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Gyedu A, Loglo L, Ablorh K, Brobbey-Kyei IA, Donkor P, Mock C. Improvement in quality of trauma care at non-tertiary hospitals in Ghana during on-hours and off-hours with a trauma intake form: A stepped-wedge cluster randomized trial. Injury 2024:111569. [PMID: 38679559 DOI: 10.1016/j.injury.2024.111569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 03/22/2024] [Accepted: 04/14/2024] [Indexed: 05/01/2024]
Abstract
BACKGROUND We sought to determine the achievement of key performance indicators (KPIs) of initial trauma care at non-tertiary hospitals in Ghana during on-hours (8AM-5PM weekdays) compared to off-hours (nights, weekends, and holidays). We also sought to assess the effectiveness of a standardized trauma intake form (TIF) with built-in decision support prompts to improve care and to assess whether this effectiveness varied between on-hours and off-hours. METHODS A stepped-wedge cluster randomized trial was performed with research assistants directly observing trauma care before and after introducing the TIF at emergency units of eight hospitals for 17.5 months. Differences in KPIs and mortality were assessed using multivariable logistic regression and generalized linear mixed regression. RESULTS Management of 4,077 patients was observed; 1,126 (28 %) during on-hours and 2,951(72 %) during off-hours. At baseline, four of 20 KPIs were performed significantly more often during off-hours. TIF improved care during both on- and off-hours. Seventeen KPIs improved during on-hours and 18 KPIs improved during off-hours. After TIF, six KPIs were performed more often during on-hours, but differences, though significant, were small (1-5 %). Examples of KPIs which were performed more often during on-hours after TIF included: airway assessment (99 % for on-hours vs. 98 % for off-hours), evaluation for intra-abdominal bleeding (91 % vs. 87 %), and spine immobilization for blunt trauma (90 % vs. 85 %) (all p < 0.05). At baseline, mortality among seriously injured patients (Injury Severity Score >9) was higher during on-hours (27 %) compared to off-hours (17 %, p = 0.047). TIF lowered mortality for seriously injured patients during both on-hours (27 % before TIF, 8 % after, p = 0.027) and during off-hours (17 % before, 7 % after, p = 0.004). After TIF, mortality among seriously injured patients was equal between on- and off-hours (8 % vs. 7 %, NS). CONCLUSIONS At baseline, KPIs of trauma care were slightly better during off-hours compared with on-hours, and mortality was lower among seriously injured patient during off-hours. A quality improvement initiative (the TIF) using built-in decision support prompts improved care strongly in both on- and off-hours and eliminated the mortality difference between on- and off-hours. Use of similar decision support prompts during initial trauma care should be promoted widely in other low- and middle-income countries.
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Affiliation(s)
- Adam Gyedu
- Department of Surgery, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana; University Hospital, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.
| | - Lord Loglo
- Konongo-Odumase Government Hospital, Konongo, Ghana
| | | | | | - Peter Donkor
- Department of Surgery, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Charles Mock
- Department of Surgery, University of Washington, Seattle, WA, USA
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Buetti N, Ruckly S, Lucet JC, Mageau A, Dupuis C, Souweine B, Mimoz O, Timsit JF. Practices and intravascular catheter infection during on- and off-hours in critically ill patients. Ann Intensive Care 2021; 11:153. [PMID: 34714451 PMCID: PMC8556470 DOI: 10.1186/s13613-021-00940-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 10/17/2021] [Indexed: 12/14/2022] Open
Abstract
Background The potential relationship between intravascular catheter infections with their insertion during weekend or night-time (i.e., off-hours or not regular business hours) remains an open issue. Our primary aim was to describe differences between patients and catheters inserted during on- versus off-hours. Our secondary aim was to investigate whether insertions during off-hours influenced the intravascular catheter infectious risks. Methods We performed a post hoc analysis using the databases from four large randomized-controlled trials. Adult patients were recruited in French ICUs as soon as they required central venous catheters or peripheral arterial (AC) catheter insertion. Off-hours started at 6 P.M. until 8:30 A.M. during the week; at weekend, we defined off-hours from 1 P.M. on Saturday to 8.30 A.M. on Monday. We performed multivariable marginal Cox models to estimate the effect of off-hours (versus on-hours) on major catheter-related infections (MCRI) and catheter-related bloodstream infections (CRBSIs). Results We included 7241 patients in 25 different ICUs, and 15,208 catheters, including 7226 and 7982 catheters inserted during off- and on-hours, respectively. Catheters inserted during off-hours were removed after 4 days (IQR 2, 9) in median, whereas catheters inserted during on-hours remained in place for 6 days (IQR 3,10; p < 0.01) in median. Femoral insertion was more frequent during off-hours. Among central venous catheters and after adjusting for well-known risk factors for intravascular catheter infection, we found a similar risk between off- and on-hours for MCRI (HR 0.91, 95% CI 0.61–1.37, p = 0.65) and CRBSI (HR 1.05, 95% CI 0.65–1.68, p = 0.85). Among central venous catheters with a dwell-time > 4 or > 6 days, we found a similar risk for MCRI and CRBSI between off- and on-hours. Similar results were observed for ACs. Conclusions Off-hours did not increase the risk of intravascular catheter infections compared to on-hours. Off-hours insertion is not a sufficient reason for early catheter removal, even if femoral route has been selected. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-021-00940-3.
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Affiliation(s)
- Niccolò Buetti
- University of Paris, INSERM, IAME, 75006, Paris, France. .,Infection Control Program and WHO Collaborating Centre On Patient Safety, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland.
| | | | - Jean-Christophe Lucet
- University of Paris, INSERM, IAME, 75006, Paris, France.,AP-HP, Infection Control Unit, Bichat- Claude Bernard University Hospital, 46 rue Henri Huchard, 75877, Paris Cedex, France
| | - Arthur Mageau
- University of Paris, INSERM, IAME, 75006, Paris, France
| | - Claire Dupuis
- University of Paris, INSERM, IAME, 75006, Paris, France
| | - Bertrand Souweine
- Medical ICU, Gabriel-Montpied University Hospital, Clermont-Ferrand, France
| | - Olivier Mimoz
- Services des Urgences Adultes and SAMU 86, Centre Hospitalier Universitaire de Poitiers, 86021, Poitiers, France.,Université de Poitiers, Poitiers, France.,Inserm U1070, Poitiers, France
| | - Jean-François Timsit
- University of Paris, INSERM, IAME, 75006, Paris, France.,Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat-Claude Bernard University Hospital, 46 rue Henri Huchard, 75877, Paris Cedex, France
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