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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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Rogers L, Hughes Spence S, Aivalli P, De Brún A, McAuliffe E. A systematic review critically appraising quantitative survey measures assessing power dynamics among multidisciplinary teams in acute care settings. J Interprof Care 2024; 38:156-171. [PMID: 36708308 DOI: 10.1080/13561820.2023.2168632] [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: 07/22/2022] [Accepted: 01/07/2023] [Indexed: 01/29/2023]
Abstract
By valuing the knowledge of each discipline holistic patient-centered care can be achieved as decisions arise from expertise rather than established hierarchies. While healthcare has historically operated as a hierarchical power structure (i.e., some voices have more influence), these dynamics are rarely discussed. This review addresses this issue by appraising extant quantitative measures that assess multidisciplinary team (MDT) power dynamics. By identifying psychometrically sound measures, change agents can uncover the collective thought processes informing power structures in practice and develop strategies to mitigate power disparities. Several databases were searched. English language articles were included if they reported on quantitative measures assessing power dynamics among MDTs in acute/hospital settings. Results were synthesized using a narrative approach. In total, 6,202 search records were obtained of which 62 met the eligibility criteria. The review reveals some promising measures to assess power dynamics (e.g., Interprofessional Collaboration Scale). However, the findings also confirm several gaps in the current evidence base: 1) need for further psychometric and pragmatic testing of measures; 2) inclusion of more representative MDT samples; 3) further evaluation of unmatured power dimensions. Addressing these gaps will support the development of future interventions aimed at mitigating power imbalances and ultimately improve collaborative working within MDTs.
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Affiliation(s)
- Lisa Rogers
- University College Dublin Centre for Interdisciplinary Research, Education, and Innovation (UCD IRIS), UCD School of Nursing, Midwifery and Health Systems, Dublin 4, Ireland
| | - Shannon Hughes Spence
- University College Dublin Centre for Interdisciplinary Research, Education, and Innovation (UCD IRIS), UCD School of Nursing, Midwifery and Health Systems, Dublin 4, Ireland
| | - Praveenkumar Aivalli
- University College Dublin Centre for Interdisciplinary Research, Education, and Innovation (UCD IRIS), UCD School of Nursing, Midwifery and Health Systems, Dublin 4, Ireland
| | - Aoife De Brún
- University College Dublin Centre for Interdisciplinary Research, Education, and Innovation (UCD IRIS), UCD School of Nursing, Midwifery and Health Systems, Dublin 4, Ireland
| | - Eilish McAuliffe
- University College Dublin Centre for Interdisciplinary Research, Education, and Innovation (UCD IRIS), UCD School of Nursing, Midwifery and Health Systems, Dublin 4, Ireland
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McGilton KS, Krassikova A, Wills A, Bethell J, Boscart V, Escrig-Pinol A, Iaboni A, Vellani S, Maxwell C, Keatings M, Stewart SC, Sidani S. Nurse practitioner led implementation of huddles for staff in long term care homes during the COVID-19 pandemic. BMC Geriatr 2023; 23:713. [PMID: 37919676 PMCID: PMC10623826 DOI: 10.1186/s12877-023-04382-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 10/05/2023] [Indexed: 11/04/2023] Open
Abstract
BACKGROUND Staff working in long-term care (LTC) homes during COVID-19 frequently reported a lack of communication, collaboration, and teamwork, all of which are associated with staff dissatisfaction, health concerns, lack of support and moral distress. Our study introduced regular huddles to support LTC staff during COVID-19, led by a Nurse Practitioner (NP). The objectives were to evaluate the process of huddle implementation and to examine differences in outcomes between categories of staff (direct care staff, allied care and support staff, and management) who attended huddles and those who did not. METHODS All staff and management at one LTC home (< 150 beds) in Ontario, Canada were included in this pre-experimental design study. The process evaluation used a huddle observation tool and focused on the dose (duration, frequency) and fidelity (NP's adherence to the huddle guide) of implementation. The staff attending and non-attending huddles were compared on outcomes measured at post-test: job satisfaction, physical and mental health, perception of support received, and levels of moral distress. The outcomes were assessed with validated measures and compared between categories of staff using Bayesian models. RESULTS A total of 42 staff enrolled in the study (20 attending and 22 non-attending huddles). Forty-eight huddles were implemented by the NP over 15 weeks and lasted 15 min on average. Huddles were most commonly attended by direct care staff, followed by allied care/support, and management staff. All huddles adhered to the huddle guide as designed by the research team. Topics most often addressed during the huddles were related to resident care (46%) and staff well-being (34%). Differences were found between staff attending and non-attending huddles: direct care staff attending huddles reported lower levels of overall moral distress, and allied care and support staff attending huddles perceived higher levels of support from the NP. CONCLUSIONS NP-led huddles in LTC homes may positively influence staff outcomes. The process evaluation provided some understanding of why the huddles may have been beneficial: the NP addressed resident care issues which were important to staff, encouraged a collaborative approach to solving issues on the unit, and discussed their well-being. TRIAL REGISTRATION NUMBER NCT05387213, registered on 24/05/2022.
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Affiliation(s)
- Katherine S McGilton
- KITE Research Institute, Toronto Rehabilitation Institute, University Health Network, Toronto, Canada.
- Lawrence S Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada.
| | - Alexandra Krassikova
- KITE Research Institute, Toronto Rehabilitation Institute, University Health Network, Toronto, Canada
| | - Aria Wills
- KITE Research Institute, Toronto Rehabilitation Institute, University Health Network, Toronto, Canada
| | - Jennifer Bethell
- KITE Research Institute, Toronto Rehabilitation Institute, University Health Network, Toronto, Canada
| | - Veronique Boscart
- School of Health and Life Sciences, Conestoga College, Kitchener, Canada
| | - Astrid Escrig-Pinol
- Mar School of Nursing, Universitat Pompeu Fabra, Barcelona, Spain
- Social Determinants and Health Education Research Group, Hospital del Mar Medical Research Institute, Barcelona, Spain
| | - Andrea Iaboni
- KITE Research Institute, Toronto Rehabilitation Institute, University Health Network, Toronto, Canada
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Shirin Vellani
- KITE Research Institute, Toronto Rehabilitation Institute, University Health Network, Toronto, Canada
| | - Colleen Maxwell
- Schools of Pharmacy and Public Health Sciences, University of Waterloo, Waterloo, Ontario, Canada
| | - Margaret Keatings
- KITE Research Institute, Toronto Rehabilitation Institute, University Health Network, Toronto, Canada
| | - Steven C Stewart
- KITE Research Institute, Toronto Rehabilitation Institute, University Health Network, Toronto, Canada
| | - Souraya Sidani
- Faculty of Nursing, Toronto Metropolitan University, Toronto, Canada
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Choi JJ, Rosen MA, Shapiro MF, Safford MM. Towards diagnostic excellence on academic ward teams: building a conceptual model of team dynamics in the diagnostic process. Diagnosis (Berl) 2023; 10:363-374. [PMID: 37561698 DOI: 10.1515/dx-2023-0065] [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: 06/08/2023] [Accepted: 07/31/2023] [Indexed: 08/12/2023]
Abstract
OBJECTIVES Achieving diagnostic excellence on medical wards requires teamwork and effective team dynamics. However, the study of ward team dynamics in teaching hospitals is relatively underdeveloped. We aim to enhance understanding of how ward team members interact in the diagnostic process and of the underlying behavioral, psychological, and cognitive mechanisms driving team interactions. METHODS We used mixed-methods to develop and refine a conceptual model of how ward team dynamics in an academic medical center influence the diagnostic process. First, we systematically searched existing literature for conceptual models and empirical studies of team dynamics. Then, we conducted field observations with thematic analysis to refine our model. RESULTS We present a conceptual model of how medical ward team dynamics influence the diagnostic process, which serves as a roadmap for future research and interventions in this area. We identified three underexplored areas of team dynamics that are relevant to diagnostic excellence and that merit future investigation (1): ward team structures (e.g., team roles, responsibilities) (2); contextual factors (e.g., time constraints, location of team members, culture, diversity); and (3) emergent states (shared mental models, psychological safety, team trust, and team emotions). CONCLUSIONS Optimizing the diagnostic process to achieve diagnostic excellence is likely to depend on addressing all of the potential barriers and facilitators to ward team dynamics presented in our model.
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Affiliation(s)
- Justin J Choi
- Department of Medicine, Division of General Internal Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Michael A Rosen
- Department of Anesthesiology and Critical Care Medicine, Armstrong Institute for Patient Safety and Quality, Institute for Clinical and Translational Research, and JHSOM Simulation Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Martin F Shapiro
- Department of Medicine, Division of General Internal Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Monika M Safford
- Department of Medicine, Division of General Internal Medicine, Weill Cornell Medicine, New York, NY, USA
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Britton H. Increasing staff time for patient facing care on an inpatient geriatric unit through modification of multidisciplinary board rounds: a quality improvement project. BMJ Open Qual 2023; 12:e002405. [PMID: 37793675 PMCID: PMC10551953 DOI: 10.1136/bmjoq-2023-002405] [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: 05/05/2023] [Accepted: 09/16/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND NHS staff recruitment and retention have failed to keep pace with service demands and workforce burn-out is of significant concern. This quality improvement project (QIP) aimed to increase staff time for patient facing care through reducing duplication of hospital board rounds within a 36-bedded NHS inpatient geriatric ward. INTERVENTION Thirty-minute board rounds were reduced from twice daily (Monday-Friday) at 08:30 hours and midday to once daily at midday with the aim of freeing up staff time for patient care. A multidisciplinary team (MDT) safety briefing at 08:30 hours lasting 5-10 min was implemented to enable review of shift pressures and identification of patients who are unwell, newly admitted or due for discharge. Safety briefing format was amended to further support staff prioritisation. METHODS This QIP was underpinned by the model for improvement, using Plan-Do-Study-Act cycles. Data were collected through a staff questionnaire alongside calculation of staff time spent at board rounds and safety huddles. Staff verbal feedback and questionnaire results were also used to improve and modify process'. Patient discharge data were collated via trust metrics as a balancing measure. RESULTS Through board round modification, 25 hours of MDT time was saved each week, with all responding staff reporting increased time for patient facing care following QIP implementation. >85% of questionnaire respondents agreed that board round changes resulted in improvement. Balancing measures collected as part of the project also revealed an increase in weekly ward discharges from an average of 15.75-17.5 confirming no negative impact on patient flow following board round amendments. CONCLUSION While significant staffing shortages continue, local innovations focused on staff time may have the potential to support effective use of limited resources.
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Affiliation(s)
- Hannah Britton
- Care of the elderly medicine, North Bristol NHS Trust, Westbury on Trym, UK
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6
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Lin SP, Chang CW, Wu CY, Chin CS, Lin CH, Shiu SI, Chen YW, Yen TH, Chen HC, Lai YH, Hou SC, Wu MJ, Chen HH. The Effectiveness of Multidisciplinary Team Huddles in Healthcare Hospital-Based Setting. J Multidiscip Healthc 2022; 15:2241-2247. [PMID: 36225857 PMCID: PMC9549805 DOI: 10.2147/jmdh.s384554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 09/23/2022] [Indexed: 11/23/2022] Open
Abstract
Objective Huddles are short, regular debriefings that are designed to provide frontline staff and bedside caregivers environments to share problems and identify solutions. Daily huddle implementation could improve medical safety work, problem identification and improvement, situation awareness and teamwork enhancement, the collaboration and communication between professionals and departments, and patient safety. This study aimed evaluated the effectiveness of a hospital-based huddle at a general medical ward in Taiwan. Methods A Continuous Integration team was conducted by combining multidisciplinary frontline staff to huddle at a 74-bed general medical ward. Team Huddles started twice a week. A physical huddle run board was created, which contained four parts, including idea submitted, idea approved, working on an idea and standardizing. Problems were submitted to the board to be identified, and the solutions were evaluated through huddle discussion. We divided the problems into two groups: quick hits (resolved within 24-48hrs) and complex issues (resolved >48hrs). An anonymous questionnaire was designed to evaluate the huddle response. Results A total of 44 huddles occurred from September 9th, 2020, to September 30th, 2021, and 81 issues were identified and resolved. The majority issues were policy documentation (n=23; 28.4%). Sixty-seven (82.7%) issues were defined as quick hits, and the other fourteen (17.3%) issues were complex. The mean hours to the resolution of quick hits was 5.17 hours, median 3.5 hours, and range from 0.01-15.4 hours. The mean days to resolve completion issues were 19.73 days, median 7.5 days, and range 3.57-26.14 days. An overwhelming 92.9% of staff responded that huddles help to expedite the process to reach treatment goals, reduce clinical mistakes, near misses, reduce patient incidences, and help teamwork enhancement, with rating of 4.52 (on a 5-point Likert scale). Conclusion Implementing of multidisciplinary team huddle improved the accountability of issue identification, problem-solving and teamwork enhancement.
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Affiliation(s)
- Shih Ping Lin
- Division of General Medicine, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan,Division of Infection, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan,Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Ching-Wein Chang
- Department of Nursing, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chun-Yi Wu
- Division of General Medicine, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan,Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chun-Shih Chin
- Division of General Medicine, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan,Division of Chest Medicine, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Cheng-Hsien Lin
- Division of General Medicine, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan,Division of Hematology and Oncology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Sz-Iuan Shiu
- Division of General Medicine, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan,Gastroenterology and Hepatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Yun-Wen Chen
- Division of General Medicine, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan,Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Tsai-Hung Yen
- Division of General Medicine, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan,Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Hui-Chi Chen
- Department of Nursing, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Yi-Hung Lai
- Department of Nursing, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Shu-Chin Hou
- Department of Nursing, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Ming-Ju Wu
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan,Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Hsin-Hua Chen
- Division of General Medicine, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan,Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan,Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan,Institute of Biomedical Science and Rong Hsing Research Centre for Translational Medicine, Big Data Center, Chung Hsing University, Taichung, Taiwan,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan,Correspondence: Hsin-Hua Chen, Division of General Medicine, Department of Internal Medicine, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sect. 4, Taichung, 40705, Taiwan, Email
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Nally DM, Lonergan PE, O’Connell EP, McNamara DA, Elwahab SA, Bass G, Burke E, Cagney D, Canas A, Cronin C, Cullinane C, Devane L, Fearon N, Fowler A, Fullard A, Hechtl D, Kelly M, Lenihan J, Murphy E, Neary C, O'Connell R, O'Neill M, Ramkaran C, Troy A, Tully R, White C, Yadav H. Increasing the use of perioperative risk scoring in emergency laparotomy: nationwide quality improvement programme. BJS Open 2022; 6:6649489. [PMID: 35876188 PMCID: PMC9309802 DOI: 10.1093/bjsopen/zrac092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 06/07/2022] [Accepted: 06/15/2022] [Indexed: 11/29/2022] Open
Abstract
Background Emergency laparotomy is associated with high morbidity and mortality. The early identification of high-risk patients allows for timely perioperative care and appropriate resource allocation. The aim of this study was to develop a nationwide surgical trainee-led quality improvement (QI) programme to increase the use of perioperative risk scoring in emergency laparotomy. Methods The programme was structured using the active implementation framework in 15 state-funded Irish hospitals to guide the staged implementation of perioperative risk scoring. The primary outcome was a recorded preoperative risk score for patients undergoing an emergency laparotomy at each site. Results The rate of patients undergoing emergency laparotomy receiving a perioperative risk score increased from 0–11 per cent during the exploratory phase to 35–100 per cent during the full implementation phase. Crucial factors for implementing changes included an experienced central team providing implementation support, collaborator engagement, and effective communication and social relationships. Conclusions A trainee-led QI programme increased the use of perioperative risk assessment in patients undergoing emergency laparotomy, with the potential to improve patient outcomes and care delivery.
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Affiliation(s)
- Deirdre M Nally
- Department of Surgical Affairs, Royal College of Surgeons in Ireland , Dublin , Ireland
- Department of Surgery, Mater Misericordiae University Hospital , Dublin , Ireland
| | - Peter E Lonergan
- National Clinical Programme in Surgery, Royal College of Surgeons in Ireland , Dublin , Ireland
- Department of Urology, St. James’s Hospital , Dublin , Ireland
- Department of Surgery, Trinity College , Dublin , Ireland
| | | | - Deborah A McNamara
- National Clinical Programme in Surgery, Royal College of Surgeons in Ireland , Dublin , Ireland
- Department of Surgery, Beaumont Hospital , Dublin , Ireland
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Rowan BL, Anjara S, De Brún A, MacDonald S, Kearns EC, Marnane M, McAuliffe E. The impact of huddles on a multidisciplinary healthcare teams' work engagement, teamwork and job satisfaction: A systematic review. J Eval Clin Pract 2022; 28:382-393. [PMID: 35174941 DOI: 10.1111/jep.13648] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 12/09/2021] [Accepted: 12/14/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Job satisfaction and retention of healthcare staff remains an ongoing issue in many health systems. Huddles have been endorsed as a mechanism to improve patient safety by improving teamwork, collaboration, and communication in teams. AIM This study aims to synthesises the literature to investigate the impact of huddles on job satisfaction, teamwork, and work engagement in multidisciplinary healthcare teams. METHODS Five academic databases were searched to conduct a systematic review of peer-reviewed literature published from January 2000 to January 2020. Articles were included if they (1) featured a daily huddle, were conducted in a healthcare setting, and involved a multidisciplinary team and (2) measured variables including job satisfaction, work engagement, or teamwork. Results were reported in accordance with the systematic synthesis without meta-analysis and preferred reporting items for systematic reviews and meta-analysis guidelines. We identified 445 articles of which 12 met the eligibility criteria and are included in this review. RESULTS All 12 included studies found a predominantly positive impact on teamwork and job satisfaction. None of the studies discussed or reported evidence of the impact of huddles on work engagement. This review highlights the value of a daily multidisciplinary healthcare team huddle in improving job satisfaction and teamwork for the healthcare staff involved. However, there is a dearth of high-quality, peer-reviewed evidence regarding the direct impact of huddles on job satisfaction, teamwork and in particular on work engagement. Further research-particularly controlled studies on adoption, implementation and outcomes for healthcare team culture-is needed to further assess this intervention.
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Affiliation(s)
- Brendan L Rowan
- UCD Centre for Interdisciplinary Research, Education, and Innovation in Health Systems (UCD IRIS), School of Nursing, Midwifery & Health Systems, Health Sciences Centre, University College Dublin, Dublin, Ireland.,Department of Intensive Care Medicine, Department of Neurology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Sabrina Anjara
- UCD Centre for Interdisciplinary Research, Education, and Innovation in Health Systems (UCD IRIS), School of Nursing, Midwifery & Health Systems, Health Sciences Centre, University College Dublin, Dublin, Ireland
| | - Aoife De Brún
- UCD Centre for Interdisciplinary Research, Education, and Innovation in Health Systems (UCD IRIS), School of Nursing, Midwifery & Health Systems, Health Sciences Centre, University College Dublin, Dublin, Ireland
| | - Steve MacDonald
- School of Medicine, University of Limerick, Limerick, Ireland
| | - Emma C Kearns
- UCD Centre for Interdisciplinary Research, Education, and Innovation in Health Systems (UCD IRIS), School of Nursing, Midwifery & Health Systems, Health Sciences Centre, University College Dublin, Dublin, Ireland.,Department of Surgery, St. Vincent's University Hospital, Dublin, Ireland
| | - Michael Marnane
- Department of Intensive Care Medicine, Department of Neurology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Eilish McAuliffe
- UCD Centre for Interdisciplinary Research, Education, and Innovation in Health Systems (UCD IRIS), School of Nursing, Midwifery & Health Systems, Health Sciences Centre, University College Dublin, Dublin, Ireland
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Huddles and their effectiveness at the frontlines of clinical care: a scoping review. J Gen Intern Med 2021; 36:2772-2783. [PMID: 33559062 PMCID: PMC8390736 DOI: 10.1007/s11606-021-06632-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 01/17/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Brief, stand-up meetings known as huddles may improve clinical care, but knowledge about huddle implementation and effectiveness at the frontlines is fragmented and setting specific. This work provides a comprehensive overview of huddles used in diverse health care settings, examines the empirical support for huddle effectiveness, and identifies knowledge gaps and opportunities for future research. METHODS A scoping review was completed by searching the databases PubMed, EBSCOhost, ProQuest, and OvidSP for studies published in English from inception to May 31, 2019. Eligible studies described huddles that (1) took place in a clinical or medical setting providing health care patient services, (2) included frontline staff members, (3) were used to improve care quality, and (4) were studied empirically. Two reviewers independently screened abstracts and full texts; seven reviewers independently abstracted data from full texts. RESULTS Of 2,185 identified studies, 158 met inclusion criteria. The majority (67.7%) of studies described huddles used to improve team communication, collaboration, and/or coordination. Huddles positively impacted team process outcomes in 67.7% of studies, including improvements in efficiency, process-based functioning, and communication across clinical roles (64.4%); situational awareness and staff perceptions of safety and safety climate (44.6%); and staff satisfaction and engagement (29.7%). Almost half of studies (44.3%) reported huddles positively impacting clinical care outcomes such as patients receiving timely and/or evidence-based assessments and care (31.4%); decreased medical errors and adverse drug events (24.3%); and decreased rates of other negative outcomes (20.0%). DISCUSSION Huddles involving frontline staff are an increasingly prevalent practice across diverse health care settings. Huddles are generally interdisciplinary and aimed at improving team communication, collaboration, and/or coordination. Data from the scoping review point to the effectiveness of huddles at improving work and team process outcomes and indicate the positive impact of huddles can extend beyond processes to include improvements in clinical outcomes. STUDY REGISTRATION This scoping review was registered with the Open Science Framework on 18 January 2019 ( https://osf.io/bdj2x/ ).
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10
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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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11
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Hullick CJ, Hall AE, Conway JF, Hewitt JM, Darcy LF, Barker RT, Oldmeadow C, Attia JR. Reducing Hospital Transfers from Aged Care Facilities: A Large-Scale Stepped Wedge Evaluation. J Am Geriatr Soc 2020; 69:201-209. [PMID: 33124692 DOI: 10.1111/jgs.16890] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 09/18/2020] [Accepted: 09/28/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND/OBJECTIVES Older people living in residential aged care facilities (RACFs) experience acute deterioration requiring assessment and decision making. We evaluated the impact of a large-scale regional Aged Care Emergency (ACE) program in reducing hospital admissions and emergency department (ED) transfers. DESIGN A stepped wedge nonrandomized cluster trial with 11 steps, implemented from May 2013 to August 2016. SETTING A large regional and rural area of northern and western New South Wales, Australia. PARTICIPANTS Nine hospital EDs and 81 RACFs participated in the evaluation. INTERVENTION The ACE program is an integrated nurse-led intervention underpinned by a community of practice designed to improve the capability of RACFs managing acutely unwell residents. It includes telephone support, evidence-based algorithms, defining goals of care for ED transfer, case management in the ED, and an education program. MEASUREMENTS ED transfers and subsequent hospital admissions were collected from administrative data including 13 months baseline and 9 months follow-up. RESULTS A total of 18,837 eligible ED visits were analyzed. After accounting for clustering by RACFs and adjusting for time of the year as well as RACF characteristics, a statistically significant reduction in hospital admissions (adjusted incident rate ratio = .79; 95% confidence interval [CI] = .68-.92); P = .0025) was seen (i.e., residents were 21% less likely to be admitted to the hospital). This was also observed in ED visit rates (adjusted incidence rate ratio = .80; 95% CI = .69-.92; P = .0023) (i.e., residents were 20% less likely to be transferred to the ED). Seven-day ED re-presentation fell from 5.7% to 4.9%, and 30-day hospital readmissions fell from 12% to 10%. CONCLUSION The stepped wedge design allowed rigorous evaluation of a real-world large-scale intervention. These results confirm that the ACE program can be scaled up to a large geographic area and can reduce ED visits and hospitalization of older people with complex healthcare needs living in RACFs.
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Affiliation(s)
- Carolyn J Hullick
- Belmont District Hospital, Belmont, New South Wales, Australia.,Hunter New England Local Health District, New Lambton Heights, New South Wales, Australia.,School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, New South Wales, Australia.,Hunter Medical Research Institute, Kookaburra Circuit, New Lambton Heights, New South Wales, Australia
| | - Alix E Hall
- School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, New South Wales, Australia.,Hunter Medical Research Institute, Kookaburra Circuit, New Lambton Heights, New South Wales, Australia
| | - Jane F Conway
- School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, New South Wales, Australia.,Faculty of Medicine and Health, University of New England, Armidale, New South Wales, Australia
| | - Jacqueline M Hewitt
- Hunter New England Central Coast Primary Health Network, Newcastle, New South Wales, Australia
| | - Leigh F Darcy
- Hunter Primary Care, Warabrook, New South Wales, Australia
| | - Roslyn T Barker
- Hunter New England Local Health District, New Lambton Heights, New South Wales, Australia
| | - Christopher Oldmeadow
- Hunter Medical Research Institute, Kookaburra Circuit, New Lambton Heights, New South Wales, Australia
| | - John R Attia
- Belmont District Hospital, Belmont, New South Wales, Australia.,Hunter New England Local Health District, New Lambton Heights, New South Wales, Australia.,School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, New South Wales, Australia.,Hunter Medical Research Institute, Kookaburra Circuit, New Lambton Heights, New South Wales, Australia
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12
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Franklin BJ, Gandhi TK, Bates DW, Huancahuari N, Morris CA, Pearson M, Bass MB, Goralnick E. Impact of multidisciplinary team huddles on patient safety: a systematic review and proposed taxonomy. BMJ Qual Saf 2020; 29:1-2. [PMID: 32265256 DOI: 10.1136/bmjqs-2019-009911] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 02/16/2020] [Accepted: 03/04/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Despite significant advances, patient safety remains a critical public health concern. Daily huddles-discussions to identify and respond to safety risks-have been credited with enhancing safety culture in operationally complex industries including aviation and nuclear power. More recently, huddles have been endorsed as a mechanism to improve patient safety in healthcare. This review synthesises the literature related to the impact of hospital-based safety huddles. METHODS We conducted a systematic review of peer-reviewed literature related to scheduled, multidisciplinary, hospital-based safety huddles through December 2019. We screened for studies (1) in which huddles were the primary intervention being assessed and (2) that measured the huddle programme's apparent impact using at least one quantitative metric. RESULTS We identified 1034 articles; 24 met our criteria for review, of which 19 reflected unit-based huddles and 5 reflected hospital-wide or multiunit huddles. Of the 24 included articles, uncontrolled pre-post comparison was the prevailing study design; we identified only two controlled studies. Among the 12 unit-based studies that provided complete measures of statistical significance for reported outcomes, 11 reported statistically significant improvement among some or all outcomes. The objectives of huddle programmes and the language used to describe them varied widely across the studies we reviewed. CONCLUSION While anecdotal accounts of successful huddle programmes abound and the evidence we reviewed appears favourable overall, high-quality peer-reviewed evidence regarding the effectiveness of hospital-based safety huddles, particularly at the hospital-wide level, is in its earliest stages. Additional rigorous research-especially focused on huddle programme design and implementation fidelity-would enhance the collective understanding of how huddles impact patient safety and other targeted outcomes. We propose a taxonomy and standardised reporting measures for future huddle-related studies to enhance comparability and evidence quality.
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Affiliation(s)
- Brian J Franklin
- University of Michigan Medical School, Ann Arbor, Michigan, USA .,Harvard Business School, Boston, Massachusetts, USA
| | | | - David W Bates
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Nadia Huancahuari
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Charles A Morris
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | | | - Michelle Beth Bass
- Countway Library of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Eric Goralnick
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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13
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Buljac-Samardzic M, Doekhie KD, van Wijngaarden JDH. Interventions to improve team effectiveness within health care: a systematic review of the past decade. HUMAN RESOURCES FOR HEALTH 2020; 18:2. [PMID: 31915007 PMCID: PMC6950792 DOI: 10.1186/s12960-019-0411-3] [Citation(s) in RCA: 148] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 09/05/2019] [Indexed: 05/19/2023]
Abstract
BACKGROUND A high variety of team interventions aims to improve team performance outcomes. In 2008, we conducted a systematic review to provide an overview of the scientific studies focused on these interventions. However, over the past decade, the literature on team interventions has rapidly evolved. An updated overview is therefore required, and it will focus on all possible team interventions without restrictions to a type of intervention, setting, or research design. OBJECTIVES To review the literature from the past decade on interventions with the goal of improving team effectiveness within healthcare organizations and identify the "evidence base" levels of the research. METHODS Seven major databases were systematically searched for relevant articles published between 2008 and July 2018. Of the original search yield of 6025 studies, 297 studies met the inclusion criteria according to three independent authors and were subsequently included for analysis. The Grading of Recommendations, Assessment, Development, and Evaluation Scale was used to assess the level of empirical evidence. RESULTS Three types of interventions were distinguished: (1) Training, which is sub-divided into training that is based on predefined principles (i.e. CRM: crew resource management and TeamSTEPPS: Team Strategies and Tools to Enhance Performance and Patient Safety), on a specific method (i.e. simulation), or on general team training. (2) Tools covers tools that structure (i.e. SBAR: Situation, Background, Assessment, and Recommendation, (de)briefing checklists, and rounds), facilitate (through communication technology), or trigger (through monitoring and feedback) teamwork. (3) Organizational (re)design is about (re)designing structures to stimulate team processes and team functioning. (4) A programme is a combination of the previous types. The majority of studies evaluated a training focused on the (acute) hospital care setting. Most of the evaluated interventions focused on improving non-technical skills and provided evidence of improvements. CONCLUSION Over the last decade, the number of studies on team interventions has increased exponentially. At the same time, research tends to focus on certain interventions, settings, and/or outcomes. Principle-based training (i.e. CRM and TeamSTEPPS) and simulation-based training seem to provide the greatest opportunities for reaching the improvement goals in team functioning.
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Affiliation(s)
- Martina Buljac-Samardzic
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Bayle building, p.o. box 1738, 3000 DR Rotterdam, The Netherlands
| | - Kirti D. Doekhie
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Bayle building, p.o. box 1738, 3000 DR Rotterdam, The Netherlands
| | - Jeroen D. H. van Wijngaarden
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Bayle building, p.o. box 1738, 3000 DR Rotterdam, The Netherlands
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14
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Yang F, Walker S, Richardson G, Stephens T, Phull M, Thompson A, Pearse RM. Cost-effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery: Learning from 15,856 patients. Int J Surg 2019; 72:25-31. [PMID: 31604139 DOI: 10.1016/j.ijsu.2019.10.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 09/25/2019] [Accepted: 10/02/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients undergoing emergency abdominal surgery are exposed to a high risk of death. A quality improvement (QI) programme to improve the survival for these patients was evaluated in the Enhanced Peri-Operative Care for High-risk patients (EPOCH) trial. This study aims to assess its cost-effectiveness versus usual care from a UK health service perspective. METHODS Data collected in a subsample of trial participants were employed to estimate costs and quality-adjusted life years (QALYs) for the QI programme and usual care within the 180-day trial period, with results also extrapolated to estimate lifetime costs and QALYs. Cost-effectiveness was estimated using incremental cost-effectiveness ratios (ICERs). The probability of being cost-effective was determined for different cost-effectiveness thresholds (£13,000 to £30,000 per QALY). Analyses were performed for lower-risk and higher-risk subgroups based on the number of surgical indications (single vs multiple). RESULTS Within the trial period, QI was more costly (£467) but less effective (-0.002 QALYs). Over a lifetime, it was more costly (£1395) and more effective (0.018 QALYs), but did not appear to be cost-effective (ICER: £77,792 per QALY, higher than all cost-effectiveness thresholds; probability of being cost-effective: 28.7%-43.8% across the thresholds). For lower-risk patients, QI was more costly and less effective both within trial period and over a lifetime and it did not appear to be cost-effective. For higher-risk patients, it was more costly and more effective, and did not appear cost-effective within the trial period (ICER: £158,253 per QALY) but may be cost-effective over a lifetime (ICER: £14,293 per QALY). CONCLUSION The QI programme does not appear cost-effective at standard cost-effectiveness thresholds. For patients with multiple surgical indications, this programme is potentially cost-effective over a lifetime, but this is highly uncertain.
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Affiliation(s)
- Fan Yang
- Centre for Health Economics, University of York, UK.
| | - Simon Walker
- Centre for Health Economics, University of York, UK
| | | | - Tim Stephens
- Barts & The London School of Medicine and Dentistry, Queen Mary University of London, UK
| | - Mandeep Phull
- Barking, Havering and Redbridge University Hospitals, NHS Trust, UK
| | - Ann Thompson
- Pragmatic Clinical Trials Unit, Queen Mary University of London, UK
| | - Rupert M Pearse
- Barts & The London School of Medicine and Dentistry, Queen Mary University of London, UK
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15
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Peden CJ, Stephens T, Martin G, Kahan BC, Thomson A, Everingham K, Kocman D, Lourtie J, Drake S, Girling A, Lilford R, Rivett K, Wells D, Mahajan R, Holt P, Yang F, Walker S, Richardson G, Kerry S, Anderson I, Murray D, Cromwell D, Phull M, Grocott MPW, Bion J, Pearse RM. A national quality improvement programme to improve survival after emergency abdominal surgery: the EPOCH stepped-wedge cluster RCT. HEALTH SERVICES AND DELIVERY RESEARCH 2019. [DOI: 10.3310/hsdr07320] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
Emergency abdominal surgery is associated with poor patient outcomes. We studied the effectiveness of a national quality improvement (QI) programme to implement a care pathway to improve survival for these patients.
Objectives
The objectives were to assess whether or not the QI programme improves 90-day survival after emergency abdominal surgery; to assess effects on 180-day survival, hospital stay and hospital readmission; and to better understand these findings through an integrated process evaluation, ethnographic study and cost-effectiveness analysis.
Design
This was a stepped-wedge cluster randomised trial. Hospitals were organised into 15 geographical clusters, and commenced the QI programme in random order over 85 weeks. Analyses were performed on an intention-to-treat basis. The primary outcome was analysed using a mixed-effects parametric survival model, adjusting for time-related effects. Ethnographic and economics data were collected in six hospitals. The process evaluation included all hospitals.
Setting
The trial was set in acute surgical services of 93 NHS hospitals.
Participants
Patients aged ≥ 40 years who were undergoing emergency abdominal surgery were eligible.
Intervention
The intervention was a QI programme to implement an evidence-based care pathway.
Main outcome measures
The primary outcome measure was mortality within 90 days of surgery. Secondary outcomes were mortality within 180 days, length of hospital stay and hospital readmission within 180 days. The main economic measure was the quality-adjusted life-years.
Data sources
Data were obtained from the National Emergency Laparotomy Audit database; qualitative interviews and ethnographic observations; quality-of-life and NHS resource use data were collected via questionnaires.
Results
Of 15,873 eligible patients from 93 NHS hospitals, primary outcome data were analysed for 8482 participants in the usual care group and 7374 in the QI group. The primary outcome occurred in 1393 participants in the usual care group (16%), compared with 1210 patients in the QI group (16%) [QI vs. usual care hazard ratio (HR) 1.11, 95% confidence interval (CI) 0.96 to 1.28]. No differences were found in mortality at 180 days or hospital readmission; there was a small increase in hospital stay in the QI group (HR for discharge 0.90, 95% CI 0.83 to 0.97). There were only modest improvements in care processes following QI implementation. The ethnographic study revealed good QI engagement, but limited time and resources to implement change, affecting which processes teams addressed, the rate of change and eventual success. In some sites, there were challenges around prioritising the intervention in busy environments and in obtaining senior engagement. The intervention is unlikely to be cost-effective at standard cost-effectiveness thresholds, but may be cost-effective over the lifetime horizon.
Limitations
Substantial delays were encountered in securing data access to national registries. Fewer patients than expected underwent surgery and the mortality rate was lower than anticipated.
Conclusions
There was no survival benefit from a QI programme to implement a care pathway for patients undergoing emergency abdominal surgery. The modest impact of the intervention on process measures, despite good clinician engagement, may have been limited by the time and resources needed to improve patient care.
Future work
Future QI programmes must balance intervention complexity with the practical realities of NHS services to ensure that such programmes can be delivered with the resources available.
Trial registration
Current Controlled Trials ISRCTN80682973 and The Lancet protocol 13PRT/7655.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 7, No. 32. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Carol J Peden
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Tim Stephens
- William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Graham Martin
- Health Sciences, University of Leicester, Leicester, UK
| | - Brennan C Kahan
- Pragmatic Clinical Trials Unit, Queen Mary University of London, London, UK
| | - Ann Thomson
- Pragmatic Clinical Trials Unit, Queen Mary University of London, London, UK
| | - Kirsty Everingham
- William Harvey Research Institute, Queen Mary University of London, London, UK
| | - David Kocman
- Health Sciences, University of Leicester, Leicester, UK
| | | | | | - Alan Girling
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | | | | | - Ravi Mahajan
- Faculty of Medicine & Health Sciences, University of Nottingham, Nottingham, UK
| | - Peter Holt
- Molecular and Clinical Sciences Research Institute, St George’s University of London, London, UK
| | - Fan Yang
- Centre for Health Economics, University of York, York, UK
| | - Simon Walker
- Centre for Health Economics, University of York, York, UK
| | | | - Sally Kerry
- Pragmatic Clinical Trials Unit, Queen Mary University of London, London, UK
| | - Iain Anderson
- Salford Royal Hospital NHS Foundation Trust, Manchester, UK
| | - Dave Murray
- South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - David Cromwell
- London School of Hygiene and Tropical Medicine, London, UK
| | - Mandeep Phull
- William Harvey Research Institute, Queen Mary University of London, London, UK
- Department of Anaesthesia and Intensive Care, Queen’s Hospital, Romford, UK
| | - Mike PW Grocott
- National Institute for Health Research Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Anaesthesia and Critical Care Research Unit, University of Southampton, Southampton, UK
| | - Julian Bion
- Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Rupert M Pearse
- William Harvey Research Institute, Queen Mary University of London, London, UK
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16
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Peden CJ, Stephens T, Martin G, Kahan BC, Thomson A, Rivett K, Wells D, Richardson G, Kerry S, Bion J, Pearse RM. Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH): a stepped-wedge cluster-randomised trial. Lancet 2019; 393:2213-2221. [PMID: 31030986 DOI: 10.1016/s0140-6736(18)32521-2] [Citation(s) in RCA: 104] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 10/01/2018] [Accepted: 10/05/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Emergency abdominal surgery is associated with poor patient outcomes. We studied the effectiveness of a national quality improvement (QI) programme to implement a care pathway to improve survival for these patients. METHODS We did a stepped-wedge cluster-randomised trial of patients aged 40 years or older undergoing emergency open major abdominal surgery. Eligible UK National Health Service (NHS) hospitals (those that had an emergency general surgical service, a substantial volume of emergency abdominal surgery cases, and contributed data to the National Emergency Laparotomy Audit) were organised into 15 geographical clusters and commenced the QI programme in a random order, based on a computer-generated random sequence, over an 85-week period with one geographical cluster commencing the intervention every 5 weeks from the second to the 16th time period. Patients were masked to the study group, but it was not possible to mask hospital staff or investigators. The primary outcome measure was mortality within 90 days of surgery. Analyses were done on an intention-to-treat basis. This study is registered with the ISRCTN registry, number ISRCTN80682973. FINDINGS Treatment took place between March 3, 2014, and Oct 19, 2015. 22 754 patients were assessed for elegibility. Of 15 873 eligible patients from 93 NHS hospitals, primary outcome data were analysed for 8482 patients in the usual care group and 7374 in the QI group. Eight patients in the usual care group and nine patients in the QI group were not included in the analysis because of missing primary outcome data. The primary outcome of 90-day mortality occurred in 1210 (16%) patients in the QI group compared with 1393 (16%) patients in the usual care group (HR 1·11, 0·96-1·28). INTERPRETATION No survival benefit was observed from this QI programme to implement a care pathway for patients undergoing emergency abdominal surgery. Future QI programmes should ensure that teams have both the time and resources needed to improve patient care. FUNDING National Institute for Health Research Health Services and Delivery Research Programme.
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Affiliation(s)
- Carol J Peden
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Tim Stephens
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, London, UK
| | - Graham Martin
- Health Sciences, University of Leicester, Leicester, UK
| | - Brennan C Kahan
- Pragmatic Clinical Trials Unit, Barts and The London School of Medicine and Dentistry, London, UK
| | - Ann Thomson
- Pragmatic Clinical Trials Unit, Barts and The London School of Medicine and Dentistry, London, UK
| | | | | | | | - Sally Kerry
- Pragmatic Clinical Trials Unit, Barts and The London School of Medicine and Dentistry, London, UK
| | - Julian Bion
- Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Rupert M Pearse
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, London, UK.
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Feinberg J, Flynn L, Woodward M, Pennell C, Higham H, Morgan L, Holman L, Tully P, McCulloch P. Improving emergency surgical care for patients with right iliac fossa pain at a regional scale: A quality improvement study using the Supported Champions implementation strategy. Int J Surg 2018; 57:105-110. [PMID: 30114495 DOI: 10.1016/j.ijsu.2018.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 06/22/2018] [Accepted: 08/06/2018] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Methods to improve clinical systems safety suffer from significant difficulties in implementation and scaling up. We used an upscaling implementation strategy entitled Supported Champions in a quality and safety improvement programme for emergency surgery at regional level, focusing on patients with right iliac fossa pain. METHODS A before-after study was conducted across four acute NHS Trusts: A 6 month intervention phase was preceded and followed by 3 months of data collection. An established Human Factors intervention was led at each Trust by a small group of staff selected as Champions. Champions received training in teamwork and systems improvement and were supported by Human Factors experts. The primary improvement aim was to expedite surgery for patients with sepsis, using Royal College of Surgeons emergency surgery guidelines as the measure. Additional outcomes studied included length of inpatient stay and 30-day readmission rates. RESULTS Breaches of RCS urgency guidelines decreased markedly from 13.7% of operated patients pre-intervention to 3.5% post-intervention (p = 0.000). Mean time from booking to incision decreased in three of the four sites, whilst median length of stay increased in 3 of 4. Overall 30-day readmission rate remained stable (7.84% pre-intervention versus 7.31% post-intervention, p = 0.959). DISCUSSION The Supported Champions model allowed all surgical teams to reduce delay for septic patients by more than 50%, using distinct Quality Improvement strategies to address local issues. Improvement was implemented in 4 diverse settings with a quarter of the level of expert input previously used in a single hospital.
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Affiliation(s)
- Joshua Feinberg
- Nuffield Department of Surgery, University of Oxford, Oxford, UK; Department of Surgery, Maimonides Medical Center, Brooklyn, NY, USA
| | - Lorna Flynn
- Nuffield Department of Surgery, University of Oxford, Oxford, UK
| | - Matthew Woodward
- Nuffield Department of Surgery, University of Oxford, Oxford, UK
| | | | - Helen Higham
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Lauren Morgan
- Nuffield Department of Surgery, University of Oxford, Oxford, UK
| | - Lance Holman
- Department of Anaesthetics, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Patrick Tully
- Nuffield Department of Surgery, University of Oxford, Oxford, UK
| | - Peter McCulloch
- Nuffield Department of Surgery, University of Oxford, Oxford, UK.
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