The top patient safety strategies that can be encouraged for adoption now

Venous thromboembolism performance measurement in the United States: An evolving landscape with many stakeholders

Venous thromboembolism (VTE), including deep vein thrombosis and pulmonary embolism, is a life-threatening, costly, and common preventable complication associated with hospitalization. Although VTE prevention strategies such as risk assessment and prophylaxis are available, they are not applied uniformly or systematically across US hospitals and healthcare systems. Hospital-level performance measurement has been used nationally to promote standardized approaches for VTE prevention and incentivize the adoption of guideline-based care management. Though most measures reflect care processes rather than outcomes, certain domains including diagnosis, treatment, and continuity of care remain unmeasured. In this article, we describe the development of VTE prevention measures from various stakeholders, measure strengths and limitations, publicly reported rates, the impact of technology and health policy on measure use, and perspectives on future options for surveillance and performance monitoring.

Comparison of medical students' perceptions of patient safety: Focusing on simulation training using a high-fidelity simulator

Patient safety education is necessary for the provision of high-quality medical services. A significant aspect of patient safety education is simulation training, which allows medical students to experience realistic clinical environments. This study aimed to verify the effectiveness of patient safety education using simulation training. We retrospectively analyzed the results of a 30-question questionnaire survey on the perceptions of patient safety before and after simulation training, which was completed by 40 medical students who participated in clinical practice between June and December 2021. A paired t-test was performed by calculating the mean and standard deviation for each item. We found that students' overall perceptions of patient safety improved after training. Specifically, after simulation training, attitudes toward patient safety were maintained at the same level as before training, while students' self-efficacy of patient safety increased. Simulation training is effective in improving students' perceptions of patient safety, and increasing students' confidence can improve their clinical performance. To maintain this effect, repeated learning is required, and theoretical classes and simulation training should be used appropriately for patient safety education in the future.

Real-Time Ultrasound Tip Location Reduces Malposition and Radiation Exposure during Epicutaneo-Caval Catheter Placement in Neonates

OBJECTIVE

Epicutaneo-caval catheters (ECCs) are essential for the care of sick infants who require long-term medical and nutritional management. The aim of this study was to investigate the use of real-time ultrasound as an alternative to X-rays to reduce the incidence of primary malpositions during catheter insertion.

STUDY DESIGN

Data on ECCs were retrospectively collected in a tertiary neonatal intensive care unit. Catheter were analyzed considering the tip location technique (standard chest-abdominal radiograph vs real-time ultrasound) RESULTS:  A total of 248 ECCs were analyzed. Of these, 118 catheters had primary malposition (47.6%). The tip of 165 catheters was assessed using standard chest-abdominal X-rays and 107 (64.8%) were found to be in an inappropriate location. In the group of 83 catheters that were placed using real-time ultrasound for tip location, only 11 catheters (13.2%) had primary malposition. The rate of malposition among the two groups showed a statistically significant difference (p < 0.001). Hypothetically, 300 chest X-rays could have been saved if real-time ultrasound had been used to locate the tip, reducing radiation exposure to infants.

CONCLUSION

The use of a real-time ultrasound may be beneficial in reducing primary catheter malpositions compared with conventional radiography. In addition, secondary malpositions and catheter-related complications can be monitored over time.

KEY POINTS

· Conventional radiology cannot be considered the "gold standard" for ECC tip location.. · Ultrasound is more accurate and reduces insertion time reducing the rate of primary malposition.. · Ultrasound can be performed in real time and it is the best technique for ECC tip location in infants..

Addition of aspirin to venous thromboembolism chemoprophylaxis safely decreases venous thromboembolism rates in trauma patients

Background

Trauma patients exhibit a multifactorial hypercoagulable state and have increased risk of venous thromboembolism (VTE). Despite early and aggressive chemoprophylaxis (CP) with various heparin compounds ("standard" CP; sCP), VTE rates remain high. In high-quality studies, aspirin has been shown to decrease VTE in postoperative elective surgical and orthopedic trauma patients. We hypothesized that inhibiting platelet function with aspirin as an adjunct to sCP would reduce the risk of VTE in trauma patients.

Methods

We performed a retrospective observational study of prospectively collected data from all adult patients admitted to an American College of Surgeons Level I Trauma center from January 2012 to June 2015 to evaluate the addition of aspirin (sCP+A) to sCP regimens for VTE mitigation. Cox proportional hazard models were used to assess the potential benefit of adjunctive aspirin for symptomatic VTE incidence.

Results

10,532 patients, median age 44 (IQR 28 to 62), 68% male, 89% blunt mechanism of injury, with a median Injury Severity Score (ISS) of 12 (IQR 9 to 19), were included in the study. 8646 (82%) of patients received only sCP, whereas 1886 (18%) patients received sCP+A. The sCP+A cohort displayed a higher median ISS compared with sCP (13 vs 11; p<0.01). The overall median time of sCP initiation was hospital day 1 (IQR 0.8 to 2) and the median day for aspirin initiation was hospital day 3 (IQR 1 to 6) for the sCP+A cohort. 353 patients (3.4%) developed symptomatic VTE. Aspirin administration was independently associated with a decreased relative hazard of VTE (HR 0.57; 95% CI 0.36 to 0.88; p=0.01). There were no increased bleeding or wound complications associated with sCP+A (point estimate 1.23, 95% CI 0.68 to 2.2, p=0.50).

Conclusion

In this large trauma cohort, adjunctive aspirin was independently associated with a significant reduction in VTE and may represent a potential strategy to safely mitigate VTE risk in trauma patients. Further prospective studies evaluating the addition of aspirin to heparinoid-based VTE chemoprophylaxis regimens should be sought.

Level of evidence

Level III/therapeutic.

Racial Disparities in Administration of Venous Thromboembolism Prophylaxis After Severe Traumatic Injuries

BACKGROUND

Race is associated with differences in quality of care process measures and incidence of venous thromboembolism (VTE) in trauma patients. We aimed to investigate if racial disparities exist in the administration of VTE prophylaxis in trauma patients.

METHODS

We queried the Trauma Quality Improvement Project database from 2017 to 2019. Patients ages ≥16 years old with ISS ≥15 were included. Patients with no signs of life on arrival, any AIS ≥6, hospital length of stay <1 day, anticoagulant use before admission, or without recorded race were excluded. Patients were grouped by race: white, black, Asian, American Indian, and Native Hawaiian or Pacific Islander. The association between VTE prophylaxis administration and race was determined using a Poisson regression model with robust standard errors to adjust for confounders.

RESULTS

A total of 285,341 patients were included. Black patients had the highest rates of VTE prophylaxis exposure (73.8%), shortest time to administration (1.6 days), and highest use of low molecular weight heparin (56%). Black patients also had the highest incidence of deep vein thrombosis (2.8%) and pulmonary embolism (1.4%). Black patients were 4% more likely to receive VTE prophylaxis than white patients [adj. IRR (95% CI): 1.04 (1.03-1.05), P < .001]. American Indians were 8% less likely to receive VTE prophylaxis [adj. IRR (95% CI): .92 (.88-.97), P < .001] than white patients. No differences between white and Asian or Native Hawaiian or Pacific Islander patients existed.

DISCUSSION

While black patients had the highest incidence of DVT and PE, they had higher administration rates and earlier initiation of VTE prophylaxis. Further work can elucidate modifiable causes of these differences.

Clinicians' use and perceptions of the pre-medical emergency team tier of one rapid response system: A mixed-methods study

BACKGROUND

The pre-medical emergency team (pre-MET) tier of rapid response systems facilitates early recognition and treatment of deteriorating ward patients using ward-based clinicians before a MET review is needed. However, there is growing concern that the pre-MET tier is inconsistently used.

OBJECTIVE

This study aimed to explore clinicians' use of the pre-MET tier.

METHODS

A sequential mixed-methods design was used. Participants were clinicians (nurses, allied health, doctors) caring for patients on two wards of one Australian hospital. Observations and medical record audits were conducted to identify pre-MET events and examine clinicians' use of the pre-MET tier as per hospital policy. Clinician interviews expanded on understandings gained from observation data. Descriptive and thematic analyses were performed.

RESULTS

Observations identified 27 pre-MET events for 24 patients that involved 37 clinicians (nurses = 24, speech pathologist = 1, doctors = 12). Nurses initiated assessments or interventions for 92.6% (n = 25/27) of pre-MET events; however, only 51.9% (n = 14/27) of pre-MET events were escalated to doctors. Doctors attended pre-MET reviews for 64.3% (n = 9/14) of escalated pre-MET events. Median time between escalation of care and in-person pre-MET review was 30 min (interquartile range: 8-36). Policy-specified clinical documentation was partially completed for 35.7% (n = 5/14) of escalated pre-MET events. Thirty-two interviews with 29 clinicians (nurses = 18, physiotherapists = 4, doctors = 7) culminated in three themes: Early Deterioration on a Spectrum, A Safety Net, and Demands Versus Resources.

CONCLUSIONS

There were multiple gaps between pre-MET policy and clinicians' use of the pre-MET tier. To optimise use of the pre-MET tier, pre-MET policy must be critically reviewed and system-based barriers to recognising and responding to pre-MET deterioration addressed.

Response to patient safety incidents in healthcare settings in Ghana: the role of teamwork, communication openness, and handoffs

BACKGROUND

Patient safety incidents (PSIs) in healthcare settings are a critical concern globally, and Ghana is no exception. Addressing PSIs to improve health outcomes requires various initiatives to be implemented including improving patient safety culture, teamwork and communication between healthcare providers during handoffs. It is essential to acknowledge the significance of teamwork, communication openness, and effective handoffs in preventing and managing such incidents. These factors play a pivotal role in ensuring the well-being of patients and the overall quality of healthcare services.

AIM

This study assessed the occurrence and types of PSIs in health facilities in Ghana. It also examined the role of teamwork, handoffs and information exchange, and communication openness in response to PSIs by health professionals.

METHODS

A cross-sectional study was conducted among 1651 health workers in three regions of Ghana. Using a multi-staged sampling technique, the Survey on Patient Safety Culture Hospital Survey questionnaire and the nurse-reported scale were used to collect the data and it was analysed by descriptive statistics, Pearson correlation, and linear multiple regression model at a significance of 0.05.

RESULTS

There was a reported prevalence of PSIs including medication errors (30.4%), wound infections (23.3%), infusion reactions (24.7%), pressure sores (21.3%), and falls (18.7%) at least once a month. There was a satisfactory mean score for responses to adverse events (3.40), teamwork (4.18), handoffs and information exchange (3.88), and communication openness (3.84) among healthcare professionals. Teamwork, handoffs and information exchange and communication openness were significant predictors of response to PSIs, accounting for 28.3% of the variance.

CONCLUSIONS

Effective teamwork, handoffs and information exchange, and communication openness in the healthcare environment are critical strategies to enhance PSI response. Creating a culture that encourages error response through teamwork, communication and handoffs provides healthcare professionals with opportunities for learning and improving patient outcomes. Training programs should therefore target health professionals to improve patient safety and competency. Through the implementation of evidence-based practices and learning from past incidents, the healthcare system will be able to deliver safe and high-quality care to patients nationwide. Patient safety must be recognized as an ongoing process. Therefore, a meaningful improvement in patient outcomes requires all stakeholders' commitment.

TeamSTEPPS®-based clinical simulation training program for critical care professionals: A mixed-methodology study

INTRODUCTION

The Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS®) programme has been shown to improve interprofessional work among healthcare professionals by enhancing teamwork. Intensive care professionals were trained in this methodology through the course "Simulation Trainer: Improving Teamwork through TeamSTEPPS®".

OBJECTIVES

To analyse the teamwork performance and good practice in simulation of the intensive care professionals attending the course and to explore their perceptions of the training experience carried out during the course.

METHODS

A cross-sectional descriptive and phenomenological study was carried out using a mixed methodology. The 18 course participants were administered the questionnaires "TeamSTEPPS™ 2.0 Team Performance Observation Tool" to evaluate teamwork performance and "Educational Practices Questionnaire" for good practices in simulation after the simulated scenarios. Subsequently, a group interview was conducted through a focus group with 8 attendees using the Zoom™ videoconferencing platform. A thematic and content analysis of the discourses was carried out using the interpretative paradigm. Quantitative and qualitative data were analysed using IBM SPSS Statistics™ 27.0 and MAXQDA Analytics Pro™ respectively.

RESULTS

Both the level of teamwork performance (mean = 96.25; SD = 8.257) and good practice in simulation (mean = 75; SD = 1.632) following the simulated scenarios were adequate. The following main themes were identified: satisfaction with the TeamSTEPPS® methodology, usefulness of the methodology, barriers to methodology implementation and non-technical skills improved through TeamSTEPPS®.

CONCLUSIONS

TeamSTEPPS® methodology can be a good interprofessional education strategy for the improvement of communication and teamwork in intensive care professionals, both at the care level (through on-site simulation strategies) and at the teaching level (through its inclusion in the students' curriculum).

Status and Factors Affecting Patient Safety Culture at Dilla University Teaching Hospital: A Mixed-Method Cross-Sectional Study

Background

Patient safety culture is now at the forefront of the global health agenda and has been designated as a human right. Assessing safety culture is seen to be a prerequisite for improving safety culture in health-care organizations. However, no research has been conducted to examine the current study setup. Therefore, this study aims at assessing the status and factors influencing patient safety culture at Dilla University Teaching Hospital.

Methods

This cross-sectional institutional-based study was conducted from February to March 2022 at Dilla University Hospital. The study used both qualitative and quantitative methods. A total of 272 health professionals were included in the survey. The qualitative data was collected using Key Informant Interviews and In-depth Interviews and 10 health professionals were selected purposively to meet the study objective.

Results

The overall composite positive patient safety culture response rate in the current study hospital was 37% (95% CI: 35.3, 38.8). Out of the 12 dimensions, teamwork within hospital units was the highest (75.3%), while frequency of event reporting was the lowest (20.7%) positive percentage response. Only two of the 12 dimensions scored above 50%. Factors affecting patient safety culture majorly at organizational and individual level were poor/low attitude of health professionals, poor documentation practice, and poor cooperation by clients, lack of training and continuous education, lack of standard operating procedure, Staff shortage and high work load.

Conclusion

This study revealed that the overall composite positive patient safety culture response rate within the surveyed facility was alarmingly low compared to other hospitals in various countries. The results indicate that there is a need for improvement in areas such as event reporting, documentation, health-care workers' attitude, and staff training. Hospitals must prioritize patient safety by cultivating a strong safety culture through effective leadership, adequate staffing, and education to enhance overall patient care.

Cross-cultural adaptation and validation of the Hospital Survey on Patient Safety Culture 2.0 - Brazilian version

BACKGROUND

Patient safety culture concerns the values, beliefs and standards shared by an organisation's health staff and other personnel which influence their care provision actions and conduct. Several countries have made a priority of strengthening patient safety culture to improve the quality and safety of health care. In this direction, measuring the patient safety culture through validated instruments is a strategy applied worldwide. The purpose of this study was to adapt transculturally and validate the HSOPSC 2.0 to Brazilian Portuguese and the hospital context in Brazil.

METHODS

Of the various validated scales for measuring safety culture, the instrument most used internationally is the Hospital Survey on Patient Safety Culture (HSOPSC) developed by the United States Agency for Healthcare Research and Quality in 2004 and revised in 2019, when version 2.0 was released. Adaptation was conducted on a universalist approach and the adapted instrument was then applied to a sample of 2,702 respondents (56% response rate) comprising staff of a large general hospital in the city of São Paulo. Construct validity was investigated by Exploratory Structural Equation Modelling-within-Confirmatory Factor Analysis (ESEM-within-CFA) and reliability was measured in each dimension by means of Cronbach alpha coefficients.

RESULTS

ESEM fit indexes showed good data fit with the proposed model: χ2 = 634.425 df = 221 χ2/df ratio = 2.9 p-value < 0.0000; RMSEA = 0.045 (90% C.I. = 0.041-0.050) and probability RMSEA <  = .05 = 0.963; CFI = 0.986; TLI = 0.968. However, ten items had loads lower than 0.4. Cronbach alpha values were 0.6 or more for all dimensions, except Handoffs and information exchange ([Formula: see text]= 0.50) and Staffing and work pace ([Formula: see text] = 0.41).

CONCLUSION

The psychometric properties of the Brazilian version were found to be satisfactory, demonstrating good internal consistency and construct validity as expressed by estimates of reliability and indexes of model fit. However, given factor loadings smaller than 0.4 observed in ten items and considering that the scale translated and adapted to Portuguese was tested on a single sample during the Covid-19 pandemic, the authors recognize the need for it to be tested on other samples in Brazil to investigate its validity.

A systematic approach to venous thromboembolism prevention: a focus on UK experience

Venous thromboembolism (VTE) remains a leading cause of preventable morbidity and mortality associated with hospitalization. Despite evidence that providing appropriate thromboprophylaxis to those at risk of VTE in hospital, recent data suggest that the delivery of thromboprophylaxis remains suboptimal across the globe, with a lack of standardization in approach to VTE prevention. This review considers the role of VTE risk assessment and interventions to improve the implementation of the VTE prevention pathway and highlights the systematic approach to VTE prevention adopted in England and its impact. Finally, the critical areas for further research and the emerging data presented during the 2022 ISTH annual congress in London, UK, are summarized.

[Safety culture in the operating room-an overview]

Reduction and treatment of complications can be achieved through improvement of treatment options, complication management, and the abilities to remedy complications, and through the minimization of errors, respectively. Human-medical error represents an inappropriate treatment, for instance, not administered carefully, correctly or in a timely manner. It can cover all areas of physician-related and medical activities with regard to prophylaxis, diagnosis, selection of treatment modalities, and post-operative care. Different options to minimise errors are the improvement of organizational measures, technical skills and non-technical skills, like social competences. On the basis of a narrative literature research, systems and methods were gathered to describe the possibilities of error identification, research into the causes, and the avoidance of errors.

EVALUATION OF THE IMPLEMENTATION OF PREVENTION AND INFECTION CONTROL PROGRAMS IN ARMENIAN HOSPITALS DURING THE COVID-19 PANDEMIC

ABSTRACT: Aim of the study: To determine the current state of implementation of key aspects of infection prevention and control (IPC) in Armenian hospitals, defined by the main components of WHO, using the survey tool IPCAF (Infection Prevention and Control Assessment Framework). Materials and methods. 113 hospitals were involved in the study. All participants filled in IPCAF questionnaire, Все они заполнили вопросник IPCAF, consisting of 8 sections (each rated up to 100 points) devoted to various aspects IPC. Depending on the total final score, IPC programs were divided into the following categories: advanced (601-800 points), intermediate (401-600 points), basic (201-400 points) and inadequate (0-200 points). The study conducted a descriptive analysis of the overall IPCAF score as well as the evaluation of scores of the relevant core components and some selected questions of particular interest. Results: The total average score for all IPCAF components for all hospitals in Armenia in 2021 is 578.07.9 points, which is currently regarded as an intermediate level. At the same time, 47 (41.6%) hospitals were assigned to the advanced category, 63 (55.7%) - to the average category and 3 (2.7%) - to the basic category. Analysis of the main IPC components (CC, Core component) revealed that the maximum average scores were obtained for the components CC2 (IPC Guidelines) - 80.8 points, CC8 (Creating a safe environment in medical premises, as well as materials and equipment for IPC) - 75.5 points and CC7 (Workload, staffing and number of beds) - 75.2 points. The lowest average scores were obtained for the key components: CC4 (Surveillance for healthcare-associated infections) with 54.7 points and CC3 (IPC education and training) with 59.5 points. Conclusion. Legislative and practical changes implemented in the real world during the novel coronavirus infection (COVID-19) pandemic have significantly contributed to improved scores for many key components of IPC programs. The study found that the IPCAF is a useful tool for assessing IPC standards and identifying gaps, regardless of a country economic development level. In our opinion, the re-use of IPCAF in all medical institutions should be encouraged, which is important for monitoring changes and trends in IPC, as well as developing individual strategies in the development and improvement of IPC.

Education, Policy, and Advocacy in Predicting Use of Do-Not-Hospitalize Orders in Skilled Nursing Facilities

Nurses and social workers are uniquely positioned to advocate for patients' wishes for do-not-hospitalize (DNH) directives. The purpose of the current study was to explore the impact of DNH education, policy, and advocacy on the use of DNH orders by nurses (RNs and licensed practical nurses [LPNs]) and social workers employed in skilled nursing facilities (SNFs). This multisite secondary analysis used cross-sectional survey data and analyzed responses of RNs, LPNs, and social workers (N = 354) from 29 urban SNFs. Mixed model regression was used to examine possible predictors of frequency of DNH orders within SNFs while adjusting for random effects. Results showed that having a DNH written policy, education on DNH orders, and having an advanced care planning advocate in the facility were strongly associated with a higher reported frequency of DNH discussions with residents and their families (p < 0.01 for each variable). [Journal of Gerontological Nursing, 48(11), 45-52.].

Post-hepatectomy venous thromboembolism: a systematic review with meta-analysis exploring the role of pharmacological thromboprophylaxis

PURPOSE

Patients undergoing hepatectomy are at moderate-to-high risk of venous thromboembolism (VTE). This study critically examines the efficacy of combining pharmacological (PTP) and mechanical thromboprophylaxis (MTP) versus only MTP in reducing VTE events against the risk of hemorrhagic complications.

METHODS

A systematic review of major reference databases was undertaken, and a meta-analysis was performed using common-effects model. Risk of bias assessment was performed using Newcastle-Ottawa scale. Trial sequential analysis (TSA) was used to assess the precision and conclusiveness of the results.

RESULTS

8 studies (n = 4238 patients) meeting inclusion criteria were included in the analysis. Use of PTP + MTP was found to be associated with significantly lower VTE rates compared to only MTP (2.5% vs 5.3%; pooled RR 0.50, p = 0.03, I² = 46%) with minimal type I error. PTP + MTP was not associated with an increased risk of hemorrhagic complications (3.04% vs 1.9%; pooled RR 1.54, p = 0.11, I² = 0%) and had no significant impact on post-operative length of stay (12.1 vs 10.8 days; pooled MD - 0.66, p = 0.98, I² = 0%) and mortality (2.9% vs 3.7%; pooled RR 0.73, p = 0.33, I² = 0%).

CONCLUSION

Despite differences in the baseline patient characteristics, extent of hepatectomy, PTP regimens, and heterogeneity in the pooled analysis, the current study supports the use of PTP in post-hepatectomy patients (grade of recommendation: strong) as the combination of PTP + MTP is associated with a significantly lower incidence of VTE (level of evidence, moderate), without an increased risk of post-hepatectomy hemorrhage (level of evidence, low).

Patient safety culture as perceived by operating room professionals: a mixed-methods study

Background

Routine assessments of patient safety culture within hospitals have been widely recommended to improve patient safety. Experts suggested that mixed-methods studies can help gain a deeper understanding of the concept. However, studies combining quantitative and qualitative approaches exploring patient safety culture are still lacking. This study aimed to explore patient safety culture as perceived by operating room professionals of two university hospitals in Sousse, Tunisia.

Methods

Based on a mixed-methods approach, a cross-sectional survey followed by semi-structured interviews were conducted over a period of two months (December 2019 to January 2020). This study took place in all the operating rooms of two public university hospitals in the district of Sousse, Tunisia. To collect data for this survey, the French version of the Hospital Survey On Patient Safety Culture was used. For interviews, 13 participants were selected purposively using a critical case sampling approach and a topic guide was prepared. Anonymity and confidentiality were respected.

Results

Overall, twelve operating rooms, with different surgical specialties, were included in the study. Survey feedback was provided by 297 professionals representing a response rate of 85.6%. Concerning patient safety culture, the 10 dimensions had low scores (below 50%) and were considered “to be improved”. The highest score was found in ‘teamwork within units’ (45%). Whereas, the lowest scores were allocated to ‘non-punitive response to error’ (22.9%), followed by “frequency of adverse event reported” (25.6%) and “communication openness” (26.3%). Per qualitative data, participants provided a more detailed picture of patient safety issues such as underreporting, absence of an effective reporting system, lack of freedom of expression, and an existing blame culture in operating rooms.

Conclusions

The findings of this study showed a concerning perception held by participants about the lack of a patient safety culture in their operating rooms. It seems essential to design, implement and evaluate strategies that promote a positive patient safety culture and obliterate punitive climate in operating rooms.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08175-z.

Pain Management Program in Cardiology: A Template for Application of Normalization Process Theory and Social Marketing to Implement a Change in Practice Quality Improvement

Quality improvement plays a major role in healthcare, and numerous approaches have been developed to implement changes. However, the reasons for success or failure of the methods applied often remains obscure. Normalization process theory, recently developed in sociology, provides a flexible framework upon which to construct quality improvement. We sought to determine if examination of a successful quality improvement project, using normalization process theory and social marketing, provided insight into implementation. We performed a retrospective analysis of the steps taken to implement a pain management program in an electrophysiology clinic. We mapped these steps, and the corresponding social marketing tools used, to elements of normalization process theory. The combination of mapping implementation steps and marketing approaches to the theory provided insight into the quality-improvement process. Specifically, examination of the steps in the context of normalization process theory highlighted barriers to implementation at individual, group, and organizational levels. Importantly, the mapping also highlighted how facilitators were able to overcome the barriers with marketing techniques. Furthermore, integration with social marketing revealed how promotion of tangibility of benefits aided communication and how process co-creation between stakeholders enhanced value. Our implementation of a pain-management program was successful in a challenging environment composed of several stakeholder groups with entrenched initial positions. Therefore, we propose that the behavior change elements of normalization process theory combined with social marketing provide a flexible framework to initiate quality improvement.

Nosocomial Outbreak of SARS-CoV-2 in a Non-COVID Zone of a Tertiary Care Hospital of North India: Need to Upgrade Infection Control Practices

BACKGROUND

Hospital acquired infections are preventable cause for morbidity and mortality worldwide. In the current pandemic era proper implementation of infection control measures can prevent the spread of such infections including SARS-CoV 2. The study was done to identified the source and reason for spread of COVID-19 infection and devise recommendations to halt the progress of infection in a non-COVID area.

METHODS

An outbreak in a non-COVID area of a tertiary care hospital was investigated by the infection control team along with the epidemiologist when they were notified about the rising cases of COVID-19 from Advanced Trauma Center's (ATC) disaster ward. The time, place and person distribution of the cases were studied. Recommendations based on gaps identified were developed onsite and implemented to control the outbreak.

RESULTS

The outbreak lasted from 19th December 2020 to 12th January 2021, affecting 34 people (25 patients and 9 health care workers). The attack rate was 9.2%. We identified the causes of current outbreak as compromises in infection prevention measures, high bed patient ratio, irregularities in the ventilation system, overcrowding by patient attendants and communication gaps between nursing officers and doctors. Measures required to control the outbreak were implemented and no cases were reported for 2 weeks following the last positive case.

CONCLUSION

Non-COVID areas of hospitals are also at risk of nosocomial outbreaks of SARS-CoV 2 and therefore strict infection prevention measures those designated to COVID areas should be followed in non-COVID zones also to prevent such outbreaks.

Relationships Between Nurses' Work System, Safety-Related Performance, and Outcomes: A Structural Equation Model

OBJECTIVES

We examined relationships between nurses' work system, safety-related performance, and outcomes based on a modified Systems Engineering Initiative for Patient Safety model.

METHODS

A cross-sectional survey was conducted with 408 nurses from 2 general hospitals. Data on work system factors (person, organization, environment, tools, and task), processes (safety-related performance), and outcomes (staff and clinical outcomes) were collected. Structural equation modeling was used to determine the relationships between nurses' work system factors, safety-related processes, and outcomes.

RESULTS

Structural equation modeling yielded a comparative fit index of 0.918, standardized root mean square residual of 0.055, and root mean square error of approximation of 0.054, indicating an acceptable model fit. The person factor had a significant positive direct effect on nurses' safety-related performance, and significant negative direct and indirect effects on the clinical outcome. The organization factor had significant positive direct effects on nurses' safety-related performance and staff outcome, and a negative indirect effect on the clinical outcome. The task factor had a significant positive direct effect on staff outcome. However, the environment and tools factors had no significant effects on safety-related performance or outcomes.

CONCLUSIONS

The findings demonstrated the usefulness of the Systems Engineering Initiative on Patient Safety model to explain safety-related performance and outcomes, indicating differential effects of work system factors. Although the person factor significantly affected safety performance and clinical outcomes, the organization factor was the most influential component for promoting safety-related performance and staff and clinical outcomes. These results can be used to prioritize activities for patient safety.

Uncovering the 'messy details' of veterinary communication: An analysis of communication problems in cases of alleged professional negligence

BACKGROUND

Communication failure is reported as a cause of error in veterinary practice and has been associated with complaints and litigation. Evidence describing the types and nature of communication problems is lacking. This limits our ability to mitigate the risk poor communication poses.

METHODS

This study used a mixed methods approach to explore the frequency and types of communication problems present in settled cases of alleged veterinary professional negligence. Thematic analysis was conducted on written documents associated with 100 such cases involving canine patients. Interpretation was informed by human factors thinking and communication theory. Results were triangulated with findings from a focus group with the Veterinary Defence Society claims consultants and with healthcare literature on communication failures.

RESULTS

Communication problems played a contributory role in 80% of the cases examined. The analysis highlighted features of problematic communication in veterinary practice that are underrepresented in the current literature. These include the prominence of communication problems within veterinary teams, the impact of communication on the safety of care and also the interdependence of communication events with the context, system and environment in which they occur.

CONCLUSIONS

These results suggest that communication is a collective competency. Effective communication is something veterinary systems, rather than individuals alone, achieve. There is a need to consider the team and organisational contexts in which communication occurs to ensure individual communication skills can be translated into communication practices that support the delivery of high-quality, safe veterinary care for the benefits of clinicians, owners and patients.

Nurses' perspectives on workarounds in clinical practice: A phenomenological analysis

Aims and objectives

To explore the phenomenon of workarounds in clinical practice through the nurses’ perspective and identify which factors according to their experience contribute to activities carried forth non‐compliantly to procedures, protocols and rules defined by an Institution.

Background

A workaround in clinical practice is a non‐compliance and a violation of an organisation's defined procedures, regulations or rules that may prevent adverse events. Its increasing recurrence in the workplace calls for a deeper analysis of the phenomenon.

Design

A phenomenological descriptive design, following Colaizzi's analysis.

Methods

In‐depth interviews were conducted with 16 nurses about their experience of workarounds. The interviews were digitally audio‐recorded and transcribed verbatim. Two researchers conducted data analysis independently and followed three phases: extracting significant statements, creating formulated meanings and aggregating them into themes. The process employed NVivo 12 software. COREQ checklist was used for reporting.

Results

Data analysis identified 17 sub‐themes falling into the four macro‐themes: (i) living the profession in saved times; (ii) Perceiving contingencies as a guide to action; (iii) sense of personal responsibility; and (iv) emotional aspects.

Conclusions

From a nurses’ perspective, a workaround is often triggered by the need to overcome problems interfering with efficient and timely patient care in everyday clinical practice. This will of undertaking responsibilities favouring gained efficiency is closely linked to their confidence acquired over years of experience in the field.

Relevance to clinical practice

The results of this study can help clinical leadership to acknowledge workaround, understand the underlying triggers and work towards reconciling official procedures with real‐world situations. They can help nurses working in clinical practice to reflect and understand how to reconcile the needs related to the demands of organisations with the need to live their profession, which is more patient‐oriented.

The role of hospital characteristics in patient safety: a protocol for a national cohort study

BACKGROUND

Substantial expenditures on health care safety programs have been justified by their goal of reducing health care associated-harm (adverse events), but adverse event rates have not changed over the past 4 decades. The objective of this study is to describe hospital-level factors that are relevant to safety in Canadian hospitals and the impact of these factors on hospital adverse events.

METHODS

This is a protocol for a national cohort study to describe the association between hospital-level factors and adverse events. We will survey at least 90 (35%) Canadian hospitals to describe 4 safety-relevant domains, chosen based on the literature and expert consultation, namely patient safety culture, safety strategies, staffing, and volume and capacity. We will retrospectively identify hospital adverse events from a national data source. We will evaluate organization-level factors using established scales and a survey, codesigned by the study team and hospital leaders. Hospital leaders, clinical unit leaders and front-line staff will complete the surveys once a year for 3 years, with an anticipated start date of winter 2022. We will use national health administrative data to estimate the rate and type of hospital adverse events corresponding to each 1-year survey period.

INTERPRETATION

Analysis of data from this project will describe hospital organizational factors that are relevant to safety and help identify organizational initiatives that improve hospital patient safety. In addition to biyearly reports to the leaders of the participating hospitals, we have a multifaceted and tailored dissemination strategy that includes integrating the knowledge users into the study team to increase the likelihood that our study will lead to improved hospital patient safety.

Did healthcare professional perspectives on the quality and safety environment in New Zealand public hospitals change from 2012 to 2017?

PURPOSE

The work environment is known to influence professional attitudes toward quality and safety. This study sought to measure these attitudes amongst health professionals working in New Zealand District Health Boards (DHBs), initially in 2012 and again in 2017.

DESIGN/METHODOLOGY/APPROACH

Three questions were included in a national New Zealand health professional workforce survey conducted in 2012 and again in 2017. All registered health professionals employed with DHBs were invited to participate in an online survey. Areas of interest included teamwork amongst professionals; involvement of patients and families in efforts to improve patient care and ease of speaking up when a problem with patient care is perceived.

FINDINGS

In 2012, 57% of respondents (58% in 2017) agreed health professionals worked as a team; 71% respondents (73% in 2017) agreed health professionals involved patients and families in efforts to improve patient care and 69% (65% in 2017) agreed it was easy to speak up in their clinical area, with none of these changes being statistically significant. There were some response differences by respondent characteristics.

PRACTICAL IMPLICATIONS

With no change over time, there is a demand for improvement. Also for leadership in policy, management and amongst health professionals if goals of improving quality and safety are to be delivered upon.

ORIGINALITY/VALUE

This study provides a simple three-question method of probing perceptions of quality and safety and an important set of insights into progress in New Zealand DHBs.

Introduction of Group Electronic Monitoring of Hand Hygiene on Inpatient Units: A Multicenter Cluster Randomized Quality Improvement Study

BACKGROUND

The current approach to measuring hand hygiene (HH) relies on human auditors who capture <1% of HH opportunities and rapidly become recognized by staff, resulting in inflation in performance. Group electronic monitoring is a validated method of measuring HH adherence, but data demonstrating the clinical impact of this technology are lacking.

METHODS

A stepped-wedge cluster randomized quality improvement study was performed on 26 inpatient medical and surgical units across 5 acute care hospitals in Ontario, Canada. The intervention involved daily HH reporting as measured by group electronic monitoring to guide unit-led improvement strategies. The primary outcome was monthly HH adherence (percentage) between baseline and intervention. Secondary outcomes included transmission of antibiotic-resistant organisms such as methicillin-resistant Staphylococcus aureus (MRSA) and other healthcare-associated infections.

RESULTS

After adjusting for the correlation within inpatient units and hospitals, there was a significant overall improvement in HH adherence associated with the intervention (incidence rate ratio [IRR], 1.73 [95% confidence interval {CI}, 1.47-1.99]; P < .0001). Monthly HH adherence relative to the intervention increased from 29% (1 395 450/4 544 144) to 37% (598 035/1 536 643) within 1 month, followed by consecutive incremental increases up to 53% (804 108/1 515 537) by 10 months (P < .0001). There was a trend toward reduced healthcare-associated transmission of MRSA (IRR, 0.74 [95% CI, .53-1.04]; P = .08).

CONCLUSIONS

The introduction of a system for group electronic monitoring led to rapid, significant improvements in HH performance within a 2-year period. This method offers significant advantages over direct observation for measurement and improvement of HH.

Use of the pre-medical emergency team tier of rapid response systems: A scoping Review

OBJECTIVE

The aim of this review was to explore use of the pre-Medical Emergency Team (pre-MET) tier of Rapid Response Systems to recognise and respond to adult ward patients experiencing early clinical deterioration.

METHODS

A scoping review of studies published in English reporting on use of a pre-MET tier in adult ward patients was conducted. Three databases were searched (Medline, CINAHL, EMBASE) for studies published between January 1995 and September 2020. Two researchers independently performed screening and quality assessments. Findings were synthesised thematically. Reporting of the review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews.

RESULTS

Six of 1669 studies were included in this review. All were single-site studies of single-parameter Rapid Response Systems in Australian hospitals. Five were quantitative studies; one had a qualitative design. Studies fulfilled 50-100% of quality criteria. Two themes were constructed: Afferent processes - Recognising and escalating pre-MET events; and Efferent processes - Pre-MET reviews and associated interventions. There was disparity between clinical practice and pre-MET escalation protocols, and reports of nurse-initiated management of early deterioration. Prospective methods and exploration of multidisciplinary perspectives were notable research gaps.

CONCLUSION

Use of the pre-MET tier of Rapid Response Systems is under-researched. Further research is needed to understand barriers and facilitators influencing use of pre-MET strategies to address patient deterioration.

Early warning scores and critical care transfer - patient heterogeneity, low sensitivity, high mortality

Background

Emergency warning systems (EWS) are becoming a standard of care, but have unproven screening value in early critical illness. Similarly, emergency response team (ERT) care is of uncertain value. These questions are most controversial in mixed patient populations, where screening performance might vary, and intensivist-led ERT care might divert resources from existing patients.

Aims

To examine triggering events, disposition and outcome data for an intensivist-staffed EWS-ERT system.

Methods

We analysed process and outcome data over three years, classing EWS-triggered patients into three categories (non-escalated, escalated ward care and critical care transfer). The relationships between EWS data, pre-triggering clinical data, and patient disposition and outcome were examined.

Results

There were 1675 calls in 1190 patients. Most occurred later during admission, with critical care transfer in a minority; the rest were followed by escalated or non-escalated ward care. Patients transferred to critical care had high mortality (40.3%); less than half of patient transfers occurred following triggering EWS score predicted overall hospital mortality, but not mortality after critical care.

Conclusions

In a diverse hospital population, most triggering patients did not receive critical care and most critical care transfers occurred without triggering. Triggering was an insensitive screening measure for critical illness, followed by poor outcome. Higher scores predicted higher probability of transfer, but not later mortality, suggesting that EWS is being used as a decision aid but is not a true severity of illness score. Other, non-EWS data are needed for earlier detection and for prioritizing access to critical care.

Modifications to medical emergency team activation criteria and implications for patient safety: A point prevalence study

BACKGROUND

Medical emergency team (MET) activation criteria are sometimes modified to minimise unnecessary MET calls in patients who have chronic physiological derangements, have limitation of medical treatment orders in place, or have recently received treatment for clinical deterioration. However, the safety implications of modifying MET activation criteria are poorly understood.

OBJECTIVES

The aim of the study was to examine the safety of modifying MET activation criteria. Specifically, we aimed to examine the frequency and nature of modifications to MET activation criteria and compare characteristics and outcomes of patients with and without modifications to MET activation criteria.

METHODS

This was a point prevalence study using a retrospective medical record audit. Patients admitted to 14 wards on November 7, 2018, at two acute-care hospitals of one health service in Melbourne, Australia, were included (N = 430). Data were analysed using descriptive and inferential statistics. The main outcome measures included frequency and nature of modifications to MET activation criteria on a specified date, MET calls, intensive care unit admission, in-hospital cardiac arrest, and in-hospital death.

RESULTS

Amongst 430 inpatients, there were 30 modifications to MET activation criteria in 26 (6.0%) patients. All modifications were intended to trigger METs at more extreme levels of physiological derangement. Most modifications pertained to tachypnoea (26.7%; n = 8/30) and bradycardia (23.3%; n = 7/30). Patients with modifications were more likely to have documented physiological deterioration that fulfilled MET (47.8%, n = 11; p < 0.001) or pre-MET (87.0%, n = 20; p < 0.001) criteria in the preceding 24-h period than patients without modifications. Of patients with modifications, none were admitted to an intensive care unit, had a cardiac arrest, or died in the hospital. There were no differences in hospital length of stay or discharge destination between patients with and without modifications.

CONCLUSIONS

In this point prevalence study, modifications to MET activation criteria were infrequent and not associated with negative patient safety outcomes.

Building improvement capacity in mental health services

Improving the delivery of existing treatment may often bring much greater benefits than developing new treatments and technologies. To achieve this, clinical teams and organisations need to build capacity for sustained and systematic improvement. Organisations can build improvement capacity and skills by developing permanent multidisciplinary centres to provide sustained inspiration, research, training and practical support for implementation and innovation. In the longer term, organisations need to build an infrastructure for quality improvement that includes an information system to track change and dedicated improvement leads across the organisation.

Effectiveness of ambulation to prevent venous thromboembolism in patients admitted to hospital: a systematic review

BACKGROUND

Patient ambulation is frequently recommended to help prevent venous thromboembolism during hospital admission. Our objective was to synthesize the evidence for ambulation as a prophylaxis for venous thromboembolism in hospital.

METHODS

We conducted a systematic review. We searched MEDLINE, Embase, Scopus, Web of Science and Cochrane Central Register of Controlled Trials indexed from their inception through April 2020 for studies of adult patients admitted to hospital, in which ambulation or mobilization alone or concomitant with prophylaxis was indicated for prevention of venous thromboembolism. We searched ClinicalTrials.gov for unpublished trials. We included randomized controlled trials (RCTs) and observational studies. Two reviewers independently screened articles and assessed risk of bias using 2 validated tools. We scored studies on quality of reporting, internal and external validity and study power; combined scores determined the overall quality.

RESULTS

Eighteen articles met the inclusion criteria: 8 retrospective and 2 prospective cohorts, 7 RCTs and 1 secondary analysis of an RCT. The intervention (ambulation or mobilized) groups varied across studies. Five studies examined exercise as a therapeutic prophylaxis for thrombosis and 9 described an ambulation protocol. Five studies attempted to quantify amount and duration of patient ambulation and 3 reported ambulation distance. In the 5 studies rated as good or excellent statistical quality, findings were mixed. Incidence of venous thromboembolism was lowest when pharmacologic anticoagulants were added as part of the prescribed prophylaxis regimen.

INTERPRETATION

We did not find high-quality evidence supporting ambulation alone as an effective prophylaxis for venous thromboembolism. Ambulation should not be considered an adequate prophylaxis for venous thromboembolism, nor as an adequate reason to discontinue pharmacologic prophylaxis for venous thromboembolism during a patient's hospital admission.

The Association of ICU Acuity With Adherence to ICU Evidence-Based Processes of Care

BACKGROUND

Admission to high-acuity ICUs has been associated with improved outcomes compared with outcomes in low-acuity ICUs, although the mechanism for these findings is unclear.

RESEARCH QUESTION

The goal of this study was to determine if high-acuity ICUs more effectively implement evidence-based processes of care that have been associated with improved clinical outcomes.

STUDY DESIGN AND METHODS

This retrospective cohort study was performed in adult ICU patients admitted to 322 ICUs in 199 hospitals in the Philips ICU telemedicine database between 2010 and 2015. The primary exposure was ICU acuity, defined as the mean Acute Physiology and Chronic Health Evaluation IVa score of all admitted patients in a calendar year, stratified into quartiles. Multivariable logistic regression was used to examine relations of ICU acuity with adherence to evidence-based VTE and stress ulcer prophylaxis, and with the avoidance of potentially harmful events. These events included hypoglycemia, sustained hyperglycemia, and liberal transfusion practices (defined as RBC transfusions prescribed for nonbleeding patients with preceding hemoglobin levels ≥ 7 g/dL).

RESULTS

Among 1,058,510 ICU admissions, adherence to VTE and stress ulcer prophylaxis was high across acuity levels. In adjusted analyses, those admitted to low-acuity ICUs compared with the highest acuity ICUs were more likely to experience hypoglycemic events (adjusted OR [aOR], 1.12; 95% CI, 1.04-1.19), sustained hyperglycemia (aOR, 1.07; 95% CI, 1.04-1.10), and liberal transfusion practices (aOR, 1.55; 95% CI, 1.33-1.82).

INTERPRETATION

High-acuity ICUs were associated with better adherence to several evidence-based practices, which may be a marker of high-quality care. Future research should investigate how high-acuity ICUs approach ICU organization to identify targets for improving the quality of critical care across all ICU acuity levels.

Prevention of health care associated venous thromboembolism through implementing VTE prevention clinical practice guidelines in hospitalized medical patients: a systematic review and meta-analysis

BACKGROUND

Venous thromboembolism (VTE) is a leading cause of morbidity and mortality in hospitalized patients. Numerous VTE prevention clinical practice guidelines are available but not consistently implemented. This systematic review explored effectiveness of implementing VTE prevention clinical practice guidelines on VTE risk assessment and appropriateness of prophylaxis in hospitalized adult medical patients and identified the interventions followed to improve the adherence to these guidelines.

METHODS

Six electronic databases were searched for randomized controlled trials, clinical controlled trials, or pre/post evaluation studies up to January 2019. Studies identified were screened for eligibility by two reviewers independently. Data were extracted by two reviewers using a standardized form. Risk of bias was assessed using MINORS and the certainty of evidence for each outcome using the GRADE approach.

RESULTS

Of the 3537 records identified, 36 were eligible; eight studies were included for qualitative synthesis and four for meta-analysis. The meta-analysis of the studies assessing the impact of implementing VTE clinical practice guidelines favored appropriate prophylaxis (RR 1.67, 95% CI 1.41 to 1.97, 552 patients). Potential risk of bias was assessed to be low for 28% of the studies. However, using GRADE, the certainty of the evidence of all outcomes was rated very low quality.

CONCLUSIONS

The lack of randomized controlled trials in this area reduces the quality of the evidence available. The evidence from before-after studies suggests that the implementation of VTE clinical practice guidelines may increase the practice of VTE risk assessment and appropriate prophylaxis in hospitalized medical patients.

TRIAL REGISTRATION

PROSPERO CRD42018085506.

Call to Action to Prevent Venous Thromboembolism in Hospitalized Patients: A Policy Statement From the American Heart Association

Venous thromboembolism (VTE) is a major preventable disease that affects hospitalized inpatients. Risk stratification and prophylactic measures have good evidence supporting their use, but multiple reasons exist that prevent full adoption, compliance, and efficacy that may underlie the persistence of VTE over the past several decades. This policy statement provides a focused review of VTE, risk scoring systems, prophylaxis, and tracking methods. From this summary, 5 major areas of policy guidance are presented that the American Heart Association believes will lead to better implementation, tracking, and prevention of VTE events. They include performing VTE risk assessment and reporting the level of VTE risk in all hospitalized patients, integrating preventable VTE as a benchmark for hospital comparison and pay-for-performance programs, supporting appropriations to improve public awareness of VTE, tracking VTE nationwide with the use of standardized definitions, and developing a centralized data steward for data tracking on VTE risk assessment, prophylaxis, and rates.

Should You Treat This Acutely Ill Medical Inpatient With Venous Thromboembolism Chemoprophylaxis?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center

Venous thromboembolism (VTE), which includes both deep venous thrombosis and pulmonary embolism, is a common and potentially fatal condition. Medical inpatients are at high risk for VTE because of immobility as well as acute and chronic illness. Several randomized trials demonstrated that chemoprophylaxis, or low-dose anticoagulation, prevents VTE in selected medical inpatients. The 2018 American Society of Hematology clinical practice guideline on prophylaxis for hospitalized and nonhospitalized medical patients conditionally recommends chemoprophylaxis for non-critically ill medical inpatients, leaving much to the discretion of the treating physician. Here, 2 experts, a hematologist and a hospitalist, reflect on the care of a woman hospitalized with a rheumatologic disorder. They consider the risks and benefits of chemoprophylaxis, discuss VTE risk stratification, and recommend which patients should receive chemoprophylaxis and with which agents.

Using electronic health record system triggers to target delivery of a patient-centered intervention to improve venous thromboembolism prevention for hospitalized patients: Is there a differential effect by race?

Background

Racial disparities are common in healthcare. Venous thromboembolism (VTE) is a leading cause of preventable harm, and disparities observed in prevention practices. We examined the impact of a patient-centered VTE education bundle on the non-administration of preventive prophylaxis by race.

Methods

A post-hoc, subset analysis (stratified by race) of a larger nonrandomized trial. Pre-post comparisons analysis were conducted on 16 inpatient units; study periods were October 2014 through March 2015 (baseline) and April through December 2015 (post-intervention). Patients on 4 intervention units received the patient-centered, nurse educator-led intervention if the electronic health record alerted a non-administered dose of VTE prophylaxis. Patients on 12 control units received no intervention. We compared the conditional odds of non-administered doses of VTE prophylaxis when patient refusal was a reason for non-administration, stratified by race.

Results

Of 272 patient interventions, 123 (45.2%) were white, 126 (46.3%) were black, and 23 (8.5%) were other races. A significant reduction was observed in the odds of non-administration of prophylaxis on intervention units compared to control units among patients who were black (OR 0.61; 95% CI, 0.46–0.81, p<0.001), white (OR 0.57; 95% CI, 0.44–0.75, p<0.001), and other races (OR 0.50; 95% CI, 0.29–0.88, p = 0.015).

Conclusion

Our finding suggests that the patient education materials, developed collaboratively with a diverse group of patients, improved patient’s understanding and the importance of VTE prevention through prophylaxis. Quality improvement interventions should examine any differential effects by patient characteristics to ensure disparities are addressed and all patients experience the same benefits.

Epicutaneo-caval catheters in neonates: New insights and new suggestions from the recent literature

Epicutaneo-caval catheters have been widely used in neonatal intensive care units since Shaw has described them in 1973. These central venous access devices are usually placed at bedside and they have the purpose of delivering parenteral nutrition and/or drugs that are not compatible with the peripheral route. Even though in the last decade there was a fast advancement in the world of vascular access devices, such changes have only marginally affected the field of neonatal venous access. The aim of this editorial is to give 10 recommendations that correspond to 10 novelties in the field of epicutaneo-caval catheter: some are already evidence-based and should be introduced in our daily practice now, while others are particularly interesting and deserve further clinical studies.

Teaching Students How to Improve Safety and Quality in Two Children's Hospitals: Building a Pediatric Clerkship Patient Safety and Quality Experience

This report describes a novel method to enhance medical student understanding of systems-based practice and patient safety through experiential learning, assessing the perceived value of student-identified patient safety and systems vulnerabilities, and their proposed interventions at academic children's hospitals.

The influence of observational hand hygiene auditing on consultant doctors' hand hygiene behaviors: A qualitative study

BACKGROUND

Compliance with hand hygiene guidelines reduces the risk of health care-associated infection, yet doctors are less compliant than other health care workers. Use of observational hand hygiene auditing with targeted individualized feedback was implemented, with improved hand hygiene of consultant doctors; however, the factors that influenced this were not explained by previous quantitative data. The aim was to explore consultant doctors' opinions about the influence of observational hand hygiene auditing with individualized feedback on hand hygiene behavior.

METHODS

Using the Theoretical Domains Framework, we conducted 12 semi-structured in-depth interviews with consultant doctors who experienced the observational hand hygiene audit and feedback intervention. Data were analyzed using a thematic analysis approach.

RESULTS

Analysis identified 8 domains of the Theoretical Domains Framework, with 5 dominant domains: (1) behavioral regulation: receiving written individualized audit feedback positively influenced practice; (2) knowledge: provision of specific individualized feedback improved performance; (3) reinforcement: audit highlighted substandard practices; (4) social professional role and identity: audit reports triggered profession-associated competitive motivation; and (5) environmental context and resources: auditing was perceived to be synonymous with strong organizational safety culture.

CONCLUSIONS

In this study, provision of individualized targeted feedback was a critical component of observational hand hygiene auditing.

Integration of Ultrasound Into the Physician Assistant Curriculum

PURPOSE

Over the past 10 years, successful ultrasound integration into medical education has resulted in 8 residencies and 52 undergraduate medical schools requiring ultrasound training for graduation. Physician assistants (PAs) are trained in the medical model, yet very little is known about the integration of ultrasound into their curricula. This study examined how ultrasound is used, if at all, in the PA education curricula.

METHODS

Physician assistant program directors (PDs) were sent a survey addressing ultrasound integration into their curricula. Questions focused on the use of ultrasound to teach didactic courses and on inclusion of point-of-care ultrasound (POCUS) scanning skills as an adjunct to the physical examination. The survey also asked about students' feelings toward ultrasound integration into the curricula.

RESULTS

Investigators contacted 201 PDs, and 107 (53.2%) PDs responded. Twenty-five of the respondents (23.4%) reported using ultrasound in the basic sciences. The top 3 reasons for not including ultrasound in preclinical courses were no ultrasound machine, expense, and no faculty trained in ultrasound. Seventy-three of the respondents (68.2%) thought that POCUS scanning skills should be included in the curriculum. More than 83% felt that faculty or adjunct faculty should teach those skills.

CONCLUSION

This survey demonstrated that there is great interest in integrating ultrasound into the PA curriculum but that many challenges inhibit implementation. Lack of access to ultrasound machines and to trained faculty are the biggest challenges to integrating ultrasound into the PA curriculum. Physician assistant programs face content and competency challenges similar to those that medical schools face, as well as several challenges that are unique to PA education. Future research is needed to address these issues.

Effectiveness of interventions for the implementation of thromboprophylaxis in hospitalised patients at risk of venous thromboembolism: an updated abridged Cochrane systematic review and meta-analysis of randomised controlled trials

OBJECTIVE

To assess the effectiveness of system-wide interventions designed to increase the implementation of thromboprophylaxis and decrease the incidence of venous thromboembolism (VTE) in hospitalised medical and surgical patients at risk of VTE.

DESIGN

Systematic review and meta-analysis of randomised controlled trials (RCTs).

DATA SOURCES

Medline, PubMed, Embase, BIOSIS, CINAHL, Web of Science, CENTRAL, DARE, EED, LILACS and clinicaltrials.gov without language restrictions from inception to 7 January 2017, as well as the reference lists of relevant review articles.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

RCTs that evaluated the effectiveness of system-wide interventions such as alerts, multifaceted, education, and preprinted orders when compared with no intervention, existing policy or another intervention.

RESULTS

We included 13 RCTs involving 35 997 participants. Eleven RCTs had data available for meta-analysis. Compared with control, we found absolute increase in the prescription of prophylaxis associated with alerts (21% increase, 95% CI [15% to 275%]) and multifaceted interventions (4% increase, 95% CI [3% to 11%]), absolute increase in the prescription of appropriate prophylaxis associated with alerts (16% increase, 95% CI [12% to 20%]) and relative risk reductions (risk ratio 64%, 95% CI [47% to 86%]) in the incidence of symptomatic VTE associated with alerts. Computer alerts were found to be more effective than human alerts, and multifaceted interventions with an alert component appeared to be more effective than multifaceted interventions without, although comparative pooled analyses were not feasible. The quality of evidence for improvement in outcomes was judged to be low to moderate certainty.

CONCLUSIONS

Alerts increased the proportion of patients who received prophylaxis and appropriate prophylaxis, and decreased the incidence of symptomatic VTE. Multifaceted interventions increased the proportion of patients who received prophylaxis but were found to be less effective than alerts interventions.

TRIAL REGISTRATION NUMBER

CD008201.