expanded to all seven of the SCI network medical oncology clinics including hematology as the final PDSA cycle using the same training, process and tools. Results: The Epic Immunization Activity Record completion rate went from less than 1% of solid tumor patients with an active systemic treatment plan to 61% in the pilot project. After two additional PDSA cycles to refine the steps and target problem areas, the rate improved to 67% over a 3-month period. The PDSA cycle was expanded to bring the refined process to all 7 network clinics with a baseline assessment rate of 6% which increased to 45% after interventions within a 3-month period and concluding the 2023 year. Conclusions: Developing tools and implementing a new workflow for immunization assessment yielded a significant improvement in assessment rates thereby setting a foundation of assessment utilizing the CDC Standards for Immunization Practice. The use of concrete written tools improves the sustainability of the changes. Additional tools and refinement of existing tools will be studied to improve the current rate and sustain the gains. Reference: Standards for Adult Immunization Practices | CDC .

INTRODUCTION: The surgical debrief is a standardized checklist performed near the conclusion of a surgery, similar to the pre-procedure “Time Out.” This surgeon lead debrief confirms correct procedures and specimens, addresses anesthesia concerns, patient disposition, and allows all team members to participate in discussions regarding case efficiency. It has been studied in several surgical fields and shown to improve operating room safety and communication, increase efficiency, and decrease morbidity. It also provides opportunities for educational feedback in academic institutions. The surgical debrief has not been studied in gynecologic surgery. This study evaluates the implementation of a standardized surgical debrief at a teaching hospital. METHODS: This is a quality improvement study using PDSA (plan-do-study-act) cycles to implement surgical debriefs in all gynecologic surgeries performed at this hospital. All OR team members took pre/post implementation surveys regarding OR safety and communication and received surgeon lead education regarding implementation protocols. IRB approval was obtained. RESULTS: In PDSA cycle 1, 59% (33/56) of eligible gynecologic surgeries completed debriefs. In PDSA cycle 2, debriefs were completed in 70% (40/57) of eligible gynecologic surgeries. Immediate resident feedback occurred in 46% of the cases that completed debriefs. CONCLUSION: The surgical debrief was successfully implemented into gynecologic surgery. Anonymous survey results by the vast majority of OR personnel felt the debrief enhanced OR safety, improved communication, and prompted immediate resident feedback in such a positive way, that it has been adopted routinely for all cases, amongst all surgical specialties at this institution.

AimsDischarge summaries are vital documents that communicate information from hospital to primary care providers. The documents contain description of the patient's diagnostic findings, hospital management, laboratory results, medications list and arrangements for post-discharge follow-up. Ineffective communications between healthcare providers in the form of delayed or poor quality discharge summary may adversely affect patient care and safety.The setting of this project is Gwent Specialist Substance Misuse Service (GSSMS) which is the statutory specialist addictions service within Aneurin Bevan University Health Board (ABUHB). GSSMS has been arranging and managing inpatient alcohol detoxes for many years. One of the issues highlighted by an inpatient alcohol detox audit in 2017 was discharge summaries were not being completed for every patient who was admitted with a compliance rate of only 57.7%. A quality improvement project was initiated following the presentation of the audit on a Staff Education Day.The aim of the project is to increase the discharge summary completion rate from 57.7% to 80% by June 2019.MethodA discharge summary process map was developed to understand the possible causes of delay then Plan, Do, Study, Act (PDSA) methodology was utilised. The result of the original audit was taken as the baseline measurement and benchmarking activities and PDSA cycle were performed. Interventions included root cause analysis by way of brainstorming, education, communication and constructing a checklist.ResultThere has been significant improvement with the compliance rate following the PDSA cycle. It went up to 100% before tapering off to 85% by the end of the project.ConclusionAwareness building, continuous monitoring and engagement of teams alongside regular feedback were shown to be the important factors to achieve and sustain the improvement.

262 Background: Patients with cancer are at particularly high risk for falls and unfortunately may suffer worse outcomes with falls. Patients with cancer are at increased risk for fractures due to bony metastases, and worse subsequent bleeding due to thrombocytopenia from disease or from prophylaxis or treatment for deep vein thromboses. In 2020, there were 10 falls among patients with cancer in NewYork Presbyterian/Weill Cornell Medicine outpatient oncology clinics, with a fall rate of 0.31 falls per 1000 patient visit. In 2019, there were 14 falls (0.39 falls per 1000 patient visits).The aim of this project is to reduce the total number of falls and overall fall rate by 50% in NewYork Presbyterian/Weill Cornell Medicine outpatient oncology clinic areas by December 30, 2021. Methods: In Plan-Do-Study-Act (PDSA) cycle in February 2021, we identified key stakeholders (nurses, medical assistants, nurse navigators, and clinic managers) in NYP/Weill Cornell oncology outpatient areas. We engaged key stakeholders in a series of interactive conferences to introduce and implement quality improvement tools (root cause analysis and process mapping) with outpatient teams to identify risk factors for patients who fell in NYP/Weill Cornell oncology outpatient areas from 01/2020-12/2021. A standardized post-fall huddle process was implemented, and prior falls were reviewed using this process. Interventions were based on these identified risk factors to prevent falls in the outpatient clinic areas. In the second PDSA cycle which began April 1, 2021, a new handoff process was initiated in the outpatient clinic setting. Prior to the end of the shift, the charge nurse cross references the “G Drive list” with patient list for the following day and identifies patients with previous falls or those identified by nurses as being high risk for falls. This list is located in a commonly used, HIPAA compliant file location, which was already part of the normal scheduling workflow. These patients are then discussed in the daily huddle to create awareness by all staff and provide “handoff” between visits which by design cannot happen nurse to nurse with each visit. The team has been reviewing the list monthly to develop a sustainability plan. Results: Since the completion of the interactive QI conferences in PDSA cycle 1, there have zero additional falls in the oncology outpatient clinic areas. Continuing on into PDSA cycle 2 with the new handoff process, there have not been any additional falls. Conclusions: This project demonstrates an effective QI intervention to reduce falls in the outpatient oncology areas and prevent injuries in this vulnerable population. This multidisciplinary approach to identifying root causes for falls and reviewing our processes for monitoring patients in our infusion areas ultimately has led to significant reduction in falls. It has also empowered key stakeholders in our oncology clinics with QI tools to address other areas for improvement.

195 Background: As part of the quality improvement initiative, the Northwell Health Cancer Institute aimed to improve the average time to first appointment (TTA) for all new breast and thoracic cancer patients to 7 days or less. Average TTAs were 11.3 days for breast and 10 days for thoracic cancer patients. This initiative was conducted in collaboration with the ASCO Quality Training Program. Methods: Data collection included interviews, surveys, and chart reviews, with input from nurse navigators, schedulers, and social work. Data sources included the new patient unit, navigator and social work databases. Pareto analysis was used to identify key barriers to timely appointments. We chose two interventions that were high impact and relatively easy to implement: increasing tele-visit appointment availability and scheduling provider visits before all work up was completed or resulted. Results: After three Plan-Do-Study-Act (PDSA) cycles, TTA for thoracic cancer patients showed improvement: PDSA 2 TTA 9.1 days, PDSA 2 TTA 7.9 days. For breast cancer patients, similar interventions were not able to improve TTA: PDSA 2 TTA 12.9 days and PDSA 3 TTA 11.7 days. Pareto analysis revealed that delays were often due to patient preference to wait for Oncotype results or patient/ family availability before the initial oncology visit. Review of triple-negative, HER2-positive, metastatic breast cancer, and breast cancer in pregnancy indicated improved TTA for this subgroup: PDSA Cycle 2 TTA was 7.7 days and PDSA Cycle 3 TTA was 5.9 days. Discussion: Improved awareness and adoption of interventions can improve TTA. Challenges include patient preference and hospitalization, which are not amenable to change. Future steps involve refining data collection templates, addressing specific barriers such as Oncotype testing delays, and re-evaluating the appropriateness of the 7-day TTA metric for hormone positive, Her2 negative breast cancer or chemoprevention patients. Conclusions: TTA for thoracic and some subtypes of breast oncology patients improved. Oncotype or genomic testing for hormone positive breast patients is a vital part of the medical oncology visit where most patients prefer to wait for results and delay TTA.

In situ simulation has emerged as a powerful tool for identifying latent safety threats (LSTs). After the first wave of the SARS-CoV-2 pandemic, an urban community emergency department (ED) identified opportunities for improvement surrounding acute airway management and particularly focused on infection control precautions, equipment availability, and interprofessional communication during acute resuscitation. Using the Model for Improvement, a hybrid in situ/quality improvement initiative was implemented using Plan-Do-Study-Act (PDSA) cycles to enhance systems for intubating patients with SARS-CoV-2. Three PDSA cycles consisting of 10 simulations each were conducted from June 2020 through February 2021. Latent safety threats (LST) were identified through an in situ simulation scenario involving a patient with SARS-CoV-2 in acute respiratory failure. LSTs were collected through structured debriefs focused on (1) infection control, (2) equipment availability, and (3) communication. The SAFER-Matrix was used to score LSTs according to frequency and likelihood of harm by members of the ED QI team (SAFER score). The research team worked with the same QI leaders to implement action plans based on scored threats using cause-and-effect and driver diagrams. The Donabedian model was used to conceptually evaluate the quality of interventions upon conclusion of the third PDSA cycle. The median SAFER score decreased from 10.94 in PDSA cycle 1 to 6.77 in PDSA cycle 2 to 4.71 in PDSA cycle 3. Across all identified LSTs, the SAFER score decreased by 3.114 for every additional PDSA cycle ( P = 0.0167). When evaluating for threats identified as being primarily structure based, there was a decrease in SAFER score of 1.28 per every additional PDSA cycle ( P = 0.001). There was a decrease in total count of LST of 0.20 per additional simulation run ( P = 0.02) after controlling for shift type, census, perceived workload, team size, and prior attendance in simulations across all PDSA cycles. This study presents a blueprint for the utilization of in situ simulation through multiple waves of the SARS-CoV-2 pandemic to identify LSTs and use the SAFER score as a surrogate marker to monitor the impact of interventions for a safer environment for both medical staff and patients.

BackgroundThe Plan-Do-Study-Act (PDSA) cycle is a commonly used improvement process in health care settings, although its documented use in pragmatic clinical research is rare. A recent pragmatic clinical research study, called the Strategies and Opportunities to STOP Colon Cancer in Priority Populations (STOP CRC), used this process to optimize the research implementation of an automated colon cancer screening outreach program in intervention clinics. We describe the process of using this PDSA approach, the selection of PDSA topics by clinic leaders, and project leaders’ reactions to using PDSA in pragmatic research.MethodsSTOP CRC is a cluster-randomized pragmatic study that aims to test the effectiveness of a direct-mail fecal immunochemical testing (FIT) program involving eight Federally Qualified Health Centers in Oregon and California. We and a practice improvement specialist trained in the PDSA process delivered structured presentations to leaders of these centers; the presentations addressed how to apply the PDSA process to improve implementation of a mailed outreach program offering colorectal cancer screening through FIT tests. Center leaders submitted PDSA plans and delivered reports via webinar at quarterly meetings of the project’s advisory board. Project staff conducted one-on-one, 45-min interviews with project leads from each health center to assess the reaction to and value of the PDSA process in supporting the implementation of STOP CRC.ResultsClinic-selected PDSA activities included refining the intervention staffing model, improving outreach materials, and changing workflow steps. Common benefits of using PDSA cycles in pragmatic research were that it provided a structure for staff to focus on improving the program and it allowed staff to test the change they wanted to see. A commonly reported challenge was measuring the success of the PDSA process with the available electronic medical record tools.ConclusionUnderstanding how the PDSA process can be applied to pragmatic trials and the reaction of clinic staff to their use may help clinics integrate evidence-based interventions into their everyday care processes.Trial registrationClinicaltrials.gov NCT01742065. Registered October 31, 2013.