Communication science lessons for patient safety and quality care

At a time when patient-centered care is a goal and patient safety is a paramount concern across the spectrum of health care, renewed and rigorous attention to interpersonal communication skills makes good sense. In this interdisciplinary article, we share lessons from communication science that can help clinicians communicate more appropriately and effectively with each other and with their patients in healthcare encounters.

A Quality Improvement Intervention Reduces the Time to Administration of Stat Medications

INTRODUCTION

The delivery of urgent ("stat") medications to hospitalized children is important for safe quality care. The goal of this study was to evaluate the effect of a set of interventions on the percentage of stat medications administered within 30 minutes of ordering.

METHODS

A pre-post study in 2 pediatric units (36 beds) in a private hospital in Saudi Arabia between January 2015 and September 2016. Interventions included structured communication requirements, introduction of a dedicated electronic inbox for stat medication orders sent by nurses to the pharmacy, and the use of a pink envelope for the delivery of stat medications. A multivariate logistic regression model was used to model percentage of medications administered within goal.

RESULTS

Three hundred four stat orders met inclusion criteria. The proportion of orders meeting the 30-minute goal increased from a mean of 20% to a mean of 49% after the interventions (P < 0.001). In the final month of the study, compliance reached a peak of 67%. The mean turnaround time from ordering to the administration of the medication decreased from 59.7 to 40.7 minutes (P < 0.001). On multivariate analysis, medication type and unit-based availability of medications were statistically significant predictors of turnaround time. The odds of compliance being achieved was 0.3 times less if the medication was not available on the unit.

CONCLUSIONS

A set of interventions significantly increased the percentage of stat medications delivered within 30 minutes.

Eliminating Central Line–Associated Bloodstream Infections: A National Patient Safety Imperative

Background.

Several studies demonstrating that central line–associated bloodstream infections (CLABSIs) are preventable prompted a national initiative to reduce the incidence of these infections.

Methods.

We conducted a collaborative cohort study to evaluate the impact of the national “On the CUSP: Stop BSI” program on CLABSI rates among participating adult intensive care units (ICUs). The program goal was to achieve a unit-level mean CLABSI rate of less than 1 case per 1,000 catheter-days using standardized definitions from the National Healthcare Safety Network. Multilevel Poisson regression modeling compared infection rates before, during, and up to 18 months after the intervention was implemented.

Results.

A total of 1,071 ICUs from 44 states, the District of Columbia, and Puerto Rico, reporting 27,153 ICU-months and 4,454,324 catheter-days of data, were included in the analysis. The overall mean CLABSI rate significantly decreased from 1.96 cases per 1,000 catheter-days at baseline to 1.15 at 16–18 months after implementation. CLABSI rates decreased during all observation periods compared with baseline, with adjusted incidence rate ratios steadily decreasing to 0.57 (95% confidence intervals, 0.50–0.65) at 16–18 months after implementation.

Conclusion.

Coincident with the implementation of the national “On the CUSP: Stop BSI” program was a significant and sustained decrease in CLABSIs among a large and diverse cohort of ICUs, demonstrating an overall 43% decrease and suggesting the majority of ICUs in the United States can achieve additional reductions in CLABSI rates.

Collaborative Cohort Study of an Intervention to Reduce Ventilator-Associated Pneumonia in the Intensive Care Unit

Objective.

To evaluate the impact of a multifaceted intervention on compliance with evidence-based therapies and ventilator-associated pneumonia (VAP) rates.

Design.

Collaborative cohort before-after study.

Setting.

Intensive care units (ICUs) predominantly in Michigan.

Interventions.

We implemented a multifaceted intervention to improve compliance with 5 evidence-based recommendations for mechanically ventilated patients and to prevent VAP. A standardized CDC definition of VAP was used and maintained at each site, and data on the number of VAPs and ventilator-days were obtained from the hospital's infection preventionists. Baseline data were reported and postimplementation data were reported for 30 months. VAP rates (in cases per 1,000 ventilator-days) were calculated as the proportion of ventilator-days per quarter in which patients received all 5 therapies in the ventilator care bundle. Two interventions to improve safety culture and communication were implemented first.

Results.

One hundred twelve ICUs reporting 3,228 ICU-months and 550,800 ventilator-days were included. The overall median VAP rate decreased from 5.5 cases (mean, 6.9 cases) per 1,000 ventilator-days at baseline to 0 cases (mean, 3.4 cases) at 16–18 months after implementation (P < .001) and 0 cases (mean, 2.4 cases) at 28-30 months after implementation (P < .001). Compared to baseline, VAP rates decreased during all observation periods, with incidence rate ratios of 0.51 (95% confidence interval, 0.41–0.64) at 16–18 months after implementation and 0.29 (95% confidence interval, 0.24–0.34) at 28–30 months after implementation. Compliance with evidence-based therapies increased from 32% at baseline to 75% at 16–18 months after implementation (P < .001) and 84% at 28–30 months after implementation (P < .001).

Conclusions.

A multifaceted intervention was associated with an increased use of evidence-based therapies and a substantial (up to 71%) and sustained (up to 2.5 years) decrease in VAP rates.

Achieving and sustaining ventilator-associated pneumonia-free time among intensive care units (ICUs): evidence from the Keystone ICU Quality Improvement Collaborative

Our retrospective analysis of the Michigan Keystone intensive care unit (ICU) collaborative demonstrated that adult ICUs could achieve and sustain a zero rate of ventilator-associated pneumonia (VAP) for a considerable number of ventilator and calendar months. Moreover, the results highlight the importance of adjustment for ventilator-days before comparing VAP-free time among ICUs.

Comparison of intensive care unit medication errors reported to the United States' MedMarx and the United Kingdom's National Reporting and Learning System: a cross-sectional study

The objective was to compare the characteristics of medication errors reported to 2 national error reporting systems by conducting a cross-sectional analysis of errors reported from adult intensive care units to the UK National Reporting and Learning System and the US MedMarx system. Outcome measures were error types, severity of patient harm, stage of medication process, and involved medications. The authors analyzed 2837 UK error reports and 56 368 US reports. Differences were observed between UK and US errors for wrong dose (44% vs 29%), omitted dose (8.6% vs 27%), and stage of medication process (prescribing: 14% vs 49%; administration: 71% vs 42%). Moderate/severe harm or death was reported in 4.9% of UK versus 3.4% of US errors. Gentamicin was cited in 7.4% of the UK versus 0.7% of the US reports (odds ratio = 9.25). There were differences in the types of errors reported and the medications most often involved. These differences warrant further examination.

Major cultural-compatibility complex: considerations on cross-cultural dissemination of patient safety programmes

As the importance of patient safety has been broadly acknowledged, various improvement programmes have been developed. Many of the programmes with proven efficacy have been disseminated internationally. However, some of those attempts may encounter unexpected cross-cultural obstacles and may fail to harvest the expected success. Each country has different cultural background that has shaped the behavior of the constituents for centuries. It is crucial to take into account these cultural differences in effectively disseminating these programmes. As an organ transplantation requires tissue-compatibility between the donor and the recipient, there needs to be compatibility between the country where the program was originally developed and the nation implementing the program. Though no detailed guidelines exist to predict success, small-scale pilot tests can help evaluate whether a safety programme will work in a new cultural environment. Furthermore, a pilot programme helps reveal the source of potential conflict, so we can modify the original programme accordingly to better suit the culture to which it is to be applied. In addition to programme protocols, information about the cultural context of the disseminated programme should be conveyed during dissemination. Original programme designers should work closely with partnering countries to ensure that modifications do not jeopardise the original intention of the programme. By following this approach, we might limit barriers originating from cultural differences and increase the likelihood of success in cross-cultural dissemination.

The business case for quality: economic analysis of the Michigan Keystone Patient Safety Program in ICUs

Health care-associated infections affect an estimated 5% of hospitalized patients and represent one of the leading causes of illness and death in the United States. This study calculates the costs and benefits of a patient safety program in intensive care units in 6 hospitals that were part of the Michigan Keystone ICU Patient Safety Program. On average, 29.9 catheter-related bloodstream infections and 18.0 cases of ventilator-associated pneumonia were averted per hospital on an annual basis. The average cost of the intervention is $3375 per infection averted, measured in 2007 dollars. The cost of the intervention is substantially less than estimates of the additional health care costs associated with these infections, which range from $12 208 to $56 167 per infection episode. These results do not take into account the additional effect of the Michigan Keystone program in terms of reducing cases of sepsis or its effects in terms of preventing mortality, improving teamwork, and reducing nurse turnover.

Trends in imaging use during the emergency department evaluation of flank pain

PURPOSE

Patients with acute flank pain or kidney pain are most commonly evaluated in the emergency department with computerized tomography. Currently our understanding of radiographic practice patterns in emergency imaging for flank pain is limited. We characterized the use of conventional radiography (x-ray), ultrasound and computerized tomography in the emergency department evaluation of patients with acute flank pain.

MATERIALS AND METHODS

We performed a retrospective, cross-sectional analysis of emergency department visits using data on 2000 to 2008 from the National Hospital Ambulatory Medical Care Survey. Specific visits for a complaint of flank or kidney pain were further analyzed.

RESULTS

During the study period there was a significant increase in computerized tomography use (p <0.0001) and a significant decrease in x-ray use (p = 0.035) while ultrasound use remained stable (p = 0.803). During that period the proportion of patients with flank pain who were diagnosed with a kidney stone remained stable at approximately 20% (p = 0.135).

CONCLUSIONS

Between 2000 and 2008 there was a significant increase in computerized tomography use for the emergency evaluation of patients with flank pain.

Reduction of regulated medical waste using lean sigma results in financial gains for hospital

This article describes how anesthesiologists can lead innovation and process improvement focused on regulated medical waste reduction and cost savings using a process improvement methodology known as Lean Sigma.

Improving handoffs in the emergency department

Patient handoffs at shift change are a ubiquitous and potentially hazardous process in emergency care. As crowding and lengthy evaluations become the standard for an increasing proportion of emergency departments (EDs), the number of patients handed off will likely increase. It is critical now more than ever before to ensure that handoffs supply valid and useful shared understandings between providers at transitions of care. The purpose of this article is to provide the most up-to-date evidence and collective thinking about the process and safety of handoffs between physicians in the ED. It offers perspectives from other disciplines, provides a conceptual framework for handoffs, and categorizes models of existing practices. Legal and risk management issues are also addressed. A proposal for the development of handoff quality measures is outlined. Practical strategies are suggested to improve ED handoffs. Finally, a research agenda is proposed to provide a roadmap to future work that may increase knowledge in this area.

Reducing health care hazards: lessons from the commercial aviation safety team

The movement to improve quality of care and patient safety has grown, but examples of measurable and sustained progress are rare. The slow progress made in health care contrasts with the success of aviation safety. After a tragic 1995 plane crash, the aviation industry and government created the Commercial Aviation Safety Team to reduce fatal accidents. This public-private partnership of safety officials and technical experts is responsible for the decreased average rate of fatal aviation accidents. We propose a similar partnership in the health care community to coordinate national efforts and move patient safety and quality forward.

Case of the month: Right coronary artery dissection following sports-related blunt trauma

Coronary artery dissection is a rare life-threatening complication resulting from blunt traumatic injury. Most cases of coronary artery injury, including dissection, involve the left anterior descending artery given its anatomical location relative to the impact. Right coronary artery (RCA) dissection secondary to blunt trauma is a particularly unusual occurrence, and has not previously been reported in the emergency medicine literature. We present a case of RCA dissection following low impact sport-related blunt chest trauma and discuss the pathophysiology, risk factors, diagnosis and current treatment options.