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Schol CMA, van Mol MMC, Berger E, Leerentveld C, Gommers DAMPJ, Ista E. Implementation of a digital diary in the intensive care unit; understanding the facilitators and barriers: A qualitative exploration. Aust Crit Care 2024; 37:672-679. [PMID: 38719673 DOI: 10.1016/j.aucc.2024.04.002] [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: 01/14/2024] [Revised: 03/28/2024] [Accepted: 04/05/2024] [Indexed: 08/10/2024] Open
Abstract
BACKGROUND In the recent years, digital intensive care unit (ICU) diaries have emerged as more advantageous than paper diaries. Despite the advantages of digital diaries, the successful implementation and maintenance of this digital intervention present significant challenges in clinical practice. Therefore, understanding the facilitators and barriers among stakeholders influencing this process becomes imperative for devising a tailored strategy to integrate digital diaries effectively within ICU settings. AIM/OBJECTIVE The aim of this study was to explore facilitators and barriers for implementation of a digital ICU diary from the perspectives of ICU professionals, ICU survivors, and their relatives. METHODS A qualitative design was used, incorporating focus-group interviews with professionals from four Dutch ICUs, along with individual interviews with ICU survivors and relatives. The study spanned from October 2022 to April 2023. Data analysis utilised a mixed inductive-deductive approach, particularly through directed content analysis. The Consolidated Framework for Implementation Research 2.0 guided both data collection and analysis processes. FINDINGS We conducted five focus-group interviews among ICU professionals (n = 32) and 10 individual or dual interviews involving five ICU survivors and nine relatives. Key facilitators for implementing a digital diary according to ICU professionals encompassed a user-friendly interface accessible independent of time and place, with a seamless login process requiring minimal steps, comprehensive training covering all aspects of its use, and feedback from the experiences of both patients and relatives. Barriers for ICU professionals included many steps required to access the digital diary, as well as resistance to (co)writing diary entries. In contrast, professionals' involvement in writing diary entries was highly appreciated among ICU survivors and relatives. An ambiguous factor arose regarding sharing the digital diary with others; both ICU survivors and relatives found it valuable, yet it also raised privacy concerns. CONCLUSIONS This study offers insights into the most important factors influencing the implementation of a digital ICU diary. Strikingly, some factors serve as both barriers and facilitators. When developing the implementation strategy, the identified facilitators can be used to overcome the barriers faced by ICU professionals, ICU survivors, and their relatives in adopting a digital diary.
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Affiliation(s)
- Carola M A Schol
- Department of Intensive Care, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands.
| | - Margo M C van Mol
- Department of Intensive Care, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - Elke Berger
- Department of Intensive Care, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands; Department of Intensive Care, Franciscus Gasthuis & Vlietland, Rotterdam, the Netherlands
| | | | - Diederik A M P J Gommers
- Department of Intensive Care, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - Erwin Ista
- Department of Internal Medicine, Section Nursing Science, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands; Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus MC-Sophia Children's Hospital, University Medical Centre Rotterdam, Rotterdam, the Netherlands
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Gupta J, Zipursky AR, Pirie J, Freire G, Karin A, Bohn MK, Adeli K, Ostrow O. Coming in Hot: A quality improvement approach to improving care of febrile infants. Paediatr Child Health 2024; 29:135-143. [PMID: 38827372 PMCID: PMC11141599 DOI: 10.1093/pch/pxad070] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 10/09/2023] [Indexed: 06/04/2024] Open
Abstract
Background and Objectives Significant practice variation exists in managing young infants with fever. Quality improvement strategies can aid in risk stratification and standardization of best care practices, along with a reduction of unnecessary interventions. The aim of this initiative was to safely reduce unnecessary admissions, antibiotics, and lumbar punctures (LPs) by 10% in low-risk, febrile infants aged 29 to 90 days presenting to the emergency department (ED) over a 12-month period. Methods Using the Model for Improvement, a multidisciplinary team developed a multipronged intervention: an updated clinical decision tool (CDT), procalcitonin (PCT) adoption, education, a feedback tool, and best practice advisory (BPA) banner. Outcome measures included the proportion of low-risk infants that were admitted, received antibiotics, and had LPs. Process measures were adherence to the CDT and percentage of PCT ordered. Missed bacterial infections and return visits were balancing measures. The analysis was completed using descriptive statistics and statistical process control methods. Results Five hundred and sixteen patients less than 90 days of age were included in the study, with 403 patients in the 29- to 90-day old subset of primary interest. In the low-risk group, a reduction in hospital admissions from a mean of 24.1% to 12.0% and a reduction in antibiotics from a mean of 15.2% to 1.3% was achieved. The mean proportion of LPs performed decreased in the intervention period from 7.5% to 1.8%, but special cause variation was not detected. Adherence to the CDT increased from 70.4% to 90.9% and PCT was ordered in 92.3% of cases. The proportion of missed bacterial infections was 0.3% at baseline and 0.5% in the intervention period while return visits were 6.7% at baseline and 5.0% in the intervention period. Conclusions The implementation of a quality improvement strategy, including an updated evidence-based CDT for young infant fever incorporating PCT, safely reduced unnecessary care in low-risk, febrile infants aged 29 to 90 days in the ED. Purpose To develop and implement a multipronged improvement strategy including an evidence-based CDT utilizing PCT to maximize value of care delivered to well-appearing, febrile infants presenting to EDs.
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Affiliation(s)
- Joel Gupta
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Amy R Zipursky
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Jonathan Pirie
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Gabrielle Freire
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Amir Karin
- Department of Pathology and Laboratory Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Mary Kathryn Bohn
- Department of Laboratory Medicine, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Khosrow Adeli
- Department of Laboratory Medicine, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Olivia Ostrow
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
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Farcas AM, Crowe RP, Kennel J, Little N, Haamid A, Camacho MA, Pleasant T, Owusu-Ansah S, Joiner AP, Tripp R, Kimbrell J, Grover JM, Ashford S, Burton B, Uribe J, Innes JC, Page DI, Taigman M, Dorsett M. Achieving Equity in EMS Care and Patient Outcomes Through Quality Management Systems: A Position Statement. PREHOSP EMERG CARE 2024; 28:871-881. [PMID: 38727731 DOI: 10.1080/10903127.2024.2352582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 04/16/2024] [Accepted: 04/29/2024] [Indexed: 05/18/2024]
Abstract
Improving health and safety in our communities requires deliberate focus and commitment to equity. Inequities are differences in access, treatment, and outcomes between individuals and across populations that are systemic, avoidable, and unjust. Within health care in general, and Emergency Medical Services (EMS) in particular, there are demonstrated inequities in the quality of care provided to patients based on a number of characteristics linked to discrimination, exclusion, or bias. Given the critical role that EMS plays within the health care system, it is imperative that EMS systems reduce inequities by delivering evidence-based, high-quality care for the communities and patients we serve. To achieve equity in EMS care delivery and patient outcomes, the National Association of EMS Physicians recommends that EMS systems and agencies:make health equity a strategic priority and commit to improving equity at all levels.assess and monitor clinical and safety quality measures through the lens of inequities as an integrated part of the quality management process.ensure that data elements are structured to enable equity analysis at every level and routinely evaluate data for limitations hindering equity analysis and improvement.involve patients and community stakeholders in determining data ownership and stewardship to ensure its ongoing evolution and fitness for use for measuring care inequities.address biases as they translate into the quality of care and standards of respect for patients.pursue equity through a framework rooted in the principles of improvement science.
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Affiliation(s)
- Andra M Farcas
- Department of Emergency Medicine, School of Medicine, University of Colorado, Aurora, Colorado
| | | | - Jamie Kennel
- Oregon Health & Science University and Oregon Institute of Technology, Portland, Oregon
| | | | - Ameera Haamid
- Section of Emergency Medicine, University of Chicago Medicine, Chicago, Illinois
| | - Mario Andres Camacho
- Department of Emergency Medicine, Denver Health Medical Center, School of Medicine, University of Colorado, Denver, Colorado
| | | | - Sylvia Owusu-Ansah
- Division of Pediatric Emergency Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Anjni P Joiner
- Department of Emergency Medicine, School of Medicine, Duke University, Durham, North Carolina
| | - Rickquel Tripp
- Department of Emergency Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Joshua Kimbrell
- Department of Pre-Hospital Care, Jamaica Hospital Medical Center, Jamaica, New York
| | - Joseph M Grover
- UNC Department of Emergency Medicine, Chapel Hill, North Carolina
| | | | - Brooke Burton
- Unified Fire Authority in Salt Lake County, Salt Lake City, Utah
| | - Jeffrey Uribe
- Department of Emergency Medicine, Medstar Health, Columbia, Maryland
| | - Johanna C Innes
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York
| | - David I Page
- Center for Prehospital Care, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | | | - Maia Dorsett
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, New York
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Moriates C, Silverstein WK, Bandeira de Mello R, Stammen L, Wong BM. High-value care education can learn from the evidence-based medicine movement: moving beyond competencies and curricula to culture. BMJ Evid Based Med 2024; 29:147-150. [PMID: 37479241 DOI: 10.1136/bmjebm-2023-112270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/09/2023] [Indexed: 07/23/2023]
Affiliation(s)
- Christopher Moriates
- Departments of Internal Medicine and Medical Education, The University of Texas at Austin Dell Medical School, Austin, Texas, USA
- Executive Director, Costs of Care, Boston, Massachusetts, USA
| | - William K Silverstein
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Division of General Internal Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Choosing Wisely Canada, Toronto, ON, Canada
| | - Renato Bandeira de Mello
- Department of Internal Medicine, Universidade Federal do Rio Grande do Sul, Porte Alegre, Brazil
| | - Lorette Stammen
- School of Health Professions Education, Maastricht University, Maastricht, Limburg, Netherlands
| | - Brian M Wong
- Department of Medicine and Centre for Quality Improvement and Patient Safety, University of Toronto, Toronto, Ontario, Canada
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Brazil V, Reedy G. Translational simulation revisited: an evolving conceptual model for the contribution of simulation to healthcare quality and safety. Adv Simul (Lond) 2024; 9:16. [PMID: 38720396 PMCID: PMC11080180 DOI: 10.1186/s41077-024-00291-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 05/02/2024] [Indexed: 05/12/2024] Open
Abstract
The simulation community has effectively responded to calls for a more direct contribution by simulation to healthcare quality and safety, and clearer alignment with health service priorities, but the conceptual framing of this contribution has been vague. The term 'translational simulation' was proposed in 2017 as a "functional term for how simulation may be connected directly with health service priorities and patient outcomes, through interventional and diagnostic functions" (Brazil V. Adv Simul. 2:20, 2017). Six years later, this conceptual framing is clearer. Translational simulation has been applied in diverse contexts, affording insights into its strengths and limitations. Three core concepts are identifiable in recently published translational simulation studies: a clear identification of simulation purpose, an articulation of the simulation process, and an engagement with the conceptual foundations of translational simulation practice. In this article, we reflect on current translational simulation practice and scholarship, especially with respect to these three core concepts, and offer a further elaborated conceptual model based on its use to date.
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Affiliation(s)
- Victoria Brazil
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, QLD, Australia.
| | - Gabriel Reedy
- Faculty of Life Sciences and Medicine, King's College London, Waterloo Bridge Wing G7, London, UK
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Kooner GK, Bass M, Saroha V, Gonzalez PJ, Jain S. Reducing Antibiotic Duration for Uncomplicated UTI in the Pediatric Emergency Department. Hosp Pediatr 2024; 14:265-271. [PMID: 38533560 DOI: 10.1542/hpeds.2023-007561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND Short-duration (3-5 days) antibiotic treatment of uncomplicated urinary tract infection (uUTI) in children >24 months of age is equivalent to longer-duration antibiotic treatment, with added benefits of antibiotic stewardship. At our pediatric emergency department (ED), 13% of 5- to 18-year-old patients discharged with uUTI received ≤5 days of antibiotics. We aimed to increase short-duration prescriptions in patients with uUTI from 13% to >50% over 12 months. METHODS This quality improvement project was conducted from January 2021 to August 2022. Complicated UTI was excluded. Interventions included education, practice feedback, and electronic health record changes. The outcome measure, the proportion of children treated with a short antibiotic duration, was studied by using p-charts. Antibiotic days saved were calculated. Revisits with UTI within 14 days of confirmed uUTI treated with short-duration antibiotics (balancing measure) were analyzed by using Fisher's exact test. RESULTS In 1292 (n = 363 baseline, 929 post-intervention) eligible patients treated for uUTI, shorter antibiotic duration increased from 13% to 91%. We met our 50% aim within 2 months, with continued improvement leading to an additional centerline shift. Consequently, 2619 antibiotic days were saved. Two of 334 (0.6%) patients returned (P = NS) within 14 days of the index visit with a culture-positive uUTI. CONCLUSIONS By using education, feedback, and electronic health record changes, we decreased antibiotic duration in children discharged from the ED for uUTI without a significant increase in return visits with UTI. These interventions can be expanded to wider age groups and other outpatient settings.
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Affiliation(s)
- Gagandeep K Kooner
- Children's Healthcare of Atlanta, Atlanta, Georgia
- Divisions of Emergency Medicine
| | - Marissa Bass
- Children's Healthcare of Atlanta, Atlanta, Georgia
- Hospital Medicine
| | - Vivek Saroha
- Children's Healthcare of Atlanta, Atlanta, Georgia
- Neonatology, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - P J Gonzalez
- Children's Healthcare of Atlanta, Atlanta, Georgia
- Divisions of Emergency Medicine
| | - Shabnam Jain
- Children's Healthcare of Atlanta, Atlanta, Georgia
- Divisions of Emergency Medicine
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Tang KM, Lee P, Anosike BI, Asas K, Cassel-Choudhury G, Devi T, Gennarini L, Raizner A, Rhim HJH, Savva J, Shah D, Philips K. Decreasing Prescribing Errors in Antimicrobial Stewardship Program-Restricted Medications. Hosp Pediatr 2024; 14:281-290. [PMID: 38482585 DOI: 10.1542/hpeds.2023-007548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2024] [Indexed: 04/02/2024]
Abstract
OBJECTIVES Antimicrobial stewardship programs (ASPs) restrict prescribing practices to regulate antimicrobial use, increasing the risk of prescribing errors. This quality improvement project aimed to decrease the proportion of prescribing errors in ASP-restricted medications by standardizing workflow. METHODS The study took place on all inpatient units at a tertiary care children's hospital between January 2020 and February 2022. Patients <22 years old with an order for an ASP-restricted medication course were included. An interprofessional team used the Model for Improvement to design interventions targeted at reducing ASP-restricted medication prescribing errors. Plan-Do-Study-Act cycles included standardizing communication and medication review, implementing protocols, and developing electronic health record safety nets. The primary outcome was the proportion of ASP-restricted medication orders with a prescribing error. The secondary outcome was time between prescribing errors. Outcomes were plotted on control charts and analyzed for special cause variation. Outcomes were monitored for a 3-month sustainability period. RESULTS Nine-hundred ASP-restricted medication orders were included in the baseline period (January 2020-December 2020) and 1035 orders were included in the intervention period (January 2021-February 2022). The proportion of prescribing errors decreased from 10.9% to 4.6%, and special cause variation was observed in Feb 2021. Mean time between prescribing errors increased from 2.9 days to 8.5 days. These outcomes were sustained. CONCLUSIONS Quality improvement methods can be used to achieve a sustained reduction in the proportion of ASP-restricted medication orders with a prescribing error throughout an entire children's hospital.
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Affiliation(s)
- Katherine M Tang
- Children's Hospital at Montefiore, Bronx, New York
- Albert Einstein College of Medicine, Bronx, New York
| | - Philip Lee
- Children's Hospital at Montefiore, Bronx, New York
| | - Brenda I Anosike
- Children's Hospital at Montefiore, Bronx, New York
- Albert Einstein College of Medicine, Bronx, New York
| | - Kathleen Asas
- Children's Hospital at Montefiore, Bronx, New York
- Albert Einstein College of Medicine, Bronx, New York
| | - Gina Cassel-Choudhury
- Children's Hospital at Montefiore, Bronx, New York
- Albert Einstein College of Medicine, Bronx, New York
| | - Tanvi Devi
- Children's Hospital at Montefiore, Bronx, New York
| | - Lisa Gennarini
- Children's Hospital at Montefiore, Bronx, New York
- Albert Einstein College of Medicine, Bronx, New York
| | - Aileen Raizner
- Children's Hospital at Montefiore, Bronx, New York
- Albert Einstein College of Medicine, Bronx, New York
| | - Hai Jung H Rhim
- Children's Hospital at Montefiore, Bronx, New York
- Albert Einstein College of Medicine, Bronx, New York
| | | | - Dhara Shah
- Children's Hospital at Montefiore, Bronx, New York
| | - Kaitlyn Philips
- Children's Hospital at Montefiore, Bronx, New York
- Albert Einstein College of Medicine, Bronx, New York
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Crozier N, Robinson E, Murtagh NC, Coyne BD. Analysis of Intervention Employability in Pharmacy-Related Medication Safety Reports at a Tertiary Medical Center. Hosp Pharm 2024; 59:210-216. [PMID: 38450356 PMCID: PMC10913882 DOI: 10.1177/00185787231207995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2024]
Abstract
Background: The Institute for Safe Medication Practice (ISMP) suggests that patient safety reports be addressed with systematic, fail-safe, actions to prevent error recurrence. ISMP's hierarchy of effectiveness of risk reduction strategies places education-related interventions as the least effective and fail-safes at the top. UNM Hospitals creates a positive environment for safety reporting, but often we are limited to education interventions due to resource and technology constraints. This study analyzes the intervention potential and quality of pharmacy-related medication safety reports. Methods: One thousand medication-related safety reports from selected time points between 2012 and 2022 were selected. Safety reports were included in our study if they were actionable by the pharmacy department. Each safety report was categorized by type of safety event and given an intervention potential score of 1 to 10 (1 indicating education-only, 10 being forcing function) by 2 student pharmacists and 1 pharmacy director based on their potential place on ISMP's hierarchy. Safety report quality was graded based on professionalism, organization, clarity, and completeness. A standardized evaluation form was used for evaluation for all elements. Results: Six-hundred-sixty-five safety reports were pharmacy-related and evaluated by all 3 study team members for analysis. The 3 most common pharmacy-related safety reports were medication delivery, inappropriate order verification, and transcribing errors which accounted for over half of the reports (59.5%) and on average the intervention potential score of these types of safety reports was education only. Overall, safety reports were limited to a maximum actionability of education-only 75.4% of the time. Safety reports were found to be professionally written and well organized. Conclusion: The actionability of most pharmacy-related medication safety reports was limited to low leverage interventions likely because high leverage solutions were addressed with systematic change and did not recur. Errors limited to education interventions repeated and this increased relative counts of low leverage actionability of safety reports. The ISMP hierarchy of effectiveness of risk-reduction strategies is an important guide to intervening in medication-related safety events, but pharmacy staff should not be discouraged if most of the safety reports cannot be addressed through high-leverage interventions.
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Affiliation(s)
- Nick Crozier
- University of New Mexico Comprehensive Cancer Center, Albuquerque, NM, USA
| | - Elisa Robinson
- University of Washington—Seattle Campus, UW Medicine, Seattle, WA, USA
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Silverstein WK, Leis JA, Moriates C. "4 E's" Ways That Clinicians Can Reduce Low-Value Care on Medical Wards. JAMA Intern Med 2024; 184:322-323. [PMID: 38285558 DOI: 10.1001/jamainternmed.2023.7632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2024]
Abstract
This JAMA Network Insight demonstrates examples of how clinicians can implement stepwise changes to reduce unnecessary patient harms, using the 4 E’s.
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Affiliation(s)
- William K Silverstein
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of General Internal Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Jerome A Leis
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Christopher Moriates
- Division of Hospital Medicine, Greater Los Angeles VA Healthcare System, Los Angeles, California
- Department of Medicine, University of California Los Angeles
- Costs of Care, Boston, Massachusetts
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Kuhrij LS, Marang-van de Mheen PJ, van Lier L, Alimahomed R, Nelissen RGHH, van Bodegom-Vos L. Reduction in use of MRI and arthroscopy among patients with degenerative knee disease in independent treatment centers versus general hospitals: a time series analysis. Int J Qual Health Care 2024; 36:mzae004. [PMID: 38252692 PMCID: PMC10849166 DOI: 10.1093/intqhc/mzae004] [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: 09/28/2023] [Revised: 12/16/2023] [Accepted: 01/21/2024] [Indexed: 01/24/2024] Open
Abstract
The use of MRI and arthroscopy are considered low-value care in most patients with degenerative knee disease. To reduce these modalities, there have been multiple efforts to increase awareness. Reductions have been shown for general hospitals (GH), but it is unclear whether this may be partly explained by a shift of patients receiving these modalities in independent treatment centers (ITCs). The aims of this study were to assess (i) whether the trend in use of MRI and arthroscopy in patients with degenerative knee disease differs between ITCs and GH, and (ii) whether the Dutch efforts to raise awareness on these recommendations were associated with a change in the trend for both types of providers. All patients insured by a Dutch healthcare insurer aged ≥50 years with a degenerative knee disease who were treated in a GH or ITC between July 2014 and December 2019 were included. Linear regression was used with the quarterly percentage of patients receiving an MRI or knee arthroscopy weighted by center volume, as the primary outcome. Interrupted time-series analysis was used to evaluate the effect of the Dutch efforts to raise awareness. A total of 14 702 patients included were treated in 90 GHs (n = 13 303, 90.5%) and 29 ITCs (n = 1399, 9.5%). Across the study period, ITCs on an average had a 16% higher MRI use (P < .001) and 9% higher arthroscopy use (P = .003). MRI use did not change in both provider types, but arthroscopy use significantly decreased and became stronger in ITCs (P = .01). The Dutch efforts to increase awareness did not significantly influence either MRI or arthroscopy use in ITCs (P = .55 and P = .84) and GHs (P = .13 and P = .70). MRI and arthroscopy uses were higher in ITCs than GHs. MRI use did not change significantly among patients ≥ 50 years with degenerative knee disease in both provider types between 2014 and 2019. MRI- and arthroscopy use decreased with ITCs on average having higher rates for both modalities, but also showing a stronger decrease in arthroscopy use. The Dutch efforts to increase awareness did not accelerate the already declining trend in the Netherlands.
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Affiliation(s)
- Laurien S Kuhrij
- Department of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, Albinusdreef 2, Leiden 2333 ZA, the Netherlands
| | - Perla J Marang-van de Mheen
- Department of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, Albinusdreef 2, Leiden 2333 ZA, the Netherlands
| | - Lisanne van Lier
- Zorg & Zekerheid, Haagse Schouwweg 12, Leiden 2332 KG, the Netherlands
| | - Razia Alimahomed
- Zorg & Zekerheid, Haagse Schouwweg 12, Leiden 2332 KG, the Netherlands
| | - Rob G H H Nelissen
- Department of Orthopaedics, Leiden University Medical Center, Albinusdreef 2, Leiden 2333 ZA, the Netherlands
| | - Leti van Bodegom-Vos
- Department of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, Albinusdreef 2, Leiden 2333 ZA, the Netherlands
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Sung H, Han AY, Seol GH. BodyThink program-based body image education improves Korean adolescents' attitudes toward cosmetic surgery: randomized controlled trial. BMC Nurs 2023; 22:481. [PMID: 38110930 PMCID: PMC10726550 DOI: 10.1186/s12912-023-01649-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 12/11/2023] [Indexed: 12/20/2023] Open
Abstract
BACKGROUND The aims of this study were to modify the widely used BodyThink program to suit the circumstances of Korean schools and determine its effects on body esteem, body image, appearance stress, depression, and attitudes toward cosmetic surgery. METHODS Participants were 184 third-grade students from two middle schools in Korea, who were randomly assigned to a control or intervention group. Two of the participants dropped out; hence, data from 182 students were analyzed. The control group received the existing curriculum for 4 sessions, and the experimental group was provided with 4 sessions of the revised BodyThink program. Before and after the intervention, all participants completed questionnaires. RESULTS In the BodyThink group, improved body image, decreased depression, and positive improvements in attitudes toward cosmetic plastic surgery were observed after the intervention. DISCUSSION These results suggest that school health nurses can utilize interventions based on BodyThink program in their curricula to improve the physical and emotional health of adolescents. TRIAL REGISTRATION This study has been retrospectively registered with the Clinical Research information Service (CRIS) in Korea on October 5, 2023 (KCT0008839).
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Affiliation(s)
- Hyeonhwa Sung
- Department of Basic Nursing Science, College of Nursing, Korea University, Seoul, Republic of Korea
| | - A Young Han
- Department of Basic Nursing Science, College of Nursing, Korea University, Seoul, Republic of Korea
- Department of Nursing, College of Life Science and Industry, Sunchon National University, Suncheon, Republic of Korea
| | - Geun Hee Seol
- Department of Basic Nursing Science, College of Nursing, Korea University, Seoul, Republic of Korea.
- BK21 FOUR Program of Transdisciplinary Major in Learning Health Systems, Graduate School, Korea University, Seoul, Republic of Korea.
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Mattick K, Noble C. Education and educational interventions: moving beyond information provision. BMJ Qual Saf 2023; 33:10-12. [PMID: 37591516 DOI: 10.1136/bmjqs-2023-016273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2023] [Indexed: 08/19/2023]
Affiliation(s)
- Karen Mattick
- Department of Health and Community Sciences, University of Exeter-Saint Lukes Campus, Exeter, UK
| | - Christy Noble
- The University of Queensland, Herston, Queensland, Australia
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Luetsch K, Wong G, Rowett D. A realist synthesis of educational outreach visiting and integrated academic detailing to influence prescribing in ambulatory care: why relationships and dialogue matter. BMJ Qual Saf 2023; 33:43-54. [PMID: 37142414 PMCID: PMC10804006 DOI: 10.1136/bmjqs-2022-015498] [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: 08/29/2022] [Accepted: 04/19/2023] [Indexed: 05/06/2023]
Abstract
BACKGROUND Many quality improvement initiatives in healthcare employ educational outreach visits, integrating academic detailing to bridge evidence-practice gaps and accelerate knowledge translation. Replicability of their outcomes in different contexts varies, and what makes some visiting programmes more successful than others is unclear. OBJECTIVE We conducted a realist synthesis to develop theories of what makes educational outreach visiting integrating academic detailing work, for whom, under which circumstances and why, focusing on the clinician-visitor interaction when influencing prescribing of medicines in ambulatory care settings. METHODS The realist review was performed in accordance with RAMESES standards. An initial programme theory was generated, academic databases and grey literature were screened for documents with detail on contexts, intervention and outcomes. Using realist logic of analysis, data from 43 documents were synthesised in the generation of a refined programme theory, supported by additional theoretical frameworks of learning and communication. RESULTS Twenty-seven interdependent context-mechanism-outcome configurations explain how clinicians engage with educational outreach visits integrating academic detailing through programme design, what matters in programme design and the educational visitor-clinician interaction and how influence extends beyond the visit. They suggest that in addition to relevance, credibility and trustworthiness of a visit's contents, communication and clinical skills of educational visitors, the relationship between the educational visitor and clinician, built on a dialogue of learning from and sense-making with each other, creates conditions of critical thinking which are conducive to facilitating prescribing practice change when necessary. CONCLUSION This realist synthesis elucidates that the quality of clinician-educational visitor interactions is pivotal to educational outreach visiting programmes. Building and sustaining relationships, and establishing an open dialogue are important; neglecting these undermines the impact of visits. Educational visitors can facilitate clinicians' reflection on practice and influence their prescribing. Clinicians value the discussion of individualised, tailored information and advice they can translate into their practice. PROSPERO REGISTRATION NUMBER CRD42021258199.
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Affiliation(s)
- Karen Luetsch
- Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Geoff Wong
- Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Debra Rowett
- Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, Australia
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14
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Baghdadi JD, O'Hara LM, Johnson JK, Krein SL, Harris AD, Morgan DJ. Diagnostic stewardship to support optimal use of multiplex molecular respiratory panels: A survey from the Society for Healthcare Epidemiology of America Research Network. Infect Control Hosp Epidemiol 2023; 44:1823-1828. [PMID: 37129035 PMCID: PMC10862355 DOI: 10.1017/ice.2023.72] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
OBJECTIVES Multiplex polymerase chain reaction (PCR) respiratory panels are rapid, highly sensitive tests for viral and bacterial pathogens that cause respiratory infections. In this study, we (1) described best practices in the implementation of respiratory panels based on expert perspectives and (2) identified tools for diagnostic stewardship to enhance the usefulness of testing. METHODS We conducted a survey of the Society for Healthcare Epidemiology of America Research Network to explore current and future approaches to diagnostic stewardship of multiplex PCR respiratory panels. RESULTS In total, 41 sites completed the survey (response rate, 50%). Multiplex PCR respiratory panels were perceived as supporting accurate diagnoses at 35 sites (85%), supporting more efficient patient care at 33 sites (80%), and improving patient outcomes at 23 sites (56%). Thirteen sites (32%) reported that testing may support diagnosis or patient care without improving patient outcomes. Furthermore, 24 sites (58%) had implemented diagnostic stewardship, with a median of 3 interventions (interquartile range, 1-4) per site. The interventions most frequently reported as effective were structured order sets to guide test ordering (4 sites), restrictions on test ordering based on clinician or patient characteristics (3 sites), and structured communication of results (2 sites). Education was reported as "helpful" but with limitations (3 sites). CONCLUSIONS Many hospital epidemiologists and experts in infectious diseases perceive multiplex PCR respiratory panels as useful tests that can improve diagnosis, patient care, and patient outcomes. However, institutions frequently employ diagnostic stewardship to enhance the usefulness of testing, including most commonly clinical decision support to guide test ordering.
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Affiliation(s)
- Jonathan D Baghdadi
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
| | - Lyndsay M O'Hara
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
| | - J Kristie Johnson
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Sarah L Krein
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Anthony D Harris
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
| | - Daniel J Morgan
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
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Moriates C. We Need to Talk About Low-Value Care. JAMA Netw Open 2023; 6:e2342445. [PMID: 37943561 DOI: 10.1001/jamanetworkopen.2023.42445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2023] Open
Affiliation(s)
- Christopher Moriates
- Department of Internal Medicine, Dell Medical School at The University of Texas at Austin
- Costs of Care, Boston, Massachusetts
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16
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van Veen LEJ, van der Weijden BM, van Bodegom-Vos L, Hol J, Visser DH, Achten NB, Plötz FB. Barriers and Facilitators to the Implementation of the Early-Onset Sepsis Calculator: A Multicenter Survey Study. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1682. [PMID: 37892345 PMCID: PMC10605684 DOI: 10.3390/children10101682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/07/2023] [Accepted: 10/10/2023] [Indexed: 10/29/2023]
Abstract
Prior studies demonstrated the neonatal early-onset sepsis (EOS) calculator's potential in drastically reducing antibiotic prescriptions, and its international adoption is increasing rapidly. To optimize the EOS calculator's impact, successful implementation is crucial. This study aimed to identify key barriers and facilitators to inform an implementation strategy. A multicenter cross-sectional survey was carried out among physicians, residents, nurses and clinical obstetricians of thirteen Dutch hospitals. Survey development was prepared through a literature search and stakeholder interviews. Data collection and analysis were based on the Consolidated Framework for Implementation Research (CFIR). A total of 465 stakeholders completed the survey. The main barriers concerned the expectance of the department's capacity problems and the issues with maternal information transfer between departments. Facilitators concerned multiple relative advantages of the EOS calculator, including stakeholder education, EOS calculator integration in the electronic health record and existing positive expectations about the safety and effectivity of the calculator. Based on these findings, tailored implementation interventions can be developed, such as identifying early adopters and champions, conducting educational meetings tailored to the target group, creating ready-to-use educational materials, integrating the EOS calculator into electronic health records, creating a culture of collective responsibility among departments and collecting data to evaluate implementation success and innovation results.
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Affiliation(s)
- Liesanne E. J. van Veen
- Department of Paediatrics, Tergooi MC, Laan van Tergooi 2, 1212 VG Hilversum, The Netherlands; (L.E.J.v.V.); (B.M.v.d.W.)
- Department of Paediatrics, Franciscus Gasthuis en Vlietland, Kleiweg 500, 3045 PM Rotterdam, The Netherlands
- Department of Paediatrics, Erasmus MC, Sophia Children’s Hospital, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands;
| | - Bo M. van der Weijden
- Department of Paediatrics, Tergooi MC, Laan van Tergooi 2, 1212 VG Hilversum, The Netherlands; (L.E.J.v.V.); (B.M.v.d.W.)
- Amsterdam UMC, Department of Paediatrics and Amsterdam Reproduction & Development Research Institute, Location University of Amsterdam, Emma Children’s Hospital, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands;
| | - Leti van Bodegom-Vos
- Department of Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands;
| | - Jeroen Hol
- Department of Paediatrics, Noord West Ziekenhuis, Wilhelminalaan 12, 1815 JD Alkmaar, The Netherlands;
| | - Douwe H. Visser
- Amsterdam UMC, Department of Paediatrics and Amsterdam Reproduction & Development Research Institute, Location University of Amsterdam, Emma Children’s Hospital, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands;
- Amsterdam UMC, Department of Neonatology, Emma Children’s Hospital, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Niek B. Achten
- Department of Paediatrics, Erasmus MC, Sophia Children’s Hospital, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands;
| | - Frans B. Plötz
- Department of Paediatrics, Tergooi MC, Laan van Tergooi 2, 1212 VG Hilversum, The Netherlands; (L.E.J.v.V.); (B.M.v.d.W.)
- Amsterdam UMC, Department of Paediatrics and Amsterdam Reproduction & Development Research Institute, Location University of Amsterdam, Emma Children’s Hospital, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands;
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17
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Alaiev D, Krouss M, Israilov S, Musser L, Talledo J, Mestari N, Uppal A, Madaline T, Cohen G, Bravo N, Cervantes M, Contractor D, Manchego PA, Chandra K, Zaurova M, Tsega S, Cho HJ. Nudging to select single-lumen over multiple-lumen peripherally inserted central catheters (PICCs) in a large safety net system. Infect Control Hosp Epidemiol 2023; 44:1381-1385. [PMID: 36960818 DOI: 10.1017/ice.2022.306] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2023]
Abstract
BACKGROUND Peripherally inserted central catheters (PICCs) are increasingly used for vascular access in inpatient settings. Compared to multilumen PICCs, single-lumen PICCs carry a lower rate of complications, including central-line-associated bloodstream infection and thrombosis. Despite this, multilumen PICCs are still overused. METHODS This quality improvement initiative was implemented across 11 hospitals at New York City Health + Hospitals safety net system. The electronic health record (EHR) interventional radiology or vascular access team consultation orders were modified to allow for lumen choice, with default selection to a single-lumen PICC. RESULTS Average single-lumen PICC utilization increased by 25.5%, from 44.4% to 69.9% (P < .001). CLABSI rates had a nonsignificant reduction by 26.7% from 2.44 to 1.79 infections per month (P = .255). Among provider types in the postintervention period, single-lumen PICC utilization ranged from 67.7% for advanced practice providers to 82.4%-94.6% for physicians. Among provider specialties, utilization ranged from 31.8% for neurology to 97.7% for orthopedics. Additionally, there was large variation in pre- and postintervention differences in utilization by hospital. CONCLUSIONS We successfully increased single-lumen PICC utilization across all 11 safety net hospitals. This expands on previous work on improving single-lumen PICC use and use of default nudges in large, resource-limited settings. Further study is needed to examine variation among provider types, specialties, and hospitals.
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Affiliation(s)
- Daniel Alaiev
- Department of Quality and Safety, New York City Health + Hospitals, New York, New York
| | - Mona Krouss
- Department of Quality and Safety, New York City Health + Hospitals, New York, New York
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Sigal Israilov
- Department of Anesthesia, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Lara Musser
- Department of Emergency Medicine, NYC Health + Hospitals/Jacobi, The Bronx, New York
| | - Joseph Talledo
- Department of Quality and Safety, New York City Health + Hospitals, New York, New York
| | - Nessreen Mestari
- Department of Quality and Safety, New York City Health + Hospitals, New York, New York
| | - Amit Uppal
- Department of Medicine, NYC Health + Hospitals/Bellevue, New York, New York
| | - Theresa Madaline
- Department of Quality and Safety, NYC Health + Hospitals/Coney Island, Brooklyn, New York
| | - Gabriel Cohen
- Department of Population Health, NYC Health + Hospitals, New York, New York
| | - Nathaniel Bravo
- Department of Infection Control and Prevention, NYC Health + Hospitals/Queens, Queens, New York
| | - Marialeah Cervantes
- Department of Infection Control and Prevention, NYC Health + Hospitals/Queens, Queens, New York
| | - Daniel Contractor
- Department of Radiology, NYC Health + Hospitals/Queens, Queens, New York
| | - Peter Alacron Manchego
- Department of Quality and Safety, New York City Health + Hospitals, New York, New York
- Department of Pediatrics, NYC Health + Hospitals/Kings County, Brooklyn, New York
| | - Komal Chandra
- Department of Quality and Safety, New York City Health + Hospitals, New York, New York
| | - Milana Zaurova
- Department of Quality and Safety, New York City Health + Hospitals, New York, New York
- Department of Emergency Medicine, Icahn School of Medicine, New York, New York
| | - Surafel Tsega
- Department of Quality and Safety, New York City Health + Hospitals, New York, New York
| | - Hyung J Cho
- Department of Quality and Safety, Brigham and Women's Hospital, Boston, Massachusetts
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18
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Chun BC, Chmil M, Ruess L. Decreasing Radiation Exposure to the Abdomen in Children with Chronic Constipation. Pediatr Qual Saf 2023; 8:e681. [PMID: 37780600 PMCID: PMC10538869 DOI: 10.1097/pq9.0000000000000681] [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: 03/30/2023] [Accepted: 07/14/2023] [Indexed: 10/03/2023] Open
Abstract
Background Bowel management for children with chronic constipation may include repeated single-view abdomen radiographs (AXR) to monitor treatment success. Only one image of the abdomen is needed to include most of the colon, but technologists often make a second (or even third) exposure to be sure they have imaged the entire abdomen. Our quality improvement project aimed to reduce radiation exposure by decreasing the frequency of >1 exposure performed for AXR orders in children with chronic constipation from 27% to <10% by December 2022 and sustain. Methods We counted baseline (01/2020-11/2020) and intervention (12/2020-5/2023) examinations with >1 exposure. Initial interventions were a structured communication to technologists and an article in the monthly department newsletter and later, a technologist education module. Additional interventions included communication to radiologists, project updates and encouragement to all technologists, and individual technologist feedback. A statistical process control chart tracked data to study process changes over time. Results During the baseline and intervention periods, 525/1944 and 1329/8334 examinations, respectively, had >1 exposure performed for AXR orders. Interventions created 2 centerline shifts. Overall, examinations with >1 exposure decreased from 27% to 13.5%. Conclusions Frequency of >1 exposure performed for AXR orders in children with chronic constipation decreased from 27% to 13.5% through education and communication. This was sustained. We plan to assign training modules for all new technologists, policy reminders (annual training in odd years) for all technologists, and continue individualized learning opportunities.
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Affiliation(s)
- Bennet C. Chun
- From the Department of Radiology, Nationwide Children’s Hospital, Columbus, Ohio
| | - Margarita Chmil
- From the Department of Radiology, Nationwide Children’s Hospital, Columbus, Ohio
- Center for Clinical Excellence, Nationwide Children’s Hospital, Columbus, Ohio
| | - Lynne Ruess
- From the Department of Radiology, Nationwide Children’s Hospital, Columbus, Ohio
- Center for Clinical Excellence, Nationwide Children’s Hospital, Columbus, Ohio
- Department of Radiology, The Ohio State University College of Medicine, Columbus, Ohio
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19
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Moriates C. How can we finally reduce repetitive routine laboratory tests for hospitalised patients? BMJ Qual Saf 2023; 32:498-501. [PMID: 37328268 DOI: 10.1136/bmjqs-2023-016315] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2023] [Indexed: 06/18/2023]
Affiliation(s)
- Christopher Moriates
- Department of Internal Medicine, Dell Medical School at The University of Texas at Austin, Austin, Texas, USA
- Executive Director, Costs of Care, Boston, Massachusetts, USA
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20
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Ambasta A, Omodon O, Herring A, Ferrie L, Pokharel S, Mehta A, Liu L, Hews-Girard J, Tam C, Taylor S, Lonergan K, Faris P, Duncan D, Woodhouse D. Repurposing the Ordering of Routine Laboratory Tests in Hospitalised Medical Patients (RePORT): results of a cluster randomised stepped-wedge quality improvement study. BMJ Qual Saf 2023; 32:517-525. [PMID: 37164639 DOI: 10.1136/bmjqs-2022-015611] [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: 10/05/2022] [Accepted: 04/19/2023] [Indexed: 05/12/2023]
Abstract
BACKGROUND Low-value use of laboratory tests is a global challenge. Our objective was to evaluate an intervention bundle to reduce repetitive use of routine laboratory testing in hospitalised patients. METHODS We used a stepped-wedge design to implement an intervention bundle across eight medical units. Our intervention included educational tools and social comparison reports followed by peer-facilitated report discussion sessions. The study spanned October 2020-June 2021, divided into control, feasibility testing, intervention and a follow-up period. The primary outcomes were the number and costs of routine laboratory tests ordered per patient-day. We used generalised linear mixed models, and analyses were by intention to treat. RESULTS We included a total of 125 854 patient-days. Patient groups were similar in age, sex, Charlson Comorbidity Index and length of stay during the control, intervention and follow-up periods. From the control to the follow-up period, there was a 14% (incidence rate ratio (IRR)=0.86, 95% CI 0.79 to 0.92) overall reduction in ordering of routine tests with the intervention, along with a 14% (β coefficient=-0.14, 95% CI -0.07 to -0.21) reduction in costs of routine testing. This amounted to a total cost savings of $C1.15 per patient-day. There was also a 15% (IRR=0.85, 95% CI 0.79, 0.92) reduction in ordering of all common tests with the intervention and a 20% (IRR=1.20, 95% CI 1.10 to 1.30) increase in routine test-free patient-days. No worsening was noted in patient safety endpoints with the intervention. CONCLUSIONS A multifaceted intervention bundle using education and facilitated multilevel social comparison was associated with a safe and effective reduction in use of routine daily laboratory testing in hospitals. Further research is needed to understand how system-level interventions may increase this effect and which intervention elements are necessary to sustain results.
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Affiliation(s)
- Anshula Ambasta
- Medicine, University of Calgary Cumming School of Medicine, Calgary, Canada
| | - Onyebuchi Omodon
- Ward of the 21st Century, University of Calgary Cumming School of Medicine, Calgary, Canada
| | | | - Leah Ferrie
- Physician Learning Program, University of Calgary, Calgary, Canada
| | | | - Ashi Mehta
- Health Quality Council of Alberta, Calgary, Canada
| | | | | | - Cheuk Tam
- Medicine, University of Calgary Faculty of Medicine, Calgary, Canada
| | - Simon Taylor
- Medicine, University of Calgary, Calgary, Canada
| | | | - Peter Faris
- Measurement and Analysis; Research Excellence Support Team, Alberta Bone and Joint Health Institute; Alberta Health Services, Calgary, Canada
| | - Diane Duncan
- Physician Learning Program, University of Calgary, Calgary, Canada
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21
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Colman N, Hebbar KB. Let us to the TWISST; Plan, Simulate, Study and Act. Pediatr Qual Saf 2023; 8:e664. [PMID: 37434590 PMCID: PMC10332833 DOI: 10.1097/pq9.0000000000000664] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 06/01/2023] [Indexed: 07/13/2023] Open
Abstract
Translational Work Integrating Simulation and Systems Testing (TWISST) is a novel application of simulation that augments how we discover, understand, and mitigate errors in our system. TWISST is a diagnostic and interventional tool that couples Simulation-based Clinical Systems Testing with simulation-based training (SbT). TWISST tests environments and work systems to identify latent safety threats (LSTs) and process inefficiencies. In SbT, improvements made to the work system are embedded in hard wire system improvements, ensuring optimal integration into clinical workflow. Methods Simulation-based Clinical Systems Testing approach includes simulated scenarios, Summarize, Anchor, Facilitate, Explore, Elicit debriefing, and Failure Mode and Effect Analysis. In iterative Plan-Simulate-Study-Act cycles, frontline teams explored work system inefficiencies, identified LSTs, and tested potential solutions. As a result, system improvements were hardwired through SbT. Finally, we present a case study example of the TWISST application in the Pediatric Emergency Department. Results TWISST identified 41 latent conditions. LSTs were related to resource/equipment/supplies (n = 18, 44%), patient safety (n = 14, 34%), and policies/procedures (n = 9, 22%). Work system improvements addressed 27 latent conditions. System changes that eliminated waste or modified the environment to support best practices mitigated 16 latent conditions. System improvements that addressed 44% of LSTs cost the department $11,000 per trauma bay. Conclusions TWISST is an innovative and novel strategy that effectively diagnoses and remediates LSTs in a working system. This approach couples highly reliable work system improvements and training into 1 framework.
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Affiliation(s)
- Nora Colman
- From the Department of Pediatrics, Division of Pediatric Critical Care, Children’s Healthcare of Atlanta, Atlanta, Ga
| | - Kiran B. Hebbar
- From the Department of Pediatrics, Division of Pediatric Critical Care, Children’s Healthcare of Atlanta, Atlanta, Ga
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MacDonald I, de Goumoëns V, Marston M, Alvarado S, Favre E, Trombert A, Perez MH, Ramelet AS. Effectiveness, quality and implementation of pain, sedation, delirium, and iatrogenic withdrawal syndrome algorithms in pediatric intensive care: a systematic review and meta-analysis. Front Pediatr 2023; 11:1204622. [PMID: 37397149 PMCID: PMC10313131 DOI: 10.3389/fped.2023.1204622] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 05/15/2023] [Indexed: 07/04/2023] Open
Abstract
Background Pain, sedation, delirium, and iatrogenic withdrawal syndrome are conditions that often coexist, algorithms can be used to assist healthcare professionals in decision making. However, a comprehensive review is lacking. This systematic review aimed to assess the effectiveness, quality, and implementation of algorithms for the management of pain, sedation, delirium, and iatrogenic withdrawal syndrome in all pediatric intensive care settings. Methods A literature search was conducted on November 29, 2022, in PubMed, Embase, CINAHL and Cochrane Library, ProQuest Dissertations & Theses, and Google Scholar to identify algorithms implemented in pediatric intensive care and published since 2005. Three reviewers independently screened the records for inclusion, verified and extracted data. Included studies were assessed for risk of bias using the JBI checklists, and algorithm quality was assessed using the PROFILE tool (higher % = higher quality). Meta-analyses were performed to compare algorithms to usual care on various outcomes (length of stay, duration and cumulative dose of analgesics and sedatives, length of mechanical ventilation, and incidence of withdrawal). Results From 6,779 records, 32 studies, including 28 algorithms, were included. The majority of algorithms (68%) focused on sedation in combination with other conditions. Risk of bias was low in 28 studies. The average overall quality score of the algorithm was 54%, with 11 (39%) scoring as high quality. Four algorithms used clinical practice guidelines during development. The use of algorithms was found to be effective in reducing length of stay (intensive care and hospital), length of mechanical ventilation, duration of analgesic and sedative medications, cumulative dose of analgesics and sedatives, and incidence of withdrawal. Implementation strategies included education and distribution of materials (95%). Supportive determinants of algorithm implementation included leadership support and buy-in, staff training, and integration into electronic health records. The fidelity to algorithm varied from 8.2% to 100%. Conclusions The review suggests that algorithm-based management of pain, sedation and withdrawal is more effective than usual care in pediatric intensive care settings. There is a need for more rigorous use of evidence in the development of algorithms and the provision of details on the implementation process. Systematic Review Registration https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021276053, PROSPERO [CRD42021276053].
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Affiliation(s)
- Ibo MacDonald
- Institute of Higher Education and Research in Healthcare, University of Lausanne, Lausanne, Switzerland
| | - Véronique de Goumoëns
- La Source School of Nursing, HES-SO University of Applied Sciences and Arts Western Switzerland, Lausanne, Switzerland
- Bureau d’Echange des Savoirs pour des praTiques exemplaires de soins (BEST) a JBI Center of Excellence, Lausanne, Switzerland
| | - Mark Marston
- Institute of Higher Education and Research in Healthcare, University of Lausanne, Lausanne, Switzerland
- Department Woman-Mother-Child, Lausanne University Hospital, Lausanne, Switzerland
| | - Silvia Alvarado
- Institute of Higher Education and Research in Healthcare, University of Lausanne, Lausanne, Switzerland
- Department Woman-Mother-Child, Lausanne University Hospital, Lausanne, Switzerland
| | - Eva Favre
- Institute of Higher Education and Research in Healthcare, University of Lausanne, Lausanne, Switzerland
- Department of Adult Intensive Care, Lausanne University Hospital, Lausanne, Switzerland
| | - Alexia Trombert
- Medical Library, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Maria-Helena Perez
- Department Woman-Mother-Child, Lausanne University Hospital, Lausanne, Switzerland
| | - Anne-Sylvie Ramelet
- Institute of Higher Education and Research in Healthcare, University of Lausanne, Lausanne, Switzerland
- Bureau d’Echange des Savoirs pour des praTiques exemplaires de soins (BEST) a JBI Center of Excellence, Lausanne, Switzerland
- Department Woman-Mother-Child, Lausanne University Hospital, Lausanne, Switzerland
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23
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Talledo J, Cho HJ, Alaiev D, Israilov S, Chandra K, Zaurova M, Manchego PA, Shin D, Tsega S, Krouss M. Reducing Inappropriate Simultaneous Ordering of Heparin Antibody and Serotonin Release Assays. Jt Comm J Qual Patient Saf 2023; 49:306-312. [PMID: 37137754 DOI: 10.1016/j.jcjq.2023.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 03/16/2023] [Accepted: 03/17/2023] [Indexed: 04/03/2023]
Abstract
INTRODUCTION A 4T score with intermediate or high probability of heparin-induced thrombocytopenia prompts ordering of anti-platelet 4 heparin complex. If positive, a serotonin release assay (SRA) is recommended to confirm diagnosis. Despite these recommendations, overtesting of both anti-platelet 4 and SRA is highly prevalent. METHODS This was a quality improvement initiative using two forms of clinical decision support across 11 acute care hospitals. First, a 4T calculator was incorporated into anti-platelet 4 orders. Second, a Best Practice Advisory fired when anti-platelet 4 and SRA were ordered simultaneously, prompting the provider to remove the SRA order. Data were analyzed by a quasi-experimental interrupted time series linear regression comparing weekly average laboratory tests per 1,000 patient-days pre- and postintervention. RESULTS Average ordering frequency of anti-platelet 4 changed from 0.508 to 0.510 per 1,000 patient-days (0.5%, p = 0.42) without significant slope or level differences. Average ordering frequency of SRA decreased from 0.430 to 0.289 per 1,000 patient-days (32.8%, p < 0.001) with a significant level difference of -0.128 orders per 1,000 patient-days (-31.2%, p < 0.05). CONCLUSION A simultaneous Best Practice Advisory was effective in reducing SRA orders, but not anti-platelet 4 orders.
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Mathura P, Marini S, Hagtvedt R, Spalding K, Duhn L, Kassam N, Medves J. Factors of a physician quality improvement leadership coalition that influence physician behaviour: a mixed methods study. BMJ Open Qual 2023; 12:e002016. [PMID: 37290908 PMCID: PMC10255283 DOI: 10.1136/bmjoq-2022-002016] [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: 06/13/2022] [Accepted: 05/25/2023] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND A coalition (Strategic Clinical Improvement Committee), with a mandate to promote physician quality improvement (QI) involvement, identified hospital laboratory test overuse as a priority. The coalition developed and supported the spread of a multicomponent initiative about reducing repetitive laboratory testing and blood urea nitrogen (BUN) ordering across one Canadian province. This study's purpose was to identify coalition factors enabling medicine and emergency department (ED) physicians to lead, participate and influence appropriate BUN test ordering. METHODS Using sequential explanatory mixed methods, intervention components were grouped as person focused or system focused. Quantitative phase/analyses included: monthly total and average of the BUN test for six hospitals (medicine programme and two EDs) were compared pre initiative and post initiative; a cost avoidance calculation and an interrupted time series analysis were performed (participants were divided into two groups: high (>50%) and low (<50%) BUN test reduction based on these findings). Qualitative phase/analyses included: structured virtual interviews with 12 physicians/participants; a content analysis aligned to the Theoretical Domains Framework and the Behaviour Change Wheel. Quotes from participants representing high and low groups were integrated into a joint display. RESULTS Monthly BUN test ordering was significantly reduced in 5 of 6 participating hospital medicine programmes and in both EDs (33% to 76%), resulting in monthly cost avoidance (CAN$900-CAN$7285). Physicians had similar perceptions of the coalition's characteristics enabling their QI involvement and the factors influencing BUN test reduction. CONCLUSIONS To enable physician confidence to lead and participate, the coalition used the following: a simply designed QI initiative, partnership with a coalition physician leader and/or member; credibility and mentorship; support personnel; QI education and hands-on training; minimal physician effort; and no clinical workflow disruption. Implementing person-focused and system-focused intervention components, and communication from a trusted local physician-who shared data, physician QI initiative role/contribution and responsibility, best practices, and past project successes-were factors influencing appropriate BUN test ordering.
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Affiliation(s)
- Pamela Mathura
- Department of Medicine, University of Alberta Hospital, Edmonton, Alberta, Canada
- Alberta Health Services, Edmonton Zone Medicine, Edmonton, Alberta, Canada
| | - Sandra Marini
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Reidar Hagtvedt
- Alberta School of Business, University of Alberta, Edmonton, Alberta, Canada
| | - Karen Spalding
- School of Nursing, Queen's University, Kingston, Ontario, Canada
| | - Lenora Duhn
- School of Nursing, Queen's University, Kingston, Ontario, Canada
| | - Narmin Kassam
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Jennifer Medves
- School of Nursing, Queen's University, Kingston, Ontario, Canada
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Van Dulmen SA, Verkerk EW, Born K, Gupta R, Westert GP, Kool RB. Challenges and Opportunities for Reducing Low-Value Care; A Response to Recent Commentaries. Int J Health Policy Manag 2023; 12:7954. [PMID: 37579421 PMCID: PMC10461886 DOI: 10.34172/ijhpm.2023.7954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 01/31/2023] [Indexed: 08/16/2023] Open
Affiliation(s)
- Simone A. Van Dulmen
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Eva W. Verkerk
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Karen Born
- Institute for Health Policy, Management & Evaluation, University of Toronto, Toronto, ON, Canada
| | - Reshma Gupta
- University of California Health, Los Angeles, CA, USA
| | - Gert P. Westert
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Rudolf B. Kool
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
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Identifying Safety Practices Perceived as Low Value: An Exploratory Survey of Healthcare Staff in the United Kingdom and Australia. J Patient Saf 2023; 19:143-150. [PMID: 36729436 PMCID: PMC9940841 DOI: 10.1097/pts.0000000000001091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES Up to 30% of healthcare spending is considered unnecessary and represents systematic waste. While much attention has been given to low-value clinical tests and treatments, much less has focused on identifying low-value safety practices in healthcare settings. With increasing recognition of the problem of "safety clutter" in organizations, it is important to consider deimplementing safety practices that do not benefit patients, to create the time needed to deliver effective, person-centered, and safe care. This study surveyed healthcare staff to identify safety practices perceived to be of low value. METHODS Purposive and snowball sampling was used. Data collection was conducted from April 2018 to November 2019 (United Kingdom) and May 2020 to November 2020 (Australia). Participants completed the survey online or in hard copy to identify practices they perceived to not contribute to safe care. Responses were analyzed using content and thematic analysis. RESULTS A total of 1394 responses from 1041 participants were analyzed. Six hundred sixty-three responses were collected from 526 UK participants and 515 Australian participants contributed 731 responses. Frequently identified categories of practices identified included "paperwork," "duplication," and "intentional rounding." Five cross-cutting themes (e.g., covering ourselves) offered an underpinning rationale for why staff perceived the practices to be of low value. CONCLUSIONS Staff identified safety practices that they perceived to be low value. In healthcare systems under strain, removing existing low-value practices should be a priority. Careful evaluation of these identified safety practices is required to determine whether they are appropriate for deimplementation and, if not, to explore how to better support healthcare workers to perform them.
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A Multimodal Intervention for Reducing Unnecessary Repeat Glycated Hemoglobin Testing. Can J Diabetes 2023; 47:19-24. [PMID: 36008251 DOI: 10.1016/j.jcjd.2022.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 05/07/2022] [Accepted: 06/15/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Reducing unnecessary tests that do not enhance quality can promote health-care value. Glycated hemoglobin (A1C) is often ordered at a frequency exceeding the recommendation of once every 3 months. We conducted a quality improvement (QI) initiative aimed to reduce unnecessary repeat testing by 75% at a tertiary care academic hospital. METHODS A retrospective baseline analysis was conducted on laboratory data from 2019 that enumerated unnecessary A1C tests, defined as repeat tests ordered within 60 days. A multifaceted change intervention with iterative plan-do-study-act cycles was introduced in March 2019 to educate providers and to automatically cancel A1C tests requested within 60 days. Monthly totals of A1C testing processed were plotted on statistical process control charts. RESULTS In 2019, 11% of all A1C tests ordered were unnecessary. Between March 2020 and January 2021, 11% of the tests (N=14,247 tests) were unnecessary, of which 84% were cancelled with our intervention. Providers in cardiology and nephrology accounted for over half (55%) of the unnecessary tests ordered. CONCLUSIONS A 2-pronged approach informed by root-cause analysis, and comprised of gatekeeping and provider education, can effectively promote resource stewardship for reducing unnecessary A1C testing.
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Mathura P, Marini S, Spalding K, Duhn L, Kassam N, Medves J. Characteristics promoting behaviour change: physician experience with a coalition-led quality improvement initiative to reduce excessive laboratory test ordering. BMJ Open Qual 2023; 12:bmjoq-2022-001965. [PMID: 36627141 PMCID: PMC9835945 DOI: 10.1136/bmjoq-2022-001965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 12/23/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Attempts have been made to reduce excessive laboratory test ordering; however, the problem persists and barriers to physician involvement in quality improvement (QI) remain. We sought to understand physician participation experience following a laboratory test overuse initiative supported by a QI coalition. METHODS As part of a larger mixed-methods study, structured virtual interviews were conducted with 12 physicians. The Theoretical Domains Framework (TDF) and the Behavioural Change Wheel (BCW) were used to identify characteristics that influence physician behaviour change for QI leadership and participation and appropriate blood urea nitrogen (BUN) test ordering. A content analysis of physicians' statements to the TDF was performed, resulting in overarching themes; relevant TDF domains were mapped to the intervention functions of the BCW. RESULTS Nine overarching themes emerged from the data. Eight of 14 TDF domains influence QI leadership and participation, and 10 influence appropriate BUN-test ordering behaviours. The characteristics participants described that promoted a change in their QI participation, leadership and appropriate BUN-test ordering were: QI education with hands-on training; physician peer mentorship/support; personnel assistance (QI and analytics) and communication from a trusted/credible physician leader who shares data and insights about the physician role in the initiative, clinical best practice and past project success. Other elements included: a simply designed initiative requiring minimal effort and no clinical workflow disruptions; revised order forms/panels and limiting test-order frequency when laboratory tests are normal. Additionally, various future intervention strategies were identified. For their initial initiative participation, physicians acknowledged coalition leader or member credibility was more important than awareness of the coalition. CONCLUSIONS Based on physicians' described perceptions and experiences, coalition characteristics that influenced their QI leadership and participation, and appropriate BUN-test ordering behaviours were revealed; these characteristics aligned to several TDF domains. The findings suggest that these behaviours are multidimensional, requiring a multistrategy approach to change behaviour.
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Affiliation(s)
- Pamela Mathura
- Medicine, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Sandra Marini
- Medicine, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Karen Spalding
- School of Nursing, Queen's University, Kingston, Ontario, Canada
| | - Lenora Duhn
- School of Nursing, Queen's University, Kingston, Ontario, Canada
| | - Narmin Kassam
- Medicine, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Jennifer Medves
- School of Nursing, Queen's University, Kingston, Ontario, Canada
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O'Connor P, O'Malley R, Kaud Y, Pierre ES, Dunne R, Byrne D, Lydon S. A scoping review of patient safety research carried out in the Republic of Ireland. Ir J Med Sci 2023; 192:1-9. [PMID: 35122620 PMCID: PMC8817163 DOI: 10.1007/s11845-022-02930-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 01/19/2022] [Indexed: 02/04/2023]
Abstract
Maintaining the highest levels of patient safety is a priority of healthcare organisations. However, although considerable resources are invested in improving safety, patients still suffer avoidable harm. The aims of this study are: (1) to examine the extent, range, and nature of patient safety research activities carried out in the Republic of Ireland (RoI); (2) make recommendations for future research; and (3) consider how these recommendations align with the Health Service Executive's (HSE) patient safety strategy. A five-stage scoping review methodology was used to synthesise the published research literature on patient safety carried out in the RoI: (1) identify the research question; (2) identify relevant studies; (3) study selection; (4) chart the data; and (5) collate, summarise, and report the results. Electronic searches were conducted across five electronic databases. A total of 31 papers met the inclusion criteria. Of the 24 papers concerned with measuring and monitoring safety, 12 (50%) assessed past harm, 4 (16.7%) the reliability of safety systems, 4 (16.7%) sensitivity to operations, 9 (37.5%) anticipation and preparedness, and 2 (8.3%) integration and learning. Of the six intervention papers, three (50%) were concerned with education and training, two (33.3%) with simplification and standardisation, and one (16.7%) with checklists. One paper was concerned with identifying potential safety interventions. There is a modest, but growing, body of patient safety research conducted in the RoI. It is hoped that this review will provide direction to researchers, healthcare practitioners, and health service managers, in how to build upon existing research in order to improve patient safety.
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Affiliation(s)
- Paul O'Connor
- Department of General Practice, School of Medicine, National University of Ireland Galway, 1 Distillery Road, Galway, Co, Ireland.
- Irish Centre for Applied Patient Safety and Simulation, National University of Ireland Galway, Galway, Ireland.
| | - Roisin O'Malley
- Department of General Practice, School of Medicine, National University of Ireland Galway, 1 Distillery Road, Galway, Co, Ireland
- Irish Centre for Applied Patient Safety and Simulation, National University of Ireland Galway, Galway, Ireland
| | - Yazeed Kaud
- Department of General Practice, School of Medicine, National University of Ireland Galway, 1 Distillery Road, Galway, Co, Ireland
- Department of Public Health, Saudi Electronic University, Riyadh, Saudi Arabia
| | - Emily St Pierre
- School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - Rosie Dunne
- James Hardiman Library, National University of Ireland Galway, Galway, Ireland
| | - Dara Byrne
- Irish Centre for Applied Patient Safety and Simulation, National University of Ireland Galway, Galway, Ireland
- School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - Sinéad Lydon
- Irish Centre for Applied Patient Safety and Simulation, National University of Ireland Galway, Galway, Ireland
- School of Medicine, National University of Ireland Galway, Galway, Ireland
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Price DW. To Effectively Address Complex Healthcare Problems, Continuing Professional Development Must Evolve. THE JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS 2023; 43:S59-S63. [PMID: 38054493 DOI: 10.1097/ceh.0000000000000537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
ABSTRACT Continuing professional development aims to provide health professionals with the knowledge, skills, and competencies needed to improve care. Physicians and other clinicians increasingly practice within complex health care delivery organizations aiming to improve the care of populations of patients with multiple problems and differing needs. These organizations are composed of local units in different departments and venues; these teams and the patients they care for change over time. Improving outcomes within constantly changing complex organizations delivering population care takes time and persistence. It takes time to equip critical masses of clinicians and other personnel with knowledge and skills to effect change. Although some changes might be simple, those involving new workflows require implementation support. Not all change will be smooth; individuals need opportunities to learn from and adjust their early intervention efforts, measure effectiveness of change, and sustain successful practices. Longitudinal support is necessary to affect change over complex organizations. This essay proposes that to be more supportive and valuable to health care delivery organizations, continuing professional development needs to intentionally participate in longitudinal, collaborative, context-specific, team-based interventions. An expanded menu of evaluation approaches will better describe the role of continuing professional development in helping health care professionals and organizations address increasingly complex health care delivery problems and improve patient and population outcomes. Selected concepts to achieve these ends are introduced at a high level in this article. Readers are invited to explore concepts that resonate with their current situation in further detail.
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Affiliation(s)
- David W Price
- Dr. Price: Department of Family Medicine, University of Colorado Anschutz School of Medicine, Aurora, CO; and American Board of Family Medicine, Lexington, KY
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Levinson W, Leis JA. Improving healthcare value: Lessons learned from the first decade of Choosing Wisely®. J Hosp Med 2023; 18:78-81. [PMID: 36190815 PMCID: PMC10092587 DOI: 10.1002/jhm.12969] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 08/23/2022] [Accepted: 09/08/2022] [Indexed: 01/05/2023]
Affiliation(s)
- Wendy Levinson
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jerome A Leis
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Centre for Quality Improvement and Patient Safety, University of Toronto, Toronto, Ontario, Canada
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van Schie P, van Bodegom-Vos L, Zijdeman TM, Nelissen RGHH, Marang-van de Mheen PJ. Effectiveness of a multifaceted quality improvement intervention to improve patient outcomes after total hip and knee arthroplasty: a registry nested cluster randomised controlled trial. BMJ Qual Saf 2023; 32:34-46. [PMID: 35732486 DOI: 10.1136/bmjqs-2021-014472] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 05/20/2022] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To assess the effectiveness of a prospective multifaceted quality improvement intervention on patient outcomes after total hip and knee arthroplasty (THA and TKA). DESIGN Cluster randomised controlled trial nested in a national registry. From 1 January 2018 to 31 May 2020 routinely submitted registry data on revision and patient characteristics were used, supplemented with hospital data on readmission, complications and length of stay (LOS) for all patients. SETTING 20 orthopaedic departments across hospitals performing THA and TKA in The Netherlands. PARTICIPANTS 32 923 patients underwent THA and TKA, in 10 intervention and 10 control hospitals (usual care). INTERVENTION The intervention period lasted 8 months and consisted of the following components: (1) monthly updated feedback on 1-year revision, 30-day readmission, 30-day complications, long (upper quartile) LOS and these four indicators combined in a composite outcome; (2) interactive education; (3) an action toolbox including evidence-based quality improvement initiatives (QIIs) to facilitate improvement of above indicators; and (4) bimonthly surveys to report on QII undertaken. MAIN OUTCOME MEASURES The primary outcome was textbook outcome (TO), an all-or-none composite representing the best outcome on all performance indicators (ie, the absence of revision, readmissions, complications and long LOS). The individual indicators were analysed as secondary outcomes. Changes in outcomes from pre-intervention to intervention period were compared between intervention versus control hospitals, adjusted for case-mix and clustering of patients within hospitals using random effect binary logistic regression models. The same analyses were conducted for intervention hospitals that did and did not introduce QII. RESULTS 16,314 patients were analysed in intervention hospitals (12,475 before and 3,839 during intervention) versus 16,609 in control hospitals (12,853 versus 3,756). After the intervention period, the absolute probability to achieve TO increased by 4.32% (95% confidence interval (CI) 4.30-4.34) more in intervention than control hospitals, corresponding to 21.6 (95%CI 21.5-21.8), i.e., 22 patients treated in intervention hospitals to achieve one additional patient with TO. Intervention hospitals had a larger increase in patients achieving TO (ratio of adjusted odds ratios 1.24, 95%CI 1.05-1.48) than control hospitals, a larger reduction in patients with long LOS (0.74, 95%CI 0.61-0.90) but also a larger increase in patients with reported 30-day complications (1.34, 95%CI 1.00-1.78). Intervention hospitals that introduced QII increased more in TO (1.32, 95%CI 1.10-1.57) than control hospitals, with no effect shown for hospitals not introducing QII (0.93, 95%CI 0.67-1.30). CONCLUSION The multifaceted QI intervention including monthly feedback, education, and a toolbox to facilitate QII effectively improved patients achieving TO. The effect size was associated with the introduction of (evidence-based) QII, considered as the causal link to achieve better patient outcomes. TRIAL REGISTRATION NUMBER NCT04055103.
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Affiliation(s)
- Peter van Schie
- Orthopaedics, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
- Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Leti van Bodegom-Vos
- Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Tristan M Zijdeman
- Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Rob G H H Nelissen
- Orthopaedics, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Perla J Marang-van de Mheen
- Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
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Shin D, Krouss M, Alaiev D, Mestari N, Talledo J, Zaurova M, Chandra K, Manchego PA, Tsega S, Uppal A, Faillace RT, Moskovitz J, Ford K, Bouton M, Cho HJ. Reducing unnecessary routine laboratory testing for noncritically ill patients with COVID-19. J Hosp Med 2022; 17:961-966. [PMID: 36330542 PMCID: PMC9878235 DOI: 10.1002/jhm.12993] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 09/05/2022] [Accepted: 09/11/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Reducing unnecessary routine laboratory testing is a Choosing Wisely® recommendation, and new areas of overuse were noted during the COVID-19 pandemic. OBJECTIVE To reduce unnecessary repetitive routine laboratory testing for patients with COVID-19 during the pandemic across a large safety net health system. DESIGNS, SETTINGS AND PARTICIPANTS This quality improvement initiative was initiated by the System High-Value Care Council at New York City Health + Hospitals (H + H), the largest public healthcare system in the United States consisting of 11 acute care hospitals. INTERVENTION four overused laboratory tests in noncritically ill hospitalized patients with COVID-19 were identified: C-reactive protein (CRP), ferritin, lactate dehydrogenase (LDH), and procalcitonin. A two-pronged electronic health record intervention was implemented consisting of (1) nonintrusive, informational nudge statements placed on selected order sets, and (2) a forcing function of one consecutive day limit on ordering. MAIN OUTCOME AND MEASURES The average of excess tests per encounter days (ETPED) for each of four target laboratory testing only in patients with COVID-19. OBJECTIVE Interdisciplinary System High-Value Care Council identified four overused laboratory tests (inflammatory markers) in noncritically ill hospitalized patients with COVID-19: C-reactive protein (CRP), ferritin, lactate dehydrogenase (LDH), and procalcitonin. Within an 11-hospital safety net health system, a two-pronged electronic health record intervention was implemented consisting of (1) nonintrusive, informational nudge statements placed on selected order sets, and (2) a forcing function of one consecutive day limit on ordering. The preintervention period (March 16, 2020 to January 24, 2021) was compared to the postintervention period (January 25, 2021 to March 22, 2022). RESULTS Time series linear regression showed decreases in CRP (-17.9%, p < .05), ferritin (-37.6%, p < .001), and LDH (-30.1%, p < .001). Slope differences were significant (CRP, ferritin, and LDH p < 0.001; procalcitonin p < 0.05). Decreases were observed across weekly averages: CRP (-19%, p < .01), ferritin (-37.9%, p < .001), LDH (-28.7%, p < .001), and procalcitonin (-18.4%, p < .05). CONCLUSION This intervention was associated with reduced routine inflammatory marker testing in non-intensive care unit COVID-19 hospitalized patients across 11 hospitals. Variation was high among individual hospitals.
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Affiliation(s)
- Dawi Shin
- Department of Quality and SafetyNew York City Health + HospitalsNew York CityNew YorkUSA
- Department of MedicineIcahn School of MedicineNew York CityNew YorkUSA
| | - Mona Krouss
- Department of Quality and SafetyNew York City Health + HospitalsNew York CityNew YorkUSA
- Department of MedicineIcahn School of MedicineNew York CityNew YorkUSA
| | - Daniel Alaiev
- Department of Quality and SafetyNew York City Health + HospitalsNew York CityNew YorkUSA
| | - Nessreen Mestari
- Department of Quality and SafetyNew York City Health + HospitalsNew York CityNew YorkUSA
| | - Joseph Talledo
- Department of Quality and SafetyNew York City Health + HospitalsNew York CityNew YorkUSA
| | - Milana Zaurova
- Department of Quality and SafetyNew York City Health + HospitalsNew York CityNew YorkUSA
| | - Komal Chandra
- Department of Quality and SafetyNew York City Health + HospitalsNew York CityNew YorkUSA
| | - Peter A. Manchego
- Department of Quality and SafetyNew York City Health + HospitalsNew York CityNew YorkUSA
| | - Surafel Tsega
- Department of Quality and SafetyNew York City Health + HospitalsNew York CityNew YorkUSA
- Department of MedicineNYC Health + Hospitals/Kings County Hospital CenterNew York CityNew YorkUSA
| | - Amit Uppal
- Department of Medicine, Division of Pulmonary Disease and Critical Care MedicineBellevue Hospital Center and NYU Langone HealthNew York CityNew YorkUSA
| | - Robert T. Faillace
- Department of Emergency MedicineNYC Health + Hospitals/JacobiNew YorkThe BronxUSA
| | - Joshua Moskovitz
- Department of Emergency MedicineNYC Health + Hospitals/JacobiNew YorkThe BronxUSA
| | - Kenra Ford
- Office of Medical and Professional AffairsNew York City Health + HospitalsNew York CityNew YorkUSA
| | - Michael Bouton
- Enterprise Information Technology ServicesNYC Health + HospitalsNew York CityNew YorkUSA
| | - Hyung J. Cho
- Department of Quality and SafetyNew York City Health + HospitalsNew York CityNew YorkUSA
- Department of MedicineNew York University Grossman School of MedicineNew York CityNew YorkUSA
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Bonafide CP, Xiao R, Schondelmeyer AC, Pettit AR, Brady PW, Landrigan CP, Wolk CB, Cidav Z, Ruppel H, Muthu N, Williams NJ, Schisterman E, Brent CR, Albanowski K, Beidas RS. Sustainable deimplementation of continuous pulse oximetry monitoring in children hospitalized with bronchiolitis: study protocol for the Eliminating Monitor Overuse (EMO) type III effectiveness-deimplementation cluster-randomized trial. Implement Sci 2022; 17:72. [PMID: 36271399 PMCID: PMC9587657 DOI: 10.1186/s13012-022-01246-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 10/10/2022] [Indexed: 11/10/2022] Open
Abstract
Background Methods of sustaining the deimplementation of overused medical practices (i.e., practices not supported by evidence) are understudied. In pediatric hospital medicine, continuous pulse oximetry monitoring of children with the common viral respiratory illness bronchiolitis is recommended only under specific circumstances. Three national guidelines discourage its use for children who are not receiving supplemental oxygen, but guideline-discordant practice (i.e., overuse) remains prevalent. A 6-hospital pilot of educational outreach with audit and feedback resulted in immediate reductions in overuse; however, the best strategies to optimize sustainment of deimplementation success are unknown. Methods The Eliminating Monitor Overuse (EMO) trial will compare two deimplementation strategies in a hybrid type III effectiveness-deimplementation trial. This longitudinal cluster-randomized design will be conducted in Pediatric Research in Inpatient Settings (PRIS) Network hospitals and will include baseline measurement, active deimplementation, and sustainment phases. After a baseline measurement period, 16–19 hospitals will be randomized to a deimplementation strategy that targets unlearning (educational outreach with audit and feedback), and the other 16–19 will be randomized to a strategy that targets unlearning and substitution (adding an EHR-integrated clinical pathway decision support tool). The primary outcome is the sustainment of deimplementation in bronchiolitis patients who are not receiving any supplemental oxygen, analyzed as a longitudinal difference-in-differences comparison of overuse rates across study arms. Secondary outcomes include equity of deimplementation and the fidelity to, and cost of, each deimplementation strategy. To understand how the deimplementation strategies work, we will test hypothesized mechanisms of routinization (clinicians developing new routines supporting practice change) and institutionalization (embedding of practice change into existing organizational systems). Discussion The EMO trial will advance the science of deimplementation by providing new insights into the processes, mechanisms, costs, and likelihood of sustained practice change using rigorously designed deimplementation strategies. The trial will also advance care for a high-incidence, costly pediatric lung disease. Trial registration ClinicalTrials.gov,NCT05132322. Registered on November 10, 2021. Supplementary Information The online version contains supplementary material available at 10.1186/s13012-022-01246-z.
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Affiliation(s)
- Christopher P Bonafide
- Section of Hospital Medicine, Children's Hospital of Philadelphia, Children's Hospital of Philadelphia Hub for Clinical Collaboration, 3500 Civic Center Blvd, Philadelphia, PA, 19104, USA. .,Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, 2716 South Street, Philadelphia, PA, 19146, USA. .,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA. .,Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISCE@LDI), University of Pennsylvania, Philadelphia, USA.
| | - Rui Xiao
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, 206 Blockley Hall, 423 Guardian Drive, Philadelphia, PA, 19104-6021, USA
| | - Amanda C Schondelmeyer
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, 45229, USA.,Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, USA.,James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave ML 9016, Cincinnati, OH, 45229, USA
| | | | - Patrick W Brady
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, USA.,James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave ML 9016, Cincinnati, OH, 45229, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, USA
| | - Christopher P Landrigan
- Division of General Pediatrics, Boston Children's Hospital, Enders 1, 300 Longwood Ave, Boston, MA, 02115, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Courtney Benjamin Wolk
- Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISCE@LDI), University of Pennsylvania, Philadelphia, USA.,Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, Philadelphia, PA, 19104, USA.,Department of Medical Ethics and Health Policy, Perelman School of Medicine, Philadelphia, USA
| | - Zuleyha Cidav
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, Philadelphia, PA, 19104, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Halley Ruppel
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, 2716 South Street, Philadelphia, PA, 19146, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.,Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, USA
| | - Naveen Muthu
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, 2716 South Street, Philadelphia, PA, 19146, USA
| | - Nathaniel J Williams
- School of Social Work, Boise State University, 1910 W. University Drive, Boise, ID, 83725, USA.,Institute for the Study of Behavioral Health and Addiction, Boise State University, Boise, USA
| | - Enrique Schisterman
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, 206 Blockley Hall, 423 Guardian Drive, Philadelphia, PA, 19104-6021, USA
| | - Canita R Brent
- Section of Hospital Medicine, Children's Hospital of Philadelphia, Children's Hospital of Philadelphia Hub for Clinical Collaboration, 3500 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Kimberly Albanowski
- Section of Hospital Medicine, Children's Hospital of Philadelphia, Children's Hospital of Philadelphia Hub for Clinical Collaboration, 3500 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Rinad S Beidas
- Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISCE@LDI), University of Pennsylvania, Philadelphia, USA.,Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, Philadelphia, PA, 19104, USA.,Department of Medical Ethics and Health Policy, Perelman School of Medicine, Philadelphia, USA.,Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 3600 Civic Center Boulevard, 8th Floor, Philadelphia, PA, 19104, USA.,Penn Medicine Nudge Unit, University of Pennsylvania Health System, Philadelphia, USA.,Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA.,Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Verkerk EW, van Dulmen SA, Westert GP, Hooft L, Heus P, Kool RB. Reducing low-value care: what can we learn from eight de-implementation studies in the Netherlands? BMJ Open Qual 2022. [PMCID: PMC9454034 DOI: 10.1136/bmjoq-2021-001710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background Reducing the overuse of care that is proven to be of low value increases the quality and safety of care. We aimed to identify lessons for reducing low-value care by looking at: (1) The effects of eight de-implementation projects. (2) The barriers and facilitators that emerged. (3) The experiences with the different components of the projects. Methods We performed a process evaluation of eight multicentre projects aimed at reducing low-value care. We reported the quantitative outcomes of the eight projects on the volume of low-value care and performed a qualitative analysis of the project teams’ experiences and evaluations. A total of 40 hospitals and 198 general practitioners participated. Results Five out of eight projects resulted in a reduction of low-value care, ranging from 11.4% to 61.3%. The remaining three projects showed no effect. Six projects monitored balancing measures and observed no negative consequences of their strategy. The most important barriers were a lack of time, an inability to reassure the patient, a desire to meet the patient’s wishes, financial considerations and a discomfort with uncertainty. The most important facilitators were support among clinicians, knowledge of the harms of low-value care and a growing consciousness that more is not always better. Repeated education and feedback for clinicians, patient information material and organisational changes were valued components of the strategy. Conclusions Successfully reducing low-value care is possible in spite of the powerful barriers that oppose it. The projects managed to recruit many hospitals and general practices, with five of them achieving significant results without measuring negative consequences. Based on our findings, we offer practical recommendations for successfully reducing low-value care.
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Affiliation(s)
- Eva W Verkerk
- Department of IQ healthcare, Radboud university medical center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Simone A van Dulmen
- Department of IQ healthcare, Radboud university medical center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Gert P Westert
- Department of IQ healthcare, Radboud university medical center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Lotty Hooft
- Cochrane Netherlands, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Pauline Heus
- Cochrane Netherlands, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Rudolf B Kool
- Department of IQ healthcare, Radboud university medical center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
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Murray K, Fitzgerald E, Ali A, Crosby D, O'Reilly S, Lachman P. Developing future clinical leaders in patient safety: the Irish experience. BMJ LEADER 2022; 7:9-11. [PMID: 37013882 DOI: 10.1136/leader-2021-000462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 08/05/2022] [Indexed: 11/04/2022]
Abstract
IntroductionIt is 20 years since the Institute of Medicine advocated a national approach to improve care and patient safety. Patient safety infrastructure has greatly improved in certain countries. In Ireland, patient safety infrastructure is in ongoing development. To contribute to this, the Royal College of Physicians of Ireland/International Society for Quality in Healthcare Scholar in Residence Programme was launched in 2016. This programme aims to improve patient safety and develop a movement of future clinician leaders to drive improvements in patient safety and the quality of care.MethodsDoctors in postgraduate training complete a year-long immersive mentorship. This involves monthly group meetings with key patient safety opinion makers, one-on-one mentorship, leadership courses, conference attendance and presentations. Each scholar undertakes a quality improvement (QI) project.ResultsA QI project was associated with a decrease in caesarean section rates from 13.7% to 7.6% (p=0.0002) among women in spontaneous labour at term with a cephalic presentation. Other projects are ongoing.ConclusionMedical error, patient safety and QI must be addressed comprehensively at both undergraduate and postgraduate level. We believe the Irish mentorship programme will help to change the paradigm and improve patient safety.
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Affiliation(s)
- Kieran Murray
- Rheumatologist, University Hospital Limerick, Dooradoyle, Limerick, Ireland
| | | | - Ahmeda Ali
- General Practitioner, Irish College of General Practitioners, Dublin, Ireland
| | - David Crosby
- Obstetrician, National Maternity Hospital, Dublin 2, Dublin, Ireland
| | - Susanne O'Reilly
- Gastroenterology, St Vincent's Healthcare Group Ltd, Dublin 4, Dublin, Ireland
| | - Peter Lachman
- Lead Faculty Quality Improvement Programme, Royal College of Physicians of Ireland, Dublin, Ireland
- International Society for Quality in Health Care, Dublin, Ireland
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Ambasta A. Ten Years Since the Choosing Wisely Campaign: Are We Ordering Laboratory Tests More Wisely in Our Hospitalized Patients? Jt Comm J Qual Patient Saf 2022; 48:500-502. [DOI: 10.1016/j.jcjq.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Frazier SB, Walsh M, Beveridge G, Thornton C, Otillio JK, Fain E, Patterson B. It Pays to be Accurate: Improving Critical Care Documentation in a Pediatric Emergency Department. Hosp Pediatr 2022; 12:726-734. [PMID: 35818843 DOI: 10.1542/hpeds.2021-006459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Clinician documentation is highly variable, and awareness of documentation requirements remains low despite post-training experience. At our hospital, critical care (CC) documentation was inconsistent. Our aim was to increase appropriate CC attestations from 51% to 90% for status asthmaticus, anaphylaxis, and diabetic ketoacidosis in the pediatric emergency department by December 2021. METHODS A physician team developed a key driver diagram. Retrospective baseline data using International Classification of Diseases, Ninth and Tenth Revision codes were obtained from January 2018 to September 2020, after which data were followed prospectively in consecutive groups of 20 encounters. Statistical process control charts were used to analyze data. Nelson rules were used to detect special cause variation. Primary outcome was the inclusion of appropriate CC attestations. Interventions included education, CC attestation templates, and provider feedback. We also tracked charges for the 3 diagnoses studied. Process measures included template use. Balancing measure was refusal of payment by insurers. RESULTS P-charts were used to analyze primary outcome and process measures. X-bar charts were used to analyze charges. Baseline data represented 706 encounters with 51% including CC documentation. Following clinician education and release of the CC template, special cause variation was detected, and centerline shifted to 88.1% (Fig 2). Average charges per encounter increased from $4527 to $5385. There was no reported refusal of payment. CONCLUSIONS We successfully achieved improvements in CC documentation in the 3 diagnoses of interest through education and process changes in documentation, leading over $1 million in new charges over the past 15 months.
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Affiliation(s)
- S Barron Frazier
- Division of Pediatric Emergency Medicine, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Michele Walsh
- Division of Pediatric Emergency Medicine, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | | | | | - Jaime Kaye Otillio
- Division of Pediatric Emergency Medicine, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Emily Fain
- Division of Pediatric Emergency Medicine, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
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Ostrow O, Prodanuk M, Foong Y, Singh V, Morrissey L, Harvey G, Campigotto A, Science M. Decreasing Misdiagnoses of Urinary Tract Infections in a Pediatric Emergency Department. Pediatrics 2022; 150:188353. [PMID: 35773521 DOI: 10.1542/peds.2021-055866] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/29/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Urinary tract infection (UTI) is a common diagnosis in the emergency department (ED), often resulting in empirical antibiotic treatment before culture results. Diagnosis of a UTI, particularly in children, can be challenging and misdiagnosis is common. The aim of this initiative was to decrease the misdiagnosis of uncomplicated pediatric UTIs by 50% while improving antimicrobial stewardship in the ED over 4 years. METHODS By using the Model for Improvement, 3 interventions were developed: (1) an electronic UTI diagnostic algorithm, (2) a callback system, and (3) a standardized discharge antibiotic prescription. Outcome measures included the percentage of patients with UTI misdiagnosis (prescribed antibiotics, but urine culture results negative) and antibiotic days saved. As a balancing measure, positive urine culture results without a UTI diagnosis were reviewed for ED return visits or hospitalization. Statistical process control and run charts were used for analysis. RESULTS From 2017 to 2021, the mean UTI misdiagnosis decreased from 54.6% to 26.4%. The adherence to the standardized antibiotic duration improved from 45.1% to 84.6%. With the callback system, 2128 antibiotic days were saved with a median of 89% of patients with negative culture results contacted to discontinue antibiotics. Of 186 patients with positive urine culture results with an unremarkable urinalysis, 14 returned to the ED, and 2 were hospitalized for multiresistant organism UTI treatment. CONCLUSIONS A UTI diagnostic algorithm coupled with a callback system safely reduced UTI misdiagnoses and antibiotic usage. Embedding these interventions electronically as a decision support tool, targeted audit and feedback, reminders, and education all supported long-term sustainability.
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Affiliation(s)
- Olivia Ostrow
- Division of Pediatric Emergency Medicine, Department of Pediatrics.,Departments of Pediatrics
| | - Michael Prodanuk
- Division of Pediatric Medicine, Department of Pediatrics.,Departments of Pediatrics
| | - Yen Foong
- Division of Pediatric Medicine, Department of Pediatrics.,Departments of Pediatrics
| | - Valene Singh
- Division of Pediatric Medicine, Department of Pediatrics.,Departments of Pediatrics
| | - Laura Morrissey
- Division of Pediatric Emergency Medicine, Department of Pediatrics.,Departments of Pediatrics
| | - Greg Harvey
- Division of Pediatric Emergency Medicine, Department of Pediatrics.,Departments of Pediatrics
| | - Aaron Campigotto
- Division of Microbiology, Department of Pediatric Laboratory Medicine.,Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Michelle Science
- Division of Infectious Disease, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada.,Departments of Pediatrics
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Graham F, Beattie E, Fielding E. Hospital nurses' management of agitation in older cognitively impaired patients: do they recognise pain-related agitation? Age Ageing 2022; 51:6632478. [PMID: 35796135 DOI: 10.1093/ageing/afac140] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND cognitively impaired hospital patients often experience agitation and aggression due to pain. Agitation complicates care, increasing the risk of adverse outcomes and patient-to-nurse violence. Managing agitation is challenging for nurses. Literature suggests they may rely on antipsychotics while missing other more appropriately targeted treatments. However, nurses' management of agitation remains unclear and under-researched. OBJECTIVE the aim of this study was to investigate hospital nurses' management of agitation in older cognitively impaired patients with pain. DESIGN this was a descriptive correlational study using virtual simulation. SETTING AND PARTICIPANTS a total of 274 registered medical and surgical nurses from 10 public hospitals in Queensland, Australia participated in the study. METHODS nurses undertook a virtual simulation requiring them to manage agitation in a patient with dementia and an injury. Nurses also completed a post-simulation questionnaire. Their simulation performances were correlated with demographics such as seniority, workplace, training, experience and gerontology-specific knowledge. Constructed from an original, validated vignette, the simulation included branching pathways, video scenarios and an avatar that could converse with participants. RESULTS thirteen nurses (4.7%) recognised and treated the virtual patient's agitation as pain-related. Most nurses (89%) gave antipsychotics of which 207 (78%) gave these first-line and 102 (38%) used them twice. Independent of other variables, nurses most likely to diagnose pain were dementia-unit nurses (OR = 8.7), surgical-unit nurses (OR = 7.3) and senior nurses (OR = 5). CONCLUSIONS hospital nurses predominately managed agitation with antipsychotics, a decision that most made after undertaking inadequate patient assessments. This confirmed a common gap in practice that may lead to the missing of pain in the clinical care of agitated patients with dementia and/or delirium.
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Affiliation(s)
- Frederick Graham
- Division of Medicine, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
- School of Nursing, Queensland University of Technology, Brisbane City, QLD, Australia
| | - Elizabeth Beattie
- School of Nursing, Queensland University of Technology, Brisbane City, QLD, Australia
| | - Elaine Fielding
- School of Nursing, Queensland University of Technology, Brisbane City, QLD, Australia
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McShane EK, Sun BJ, Maggio PM, Spain DA, Forrester JD. Improving tracheostomy delivery for trauma and surgical critical care patients: timely trach initiative. BMJ Open Qual 2022; 11:e001589. [PMID: 35551095 PMCID: PMC9109116 DOI: 10.1136/bmjoq-2021-001589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 04/26/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Tracheostomy is recommended within 7 days of intubation for patients with severe traumatic brain injury (TBI) or requiring prolonged mechanical ventilation. A quality improvement project aimed to decrease time to tracheostomy to ≤7 days after intubation for eligible patients requiring tracheostomy in the surgical intensive care unit (SICU). LOCAL PROBLEM From January 2017 to June 2018, approximately 85% of tracheostomies were performed >7 days after intubation. The tracheostomy was placed a median of 10 days after intubation (range: 1-57). METHODS Quality improvement principles were applied at an American College of Surgeons-verified level I trauma centre to introduce and analyse interventions to improve tracheostomy timing. Using the electronic health record, we analysed changes in tracheostomy timing, hospital length of stay (LOS), ventilator-associated pneumonia and peristomal bleeding rates for three subgroups: patients with TBI, trauma patients and all SICU patients. INTERVENTIONS In July 2018, an educational roll-out for SICU residents and staff was launched to inform them of potential benefits of early tracheostomy and potential complications, which they should discuss when counselling patient decision-makers. In July 2019, an early tracheostomy workflow targeting patients with head injury was published in an institutional Trauma Guide app. RESULTS Median time from intubation to tracheostomy decreased for all patients from 14 days (range: 4-57) to 8 days (range: 1-32, p≤0.001), and median hospital LOS decreased from 38 days to 24 days (p<0.001, r=0.35). Median time to tracheostomy decreased significantly for trauma patients after publication of the algorithm (10 days (range: 3-21 days) to 6 days (range: 1-15 days), p=0.03). Among patients with TBI, family meetings were held earlier for patients who underwent early versus late tracheostomy (p=0.008). CONCLUSIONS We recommend regular educational meetings, enhanced by digitally published guidelines and strategic communication as effective ways to improve tracheostomy timing. These interventions standardised practice and may benefit other institutions.
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Affiliation(s)
- Erin K McShane
- Stanford University School of Medicine, Stanford, California, USA
| | - Beatrice J Sun
- Department of Surgery, Stanford University, Stanford, California, USA
| | - Paul M Maggio
- Department of Surgery, Stanford University, Stanford, California, USA
| | - David A Spain
- Department of Surgery, Stanford University, Stanford, California, USA
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Reducing the Time to Blood Administration after Pediatric Injury: A Quality Improvement Initiative. Pediatr Qual Saf 2022; 7:e563. [PMID: 35720867 PMCID: PMC9197352 DOI: 10.1097/pq9.0000000000000563] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 04/02/2022] [Indexed: 11/26/2022] Open
Abstract
Introduction Hemorrhage is the leading cause of preventable death in pediatric trauma patients. Timely blood administration is associated with improved outcomes in children and adults. This study aimed to identify delays to transfusion and improve the time to blood administration among injured children. Methods A multidisciplinary team identified three activities associated with blood transfusion delays during the acute resuscitation of injured children. To address delays related to these activities, we relocated the storage of un-crossmatched blood to the emergency department (ED), created and disseminated an intravenous access algorithm, and established a nursing educator role for resuscitations. We performed comparative and regression analyses to identify the impact of these factors on the timeliness and likelihood of blood administration. Results From January 2017 to June 2021, we treated 2159 injured children and adolescents in the resuscitation area, 54 (2.5%) of whom received blood products in the ED. After placing a blood storage refrigerator in the ED, we observed a centerline change that lowered the adjusted time-to-blood administration to 17 minutes (SD 11), reducing the time-to-blood administration by 11 minutes (β = -11.0, 95% CI = -22.0 to -0.9). The likelihood of blood administration was not changed after placement of the blood refrigerator. We observed no reduction in time following the implementation of the intravenous access algorithm or a nursing educator. Conclusions Relocation of un-crossmatched blood storage to the ED decreased the time to blood transfusion. This system-based intervention should be considered a strategy for reducing delays in transfusion in time-critical settings.
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44
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Sanderson PM, Loeb RG, Liley H, Liu D, Paterson E, Hinckfuss K, Zestic J. Signaling Patient Oxygen Desaturation with Enhanced Pulse Oximetry Tones. Biomed Instrum Technol 2022; 56:46-57. [PMID: 35671368 PMCID: PMC9767428 DOI: 10.2345/0899-8205-56.2.46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Manufacturers could improve the pulse tones emitted by pulse oximeters to support more accurate identification of a patient's peripheral oxygen saturation (SpO2) range. In this article, we outline the strengths and limitations of the variable-pitch tone that represents SpO2 of each detected pulse, and we argue that enhancements to the tone to demarcate clinically relevant ranges are feasible and desirable. The variable-pitch tone is an appreciated and trusted feature of the pulse oximeter's user interface. However, studies show that it supports relative judgments of SpO2 trends over time and is less effective at supporting absolute judgments about the SpO2 number or conveying when SpO2 moves into clinically important ranges. We outline recent studies that tested whether acoustic enhancements to the current tone could convey clinically important ranges more directly, without necessarily using auditory alarms. The studies cover the use of enhanced variable-pitch pulse oximeter tones for neonatal and adult use. Compared with current tones, the characteristics of the enhanced tones represent improvements that are both clinically relevant and statistically significant. We outline the benefits of enhanced tones, as well as discuss constraints of which developers of enhanced tones should be aware if enhancements are to be successful.
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Affiliation(s)
- Penelope M Sanderson
- Penelope M. Sanderson, PhD, is professor of cognitive engineering and human factors in the Schools of Psychology, Clinical Medicine, and Information Technology and Electrical Engineering at The University of Queensland in Queensland, Australia.
| | - Robert G Loeb
- Robert G. Loeb, MD, is an honorary professor in the School of Psychology at The University of Queensland in Queensland, Australia, and an emeritus clinical professor at University of Florida-Gainesville
| | - Helen Liley
- Helen Liley, MBCh, FRACP, is a senior staff specialist at Mater Mothers' Hospital and a professor in the Faculty of Medicine at The University of Queensland in Queensland, Australia
| | - David Liu
- David Liu, MBBS, PhD, is an anaesthetics registrar at Sunshine Coast University Hospital in Queensland, Australia, and a senior lecturer in the Faculty of Medicine at The University of Queensland in Queensland, Australia
| | - Estrella Paterson
- Estrella Paterson, PhD, is a postdoctoral fellow in the School of Psychology at The University of Queensland in Queensland, Australia
| | - Kelly Hinckfuss
- Kelly Hinckfuss, MPhil, is a clinical masters student in the School of Psychology at The University of Queensland in Queensland, Australia
| | - Jelena Zestic
- Jelena Zestic, PhD, is a human systems engineer at Boeing Research and Technology in Brisbane, Australia
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45
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Sanderson PM, Loeb RG, Liley H, Liu D, Paterson E, Hinckfuss K, Zestic J. Signaling Patient Oxygen Desaturation with Enhanced Pulse Oximetry Tones. Biomed Instrum Technol 2022. [PMID: 35671368 DOI: 10.2345/1943-5967-56.2.46] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Manufacturers could improve the pulse tones emitted by pulse oximeters to support more accurate identification of a patient's peripheral oxygen saturation (SpO2) range. In this article, we outline the strengths and limitations of the variable-pitch tone that represents SpO2 of each detected pulse, and we argue that enhancements to the tone to demarcate clinically relevant ranges are feasible and desirable. The variable-pitch tone is an appreciated and trusted feature of the pulse oximeter's user interface. However, studies show that it supports relative judgments of SpO2 trends over time and is less effective at supporting absolute judgments about the SpO2 number or conveying when SpO2 moves into clinically important ranges. We outline recent studies that tested whether acoustic enhancements to the current tone could convey clinically important ranges more directly, without necessarily using auditory alarms. The studies cover the use of enhanced variable-pitch pulse oximeter tones for neonatal and adult use. Compared with current tones, the characteristics of the enhanced tones represent improvements that are both clinically relevant and statistically significant. We outline the benefits of enhanced tones, as well as discuss constraints of which developers of enhanced tones should be aware if enhancements are to be successful.
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Affiliation(s)
- Penelope M Sanderson
- Penelope M. Sanderson, PhD, is professor of cognitive engineering and human factors in the Schools of Psychology, Clinical Medicine, and Information Technology and Electrical Engineering at The University of Queensland in Queensland, Australia.
| | - Robert G Loeb
- Robert G. Loeb, MD, is an honorary professor in the School of Psychology at The University of Queensland in Queensland, Australia, and an emeritus clinical professor at University of Florida-Gainesville
| | - Helen Liley
- Helen Liley, MBCh, FRACP, is a senior staff specialist at Mater Mothers' Hospital and a professor in the Faculty of Medicine at The University of Queensland in Queensland, Australia
| | - David Liu
- David Liu, MBBS, PhD, is an anaesthetics registrar at Sunshine Coast University Hospital in Queensland, Australia, and a senior lecturer in the Faculty of Medicine at The University of Queensland in Queensland, Australia
| | - Estrella Paterson
- Estrella Paterson, PhD, is a postdoctoral fellow in the School of Psychology at The University of Queensland in Queensland, Australia
| | - Kelly Hinckfuss
- Kelly Hinckfuss, MPhil, is a clinical masters student in the School of Psychology at The University of Queensland in Queensland, Australia
| | - Jelena Zestic
- Jelena Zestic, PhD, is a human systems engineer at Boeing Research and Technology in Brisbane, Australia
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Rajaram A, Patel N, Hickey Z, Wolfrom B, Newbigging J. Perspectives of undergraduate and graduate medical trainees on documenting clinical notes: Implications for medical education and informatics. Health Informatics J 2022; 28:14604582221093498. [PMID: 35593170 DOI: 10.1177/14604582221093498] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Ensuring the accuracy of unstructured clinical notes is critical for patient care, research, and quality improvement. Understanding how trainees learn to document these notes and the challenges they encounter are important steps to developing educational and informatics solutions.Authors conducted focus groups to gather the perspectives of 40 medical students (MS) and family and emergency medicine (EM) residents on recording clinical notes in the electronic medical record (EMR). Focus groups were audio recorded, transcribed, and thematically analyzed.Thematic analysis with a deductive approach revealed: a lack of formal education, a shift from information gathering to documenting clinical reasoning with seniority, and barriers to charting development, including variable preceptor expectations and EMR design constraints.Participating trainees report gaps in education around the documentation of notes in the EMR. Future work should explore opportunities to reduce gaps, including more formal education, the creation of specific competencies, and improvements to the EMR.
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Affiliation(s)
- Akshay Rajaram
- Department of Family Medicine, Queen's University, Kingston, ON, Canada.,Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Nimesh Patel
- Department of Family Medicine, Queen's University, Kingston, ON, Canada
| | - Zachary Hickey
- Department of Emergency Medicine, Queen's University, Kingston, ON, Canada
| | - Brent Wolfrom
- Department of Family Medicine, Queen's University, Kingston, Canada
| | - Joseph Newbigging
- Department of Family Medicine, Queen's University, Kingston, ON, Canada.,Department of Emergency Medicine, Queen's University, Kingston, ON, Canada
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Zhao J, Bai W, Zhang Q, Su Y, Wang J, Du X, Zhou Y, Kong C, Qing Y, Gong S, Meng M, Wei C, Li D, Wu J, Li X, Chen W, Hu J. Evidence-based practice implementation in healthcare in China: a living scoping review. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2022; 20:100355. [PMID: 35036975 PMCID: PMC8743207 DOI: 10.1016/j.lanwpc.2021.100355] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Evidence-based practice (EBP) implementation plays a crucial role in bridging the knowledge-action gaps and reducing health inequities. Little is known about its development in China. This study aims to provide an overview of the EBP implementation research progress in healthcare in China and identify gaps for future studies. METHODS We conducted a scoping review following the Joanna Briggs Institute scoping review methodology and the Cochrane Collaboration's guidance on living reviews. We performed a literature search in four Chinese databases (i.e., China National Knowledge Infrastructure, Wan Fang Database, The VIP Database, and China Biology Medicine) and three English databases (i.e., Ovid MEDLINE, the Cumulative Index to Nursing and Allied Health Literature, and EMBASE), Google scholar, and Baidu scholar from 1996 to 2021. We included EBP implementation studies conducted in healthcare settings in China and were published in Chinese and English literature. The search will be run on a regular basis to monitor the development of new literature and determine when to update the review. FINDINGS Of the 11,276 records identified, we finally included 309 papers. The publications were on a sharp rise since 2013 and were predominantly from the nursing field (292/309, 94.50%). The commonly researched areas were symptom management (75/309, 24.27%), tube care (46/309, 14.89%), perioperative care (43/309, 13.92%), and fundamental care (43/309, 13.92%). Joanna Briggs Institute model was the most frequently used model to guide the implementation process (92/159, 59.75%). A median number of 8 people often comprised an implementation team, with 113 studies (36.57%) taking a multidisciplinary approach. 204 studies reported utilizing audit criteria to assist evaluation of evidence implementation rate with diversified methods measuring the criteria. Lack of knowledge, skills, and resources, and incomplete procedures or pathways were top barriers impeding EBP implementation. Leadership support was considered the most common facilitator. Education and training were the most frequently described implementation strategies for healthcare professionals and patients. Optimizing workflows and developing evaluation tools were the primary strategies adopted by organizations. 291 studies measured patient outcomes and 174 studies measured healthcare professional outcomes. INTERPRETATION To our knowledge, this scoping review is the first one to systematically examine the EBP implementation research progress in healthcare in China. Based on this review, we identified contributions that Chinese EBP implementation research made to the global community, and provided eight recommendations for Chinese researchers in conducting implementation studies in the future. FUNDING None.
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Affiliation(s)
- Junqiang Zhao
- School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, Canada
| | - Wenhui Bai
- Department of nursing, Henan Provincial Key Medicine Laboratory of Nursing, Henan Provincial People's Hospital, Zhengzhou, China
| | - Qian Zhang
- School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, Canada
| | - Yujie Su
- School of Nursing, Lanzhou University, Lanzhou, China
| | - Jinfang Wang
- School of Nursing, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Xiaoning Du
- Department of nursing, Henan Provincial Key Medicine Laboratory of Nursing, Henan Provincial People's Hospital, Zhengzhou, China
| | - Yajing Zhou
- School of Nursing, Beijing University of Chinese Medicine, Beijing, China
| | - Chang Kong
- School of Nursing, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Yanbing Qing
- School of Nursing, Beijing University of Chinese Medicine, Beijing, China
| | - Shaohua Gong
- School of Nursing, Beijing University of Chinese Medicine, Beijing, China
| | - Meiqi Meng
- School of Nursing, Beijing University of Chinese Medicine, Beijing, China
| | - Changyun Wei
- School of Nursing, Beijing University of Chinese Medicine, Beijing, China
| | - Dina Li
- School of Nursing, Beijing University of Chinese Medicine, Beijing, China
| | - Jian Wu
- School of Nursing, Beijing University of Chinese Medicine, Beijing, China
| | - Xuejing Li
- School of Nursing, Beijing University of Chinese Medicine, Beijing, China
| | - Wenjun Chen
- School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, Canada
- Xiangya School of Nursing, Central South University, Changsha, China
| | - Jiale Hu
- Department of Nurse Anesthesia, Virginia Commonwealth University, Richmond, USA
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Hamad DM, Mandell SP, Stewart RM, Patel B, Guttman MP, Williams P, Thomas A, Jerath A, Bulger EM, Nathens AB. Error reduction in trauma care: Lessons from an anonymized, national, multicenter mortality reporting system. J Trauma Acute Care Surg 2022; 92:473-480. [PMID: 34840270 DOI: 10.1097/ta.0000000000003485] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Twenty years ago, the landmark report To Err Is Human illustrated the importance of system-level solutions, in contrast to person-level interventions, to assure patient safety. Nevertheless, rates of preventable deaths, particularly in trauma care, have not materially changed. The American College of Surgeons Trauma Quality Improvement Program developed a voluntary Mortality Reporting System to better understand the underlying causes of preventable trauma deaths and the strategies used by centers to prevent future deaths. The objective of this work is to describe the factors contributing to potentially preventable deaths after injury and to evaluate the effectiveness of strategies identified by trauma centers to mitigate future harm, as reported in the Mortality Reporting System. METHODS An anonymous structured web-based reporting template based on the Joint Commission on Accreditation of Healthcare Organizations taxonomy was made available to trauma centers participating in the Trauma Quality Improvement Program to allow for reporting of deaths that were potentially preventable. Contributing factors leading to death were evaluated. The effectiveness of mitigating strategies was assessed using a validated framework and mapped to tiers of effectiveness ranging from person-focused to system-oriented interventions. RESULTS Over a 2-year period, 395 deaths were reviewed. Of the mortalities, 33.7% were unanticipated. Errors pertained to management (50.9%), clinical performance (54.7%), and communication (56.2%). Human failures were cited in 61% of cases. Person-focused strategies like education were common (56.0%), while more effective system-based strategies were seldom used. In 7.3% of cases, centers could not identify a specific strategy to prevent future harm. CONCLUSION Most strategies to reduce errors in trauma centers focus on changing the performance of providers rather than system-level interventions such as automation, standardization, and fail-safe approaches. Centers require additional support to develop more effective mitigations that will prevent recurrent errors and patient harm. LEVEL OF EVIDENCE Therapeutic/Care Management, level V.
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Affiliation(s)
- Doulia M Hamad
- From the Department of Surgery (D.M.H., M.P.G., P.W., A.B.N.), Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada; Department of Surgery (S.P.M.), UT Southwestern Medical Center, Dallas, Texas; Department of Surgery (R.M.S.), University of Texas Health Science Center, San Antonio, Texas; Trauma Quality Improvement Program (B.P., A.T., A.B.N.), American College of Surgeons, Chicago, Illinois; Feinberg School of Medicine (A.T.), Northwestern University, Chicago, Illinois; Department of Anesthesia (A.J.), Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada; and Division of Trauma, Critical Care and Burn Surgery (E.M.B.), University of Washington, Seattle, Washington
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49
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Carrigan I, Ma IWY, Ambasta A. A Framework for Purposeful Utilization of Laboratory Tests in Hospitalized Patients. Am J Med 2022; 135:278-280. [PMID: 34537156 DOI: 10.1016/j.amjmed.2021.08.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 08/11/2021] [Indexed: 11/15/2022]
Affiliation(s)
- Ian Carrigan
- Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Irene W Y Ma
- Cumming School of Medicine, University of Calgary, Alberta, Canada; Ward of the 21(st) Century, University of Calgary, Alberta, Canada
| | - Anshula Ambasta
- Cumming School of Medicine, University of Calgary, Alberta, Canada; Ward of the 21(st) Century, University of Calgary, Alberta, Canada.
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50
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Isserman RS, Cheung J, Varallo D, Cafone J, Lee J, Chiotos K, Muhly WT, Metjian TA, Swami S, Baldwin K, Tan JM. Increasing Cefazolin Use for Perioperative Antibiotic Prophylaxis in Penicillin-Allergic Children. Pediatrics 2022; 149:184738. [PMID: 35229120 DOI: 10.1542/peds.2021-050694] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/01/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Cefazolin, a first-generation cephalosporin, is the most commonly recommended antibiotic for perioperative prophylaxis to reduce surgical site infections. Children with a reported penicillin allergy often receive an alternative antibiotic because of a common misunderstanding of the cross-reactivity between these antibiotics. This use of alternative antibiotics in surgical populations have been associated with increased infections, antibiotic resistance, and health care costs. We aimed to increase the percentage of patients with nonsevere penicillin-class allergies who receive cefazolin for antibiotic prophylaxis. METHODS A multidisciplinary team conducted this quality improvement initiative, with a series of 3 plan-do-study-act cycles aimed at children with nonsevere penicillin-class allergies undergoing surgical procedures that require antibiotic prophylaxis. The primary outcome measure was the percentage of surgical encounters among patients with nonsevere penicillin-class allergies who received cefazolin as antibiotic prophylaxis. Statistical process control charts were used to measure improvement over time. RESULTS Approximately 400 children were involved in this project. There was special cause variation and a shift in the center line from 60% to 80% of eligible patients receiving cefazolin for antibiotic prophylaxis, which was sustained for the duration of the project. In the last month, 90% of eligible patient received cefazolin, surpassing our goal of 85%. This improvement has been sustained in the 5 months after project completion. We had no cases of severe allergic reactions in the operating room. CONCLUSIONS Our multidisciplinary education-focused interventions were associated with a significant increase in the use of cefazolin for perioperative antibiotic prophylaxis in patient with penicillin allergies.
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Affiliation(s)
- Rebecca S Isserman
- Department of Anesthesiology and Critical Care Medicine.,University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Jazreel Cheung
- Center for Healthcare Quality and Analytics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Domonique Varallo
- Center for Healthcare Quality and Analytics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Juhee Lee
- Divisions of Allergy and Immunology and
| | - Kathleen Chiotos
- Department of Anesthesiology and Critical Care Medicine.,Infectious Diseases, Department of Pediatrics.,University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Wallis T Muhly
- Department of Anesthesiology and Critical Care Medicine.,University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | | | - Sanjeev Swami
- Infectious Diseases, Department of Pediatrics.,University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Keith Baldwin
- Division of Orthopaedics, Department of Surgery.,University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Jonathan M Tan
- Children's Hospital Los Angeles and Keck School of Medicine, University of Southern CaliforniaLos Angeles, California
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