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Ali S, Moors X, van Schuppen H, Mommers L, Weelink E, Meuwese CL, Kant M, van den Brule J, Kraemer CE, Vlaar APJ, Akin S, Lansink-Hartgring AO, Scholten E, Otterspoor L, de Metz J, Delnoij T, van Lieshout EMM, Houmes RJ, Hartog DD, Gommers D, Dos Reis Miranda D. A national multi centre pre-hospital ECPR stepped wedge study; design and rationale of the ON-SCENE study. Scand J Trauma Resusc Emerg Med 2024; 32:31. [PMID: 38632661 PMCID: PMC11022459 DOI: 10.1186/s13049-024-01198-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 03/16/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND The likelihood of return of spontaneous circulation with conventional advanced life support is known to have an exponential decline and therefore neurological outcome after 20 min in patients with a cardiac arrest is poor. Initiation of venoarterial ExtraCorporeal Membrane Oxygenation (ECMO) during resuscitation might improve outcomes if used in time and in a selected patient category. However, previous studies have failed to significantly reduce the time from cardiac arrest to ECMO flow to less than 60 min. We hypothesize that the initiation of Extracorporeal Cardiopulmonary Resuscitation (ECPR) by a Helicopter Emergency Medical Services System (HEMS) will reduce the low flow time and improve outcomes in refractory Out of Hospital Cardiac Arrest (OHCA) patients. METHODS The ON-SCENE study will use a non-randomised stepped wedge design to implement ECPR in patients with witnessed OHCA between the ages of 18-50 years old, with an initial presentation of shockable rhythm or pulseless electrical activity with a high suspicion of pulmonary embolism, lasting more than 20, but less than 45 min. Patients will be treated by the ambulance crew and HEMS with prehospital ECPR capabilities and will be compared with treatment by ambulance crew and HEMS without prehospital ECPR capabilities. The primary outcome measure will be survival at hospital discharge. The secondary outcome measure will be good neurological outcome defined as a cerebral performance categories scale score of 1 or 2 at 6 and 12 months. DISCUSSION The ON-SCENE study focuses on initiating ECPR at the scene of OHCA using HEMS. The current in-hospital ECPR for OHCA obstacles encompassing low survival rates in refractory arrests, extended low-flow durations during transportation, and the critical time sensitivity of initiating ECPR, which could potentially be addressed through the implementation of the HEMS system. When successful, implementing on-scene ECPR could significantly enhance survival rates and minimize neurological impairment. TRIAL REGISTRATION Clinicaltyrials.gov under NCT04620070, registration date 3 November 2020.
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Affiliation(s)
- Samir Ali
- Department of Intensive Care, Erasmus University Medical Centre, Dr. Molewaterplein 40, Rotterdam, 3015 GD, the Netherlands.
- Department of Anaesthesiology, Erasmus Medical Centre, Rotterdam, 3015 GD, the Netherlands.
- Ministry of Defence, Royal Netherlands Air Force, Breda, 4820 ZB, the Netherlands.
| | - Xavier Moors
- Department of Anaesthesiology, Erasmus Medical Centre, Rotterdam, 3015 GD, the Netherlands
- Helicopter Emergency Medical Services, Trauma Centre Zuid-West Nederland, Erasmus University Medical Centre, Rotterdam, 3045 AS, the Netherlands
| | - Hans van Schuppen
- Helicopter Emergency Medical Services, Netwerk Acute Zorg Noordwest, Amsterdam University Medical Centre, Amsterdam, 1081 HV, the Netherlands
| | - Lars Mommers
- Helicopter Emergency Medical Service, Radboud University Medical Centre, Nijmegen, 6525 GA, the Netherlands
- Department of Anaesthesiology, Maastricht University Medical Centre, Maastricht, 6229 HX, the Netherlands
| | - Ellen Weelink
- Helicopter Emergency Medical Service, University Medical Centre Groningen, Groningen, 9713 GZ, the Netherlands
| | - Christiaan L Meuwese
- Department of Intensive Care, Erasmus University Medical Centre, Dr. Molewaterplein 40, Rotterdam, 3015 GD, the Netherlands
| | - Merijn Kant
- Department of Intensive Care, Amphia Hospital, Breda, 4818 CK, the Netherlands
| | - Judith van den Brule
- Department of Intensive Care Medicine, Radboud University Medical Centre, Nijmegen, 6525 GA, the Netherlands
| | - Carlos Elzo Kraemer
- Department of Intensive Care Medicine, Leiden University Medical Centre, Leiden, 2333 ZA, the Netherlands
| | - Alexander P J Vlaar
- Department of Intensive Care Medicine, Amsterdam University Medical Centre, Amsterdam, 1105 AZ, the Netherlands
| | - Sakir Akin
- Department of Intensive Care, Haga Teaching Hospital, the Hague, 2545 AA, the Netherlands
| | | | - Erik Scholten
- Department of Intensive Care, St. Antonius Hospital, Nieuwegein, 3435 CM, the Netherlands
| | - Luuk Otterspoor
- Department of Intensive Care, Catharina Hospital, Eindhoven, 5623 EJ, the Netherlands
| | - Jesse de Metz
- Department of Intensive Care, OLVG, 1091 AC, Amsterdam, the Netherlands
| | - Thijs Delnoij
- Department of Intensive Care, Maastricht University Medical Centre, Maastricht, 6229 HX, the Netherlands
| | - Esther M M van Lieshout
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, 3015 GD, the Netherlands
| | - Robert-Jan Houmes
- Helicopter Emergency Medical Services, Trauma Centre Zuid-West Nederland, Erasmus University Medical Centre, Rotterdam, 3045 AS, the Netherlands
| | - Dennis den Hartog
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, 3015 GD, the Netherlands
| | - Diederik Gommers
- Department of Intensive Care, Erasmus University Medical Centre, Dr. Molewaterplein 40, Rotterdam, 3015 GD, the Netherlands
| | - Dinis Dos Reis Miranda
- Department of Intensive Care, Erasmus University Medical Centre, Dr. Molewaterplein 40, Rotterdam, 3015 GD, the Netherlands
- Helicopter Emergency Medical Services, Trauma Centre Zuid-West Nederland, Erasmus University Medical Centre, Rotterdam, 3045 AS, the Netherlands
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Curtin AG, Anderson V, Brockhus F, Cohen DR. Novel team-based approach to quality improvement effectively engages staff and reduces adverse events in healthcare settings. BMJ Open Qual 2021; 9:bmjoq-2019-000741. [PMID: 32241764 PMCID: PMC7170544 DOI: 10.1136/bmjoq-2019-000741] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 03/17/2020] [Accepted: 03/20/2020] [Indexed: 11/09/2022] Open
Abstract
Background Despite significant attention to safety and quality in healthcare over two decades, patient harm in hospitals remains a challenge. There is now growing emphasis on continuous quality improvement, with approaches that engage front-line staff. Our objective was to determine whether a novel approach to reviewing routine clinical practice through structured conversations—map-enabled experiential review—could improve engagement of front-line staff in quality improvement activities and drive improvements in indicators of patient harm. Methods Once a week over a 10-month period, front-line staff were engaged in 35 min team-based conversations about routine practices relating to five national safety standards. Structure for the conversations was provided by interactive graphical logic maps representing each standard. Staff awareness of—and attitudes to—quality improvement, as well as their perceptions of the intervention and its impact, were canvassed through surveys. The impact of the intervention on measures of patient safety was determined through analysis of selected incident data reported in the hospital’s risk management system. Results The map-enabled experiential review approach was well received by staff, who reported increased awareness and understanding of national standards and related hospital policies and protocols, as well as increased interest in quality issues and improvement. The data also indicate an improvement in quality and safety in the two participating units, with a 34% statistically significant decrease in the recorded incident rates of the participating units relative to the rest of the hospital for a set of independently recorded incidents relating to patient identification. Discussion This exploratory study provided promising initial results on the feasibility and effectiveness of map-enabled experiential review as a quality improvement approach in an acute clinical setting.
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Affiliation(s)
| | - Vitas Anderson
- School of Psychology, University of Wollongong, Wollongong, New South Wales, Australia
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Dekker-van Doorn C, Wauben L, van Wijngaarden J, Lange J, Huijsman R. Adaptive design: adaptation and adoption of patient safety practices in daily routines, a multi-site study. BMC Health Serv Res 2020; 20:426. [PMID: 32410618 PMCID: PMC7227082 DOI: 10.1186/s12913-020-05306-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 05/07/2020] [Indexed: 11/17/2022] Open
Abstract
Background Most interventions to improve patient safety (Patient Safety Practices (PSPs)), are introduced without engaging front-line professionals. Administrative staff, managers and sometimes a few professionals, representing only one or two disciplines, decide what to change and how. Consequently, PSPs are not fully adapted to the professionals’ needs or to the local context and as a result, adoption is low. To support adoption, two theoretical concepts, Participatory Design and Experiential Learning were combined in a new model: Adaptive Design. The aim was to explore whether Adaptive Design supports adaptation and adoption of PSPs by engaging all professionals and creating time to (re) design, reflect and learn as a team. The Time Out Procedure (TOP) and Debriefing (plus) for improving patient safety in the operating theatre (OT) was used as PSP. Methods Qualitative exploratory multi-site study using participatory action research as a research design. The implementation process consisted of four phases: 1) start-up: providing information by presentations and team meetings, 2) pilot: testing the prototype with 100 surgical procedures, 3) small scale implementation: with one or two surgical disciplines, 4) implementation hospital-wide: including all surgical disciplines. In iterations, teams (re) designed, tested, evaluated, and if necessary adapted TOPplus. Gradually all professionals were included. Adaptations in content, process and layout of TOPplus were measured following each iteration. Adoption was monitored until final implementation in every hospital’s OT. Results 10 Dutch hospitals participated. Adaptations varied per hospital, but all hospitals adapted both procedures. Adaptations concerned the content, process and layout of TOPplus. Both procedures were adopted in all OTs, but user participation and time to include all users varied between hospitals. Ultimately all users were actively involved and TOPplus was implemented in all OTs. Conclusions Engaging all professionals in a structured bottom-up implementation approach with a focus on learning, improves adaptation and adoption of a PSP. As a result, all 10 participating hospitals implemented TOPplus with all surgical disciplines in all OTs. Adaptive Design gives professionals the opportunity to adapt the PSP to their own needs and their specific local context. All hospitals adapted TOPplus, but without compromising the essential features for its effectiveness.
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Affiliation(s)
- Connie Dekker-van Doorn
- Rotterdam University of Applied Sciences, Research Centre Innovations in Care, Rochussenstraat 198, 3015, EK, Rotterdam, The Netherlands. .,Erasmus University Medical Center, Department of Surgery, P.O. Box 2040, 3000, CA, Rotterdam, The Netherlands.
| | - Linda Wauben
- Rotterdam University of Applied Sciences, Research Centre Innovations in Care, Rochussenstraat 198, 3015, EK, Rotterdam, The Netherlands.,Delft University of Technology, Department of BioMechanical Engineering, Faculty of Mechanical Engineering, Mekelweg 2, 2628, CD, Delft, The Netherlands
| | - Jeroen van Wijngaarden
- Erasmus University Rotterdam, Erasmus School of Health Policy & Management, P.O. Box 738, 3000, DR, Rotterdam, The Netherlands
| | - Johan Lange
- Erasmus University Medical Center, Department of Surgery, P.O. Box 2040, 3000, CA, Rotterdam, The Netherlands
| | - Robbert Huijsman
- Erasmus University Rotterdam, Erasmus School of Health Policy & Management, P.O. Box 738, 3000, DR, Rotterdam, The Netherlands
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Pannick S, Athanasiou T, Long SJ, Beveridge I, Sevdalis N. Translating staff experience into organisational improvement: the HEADS-UP stepped wedge, cluster controlled, non-randomised trial. BMJ Open 2017; 7:e014333. [PMID: 28720612 PMCID: PMC5541585 DOI: 10.1136/bmjopen-2016-014333] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Frontline insights into care delivery correlate with patients' clinical outcomes. These outcomes might be improved through near-real time identification and mitigation of staff concerns. We evaluated the effects of a prospective frontline surveillance system on patient and team outcomes. DESIGN Prospective, stepped wedge, non-randomised, cluster controlled trial; prespecified per protocol analysis for high-fidelity intervention delivery. PARTICIPANTS Seven interdisciplinary medical ward teams from two hospitals in the UK. INTERVENTION Prospective clinical team surveillance (PCTS): structured daily interdisciplinary briefings to capture staff concerns, with organisational facilitation and feedback. MAIN MEASURES The primary outcome was excess length of stay (eLOS): an admission more than 24 hours above the local average for comparable patients. Secondary outcomes included safety and teamwork climates, and incident reporting. Mixed-effects models adjusted for time effects, age, comorbidity, palliation status and ward admissions. Safety and teamwork climates were measured with the Safety Attitudes Questionnaire. High-fidelity PCTS delivery comprised high engagement and high briefing frequency. RESULTS Implementation fidelity was variable, both in briefing frequency (median 80% working days/month, IQR 65%-90%) and engagement (median 70 issues/ward/month, IQR 34-113). 1714/6518 (26.3%) intervention admissions had eLOS versus 1279/4927 (26.0%) control admissions, an absolute risk increase of 0.3%. PCTS increased eLOS in the adjusted intention-to-treat model (OR 1.32, 95% CI 1.10 to 1.58, p=0.003). Conversely, high-fidelity PCTS reduced eLOS (OR 0.79, 95% CI 0.67 to 0.94, p=0.006). High-fidelity PCTS also increased total, high-yield and non-nurse incident reports (incidence rate ratios 1.28-1.79, all p<0.002). Sustained PCTS significantly improved safety and teamwork climates over time. CONCLUSIONS This study highlighted the potential benefits and pitfalls of ward-level interdisciplinary interventions. While these interventions can improve care delivery in complex, fluid environments, the manner of their implementation is paramount. Suboptimal implementation may have an unexpectedly negative impact on performance. TRIAL REGISTRATION NUMBER ISRCTN 34806867 (http://www.isrctn.com/ISRCTN34806867).
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Affiliation(s)
- Samuel Pannick
- NIHR Imperial Patient Safety Translational Research Centre, Imperial College London, London, UK
| | - Thanos Athanasiou
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Susannah J Long
- NIHR Imperial Patient Safety Translational Research Centre, Imperial College London, London, UK
- Imperial College Healthcare NHS Trust, London, UK
| | - Iain Beveridge
- West Middlesex University Hospital NHS Trust, Isleworth, UK
| | - Nick Sevdalis
- Centre for Implementation Science, Kings College London, London, UK
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Pannick S, Archer S, Johnston MJ, Beveridge I, Long SJ, Athanasiou T, Sevdalis N. Translating concerns into action: a detailed qualitative evaluation of an interdisciplinary intervention on medical wards. BMJ Open 2017; 7:e014401. [PMID: 28385912 PMCID: PMC5719651 DOI: 10.1136/bmjopen-2016-014401] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To understand how frontline reports of day-to-day care failings might be better translated into improvement. DESIGN Qualitative evaluation of an interdisciplinary team intervention capitalising on the frontline experience of care delivery. Prospective clinical team surveillance (PCTS) involved structured interdisciplinary briefings to capture challenges in care delivery, facilitated organisational escalation of the issues they identified, and feedback. Eighteen months of ethnography and two focus groups were conducted with staff taking part in a trial of PCTS. RESULTS PCTS fostered psychological safety-a confidence that the team would not embarrass or punish those who speak up. This was complemented by a hard edge of accountability, whereby team members would regulate their own behaviour in anticipation of future briefings. Frontline concerns were triaged to managers, or resolved autonomously by ward teams, reversing what had been well-established normalisations of deviance. Junior clinicians found a degree of catharsis in airing their concerns, and their teams became more proactive in addressing improvement opportunities. PCTS generated tangible organisational changes, and enabled managers to make a convincing case for investment. However, briefings were constrained by the need to preserve professional credibility, and staff found some comfort in avoiding accountability . At higher organisational levels, frontline concerns were subject to competition with other priorities, and their resolution was limited by the scale of the challenges they described. CONCLUSIONS Prospective safety strategies relying on staff-volunteered data produce acceptable, negotiated accounts, subject to the many interdisciplinary tensions that characterise ward work. Nonetheless, these strategies give managers access to the realities of frontline cares, and support frontline staff to make incremental changes in their daily work. These are goals for learning healthcare organisations. TRIAL REGISTRATION ISRCTN 34806867.
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Affiliation(s)
- Samuel Pannick
- NIHR Imperial Patient Safety Translational Research Centre, Imperial College, London, UK
| | - Stephanie Archer
- NIHR Imperial Patient Safety Translational Research Centre, Imperial College, London, UK
| | - Maximillian J Johnston
- NIHR Imperial Patient Safety Translational Research Centre, Imperial College, London, UK
| | - Iain Beveridge
- Department of Medicine, West Middlesex University Hospital NHS Trust, London, UK
| | - Susannah Jane Long
- NIHR Imperial Patient Safety Translational Research Centre, Imperial College, London, UK
- Imperial College Healthcare NHS Trust, London, UK
| | | | - Nick Sevdalis
- Centre for Implementation Science, King's College, London, UK
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Pannick S, Sevdalis N, Athanasiou T. Beyond clinical engagement: a pragmatic model for quality improvement interventions, aligning clinical and managerial priorities. BMJ Qual Saf 2015; 25:716-25. [PMID: 26647411 PMCID: PMC5013121 DOI: 10.1136/bmjqs-2015-004453] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 10/13/2015] [Indexed: 12/04/2022]
Abstract
Despite taking advantage of established learning from other industries, quality improvement initiatives in healthcare may struggle to outperform secular trends. The reasons for this are rarely explored in detail, and are often attributed merely to difficulties in engaging clinicians in quality improvement work. In a narrative review of the literature, we argue that this focus on clinicians, at the relative expense of managerial staff, has proven counterproductive. Clinical engagement is not a universal challenge; moreover, there is evidence that managers—particularly middle managers—also have a role to play in quality improvement. Yet managerial participation in quality improvement interventions is often assumed, rather than proven. We identify specific factors that influence the coordination of front-line staff and managers in quality improvement, and integrate these factors into a novel model: the model of alignment. We use this model to explore the implementation of an interdisciplinary intervention in a recent trial, describing different participation incentives and barriers for different staff groups. The extent to which clinical and managerial interests align may be an important determinant of the ultimate success of quality improvement interventions.
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Affiliation(s)
- Samuel Pannick
- NIHR Imperial Patient Safety Translational Research Centre, Imperial College London, London, UK
| | - Nick Sevdalis
- Centre for Implementation Science, King's College London, London, UK
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