Covid-19 and Pre-Morbid Lifestyle-Related Risk Factors-A Review

Since its outbreak in December 2019 in China, COVID-19 has spread like wild fire to affect many communities of the world. The high infectivity and case fatality rates of the disease among the general population and the severely ill patients respectively drew the attention of the global community. Our review showed that socio-demographic and lifestyle-related risk factors and underlying comorbid diseases were directly and indirectly associated with increased susceptibility and severity of COVID-19. These factors included older age (⩾60 years), male gender, and ethnic minority groups (especially blacks), smoking, low serum level of vitamin D, unhealthy diet, physical inactivity (with poor exposure to sunlight), overweight/obesity, high blood pressure/hypertension, high blood cholesterol, cardiovascular diseases (like stroke and coronary heart disease), diabetes mellitus, chronic obstructive pulmonary disease, chronic kidney disease, chronic liver disease, and some cancers (like leukemia, lymphoma, or myeloma). The literature further revealed that the clinical progression of the majority of these associated risk factors can be modified through effective and comprehensive risk reduction through healthy living and lifestyle modification. COVID-19 preventive and treatment guidelines that give adequate attention to risk reduction and healthy lifestyle among people-either in the pre-, peri-, or post-COVID-19 stage, should be developed by public health policymakers and clinicians. This will play a significant role in the global effort to combat the pandemic, and reduce its negative impact on the life expectancy and socio-economic development of the world particularly in low- and middle-income countries (LMICs).

Clinician consensus on "Inappropriate" presentations to the Emergency Department in the Better Data, Better Planning (BDBP) census: a cross-sectional multi-centre study of emergency department utilisation in Ireland

BACKGROUND

Utilisation of the Emergency Department (ED) for non-urgent care increases demand for services, therefore reducing inappropriate or avoidable attendances is an important area for intervention in prevention of ED crowding. This study aims to develop a consensus between clinicians across care settings about the "appropriateness" of attendances to the ED in Ireland.

METHODS

The Better Data, Better Planning study was a multi-centre, cross-sectional study investigating factors influencing ED utilisation in Ireland. Data was compiled in patient summary files which were assessed for measures of appropriateness by an academic General Practitioner (GP) and academic Emergency Medicine Consultant (EMC) National Panel. In cases where consensus was not reached charts were assessed by an Independent Review Panel (IRP). At each site all files were autonomously assessed by local GP-EMC panels.

RESULTS

The National Panel determined that 11% (GP) to 38% (EMC) of n = 306 lower acuity presentations could be treated by a GP within 24-48 h (k = 0.259; p < 0.001) and that 18% (GP) to 35% (EMC) of attendances could be considered "inappropriate" (k = 0.341; p < 0.001). For attendances deemed "appropriate" the admission rate was 47% compared to 0% for "inappropriate" attendees. There was no consensus on 45% of charts (n = 136). Subset analysis by the IRP determined that consensus for appropriate attendances ranged from 0 to 59% and for inappropriate attendances ranged from 0 to 29%. For the Local Panel review (n = 306) consensus on appropriateness ranged from 40 to 76% across ED sites.

CONCLUSIONS

Multidisciplinary clinicians agree that "inappropriate" use of the ED in Ireland is an issue. However, obtaining consensus on appropriateness of attendance is challenging and there was a significant cohort of complex heterogenous presentations where agreement could not be reached by clinicians in this study. This research again demonstrates the complexity of ED crowding, the introduction of evidence-based care pathways targeting avoidable presentations may serve to alleviate the problem in our EDs.

Better patient safety: implementing exploration and exploitation learning in daily medical practice

BACKGROUND

Current medical daily practice relies on guidelines, protocols and procedures (GPPs), which require exploitation. However, diagnosis, treatment, risk management and process improvements require exploration. Physician are often unable to switch between exploitation and exploration. This study tested a new approach to facilitate switching that included (1) a new 'thinking protocol' that encouraged leaping from exploitation to exploration and (2) a GPP that encouraged leaping from exploration to exploitation.

METHOD

Two hundred students were divided into four groups. The groups received a set of tasks that required switching between exploitation and exploration. Three groups received the thinking protocol, the GPP, or both, and the fourth group served as control.

RESULTS

With each additional task, all groups increased exploitative tendency(p<0.0001). The two groups with the thinking protocol leaped from exploitation to exploration (p<0.0001); the other two groups remained in exploitation (p=0.1173, p=0.0758). For the groups that employed exploration learning, the group that received the GPP switched back to exploitation (p<0.0001), but the other group remained in exploration (p=0.2363).

CONCLUSION

Despite the importance of timely leaping between exploration and exploitation, in some events, medical teams fail to make the appropriate leap. We suggest to use our novel approach and to encourage the leaping between exploration and exploitation in daily medical practice, to enable the prevention of medical errors and to enhance the effectiveness of risk managements and process improvements.

Clinician Perspectives of Barriers to Effective Implementation of a Rapid Response System in an Academic Health Centre: A Focus Group Study

BACKGROUND

Systemic and structural issues of rapid response system (RRS) models can hinder implementation. This study sought to understand the ways in which acute care clinicians (physicians and nurses) experience and negotiate care for deteriorating patients within the RRS.

METHODS

Physicians and nurses working within an Australian academic health centre within a jurisdictional-based model of clinical governance participated in focus group interviews. Verbatim transcripts were analysed using thematic content analysis.

RESULTS

Thirty-four participants (21 physicians and 13 registered nurses [RNs]) participated in six focus groups over five weeks in 2014. Implementing the RRS in daily practice was a process of informal communication and negotiation in spite of standardised protocols. Themes highlighted several systems or organisational-level barriers to an effective RRS, including (1) responsibility is inversely proportional to clinical experience; (2) actions around system flexibility contribute to deviation from protocol; (3) misdistribution of resources leads to perceptions of inadequate staffing levels inhibiting full optimisation of the RRS; and (4) poor communication and documentation of RRS increases clinician workloads.

CONCLUSION

Implementing a RRS is complex and multifactorial, influenced by various inter- and intra-professional factors, staffing models and organisational culture. The RRS is not a static model; it is both reflexive and iterative, perpetually transforming to meet healthcare consumer and provider demands and local unit contexts and needs. Requiring more than just a strong initial implementation phase, new models of care such as a RRS demand good governance processes, ongoing support and regular evaluation and refinement. Cultural, organizational and professional factors, as well as systems-based processes, require consideration if RRSs are to achieve their intended outcomes in dynamic healthcare settings.

Redesigning care to meet national recommendation of four or more yearly clinic visits in patients with cystic fibrosis

Cystic fibrosis (CF) is a chronic disease requiring patients to have frequent specialty healthcare visits to delay progression of lung disease, prevent and treat failure to thrive and initiate early interventions to prevent acute illness and complications. The CF Foundation recommends that patients have visits with the CF care team at least every 3 months. During participation in the CF Foundation Learning and Leadership Collaborative IV, the CF team at Arkansas Children's Hospital initiated quality improvement work with the aim to increase the percentage of patients attending clinic four or more times a year from 35% in 2004 and 56% in 2005 (CF Foundation Registry data) to 90% or greater. We redesigned our scheduling system, rescheduled missed patient appointments in a timely fashion and created a process to monitor attendance. This quality improvement work led to a sustained increase in the percentage of patients attending clinic visits four or more times a year reaching our goal of 90% in 2012. Improvements were also noted in the number of patients with body mass index/weight-for-length centile of 25 or greater, which could be related to more frequent clinic attendance.

Improved patient safety through reduced airway infection rates in a paediatric cystic fibrosis programme after a quality improvement effort to enhance infection prevention and control measures

OBJECTIVE

To reduce the risk of pathogen transmission between patients with cystic fibrosis (CF) and decrease the rate of acquisition of new CF pathogens in our patients.

DESIGN

Using the Model for Improvement, we developed a new process for infection prevention and control in our outpatient CF clinics.

SETTING

Paediatric CF programme at Ann & Robert H. Lurie Children's Hospital of Chicago; approximately 180 paediatric patients aged birth to 21 years.

PARTICIPANTS

All paediatric patients enrolled in the Cystic Fibrosis Foundation Patient Data Registry at this institution.

INTERVENTIONS

Implemented contact precautions with all patients, regardless of respiratory tract culture results.

MEASUREMENT

Respiratory tract culture rates of specific pathogens by quarter were compared prior to and after implementation.

RESULTS

Our percentage of patients with a positive respiratory tract culture for Pseudomonas aeruginosa dropped from 30% to 21% (p<0.0001) and for methicillin-resistant Staphylococcus aureus (MRSA) dropped from 10.8% to 8.7% (p=0.008).

CONCLUSIONS

Use of contact precautions by all care providers, for all patients, regardless of respiratory tract culture results resulted in decreased P aeruginosa and MRSA infection rates.

Sustained improvement in nutritional outcomes at two paediatric cystic fibrosis centres after quality improvement collaboratives

OBJECTIVE

To describe the characteristics of sustained improved nutritional outcomes through the use of quality improvement (QI) methodology.

DESIGN

Retrospective analysis of a QI intervention in two institutions, implemented as part of larger national collaboratives.

SETTING

Paediatric cystic fibrosis (CF) programmes in academic centres in Alabama and Illinois.

PARTICIPANTS

All paediatric patients enrolled in the CF Foundation (CFF) Patient Data Registry were included.

INTERVENTIONS

Improved and sustained nutrition outcomes occurred through implementation of the CFF practice guidelines for CF nutrition management via care delivery processes, nutritional interventions, team engagement and data display.

MEASUREMENT

Mean body mass index (BMI) percentile, percentage of patients less than 50th percentile and percentage less than 10th percentile for all patients aged 2-20 years were tracked through run charts and statistical process control charts. Mann-Whitney U and χ(2) tests were used to determine significance between each centre and national outcomes.

RESULTS

Each centre achieved rapid improvement in mean BMI percentile in patients, one centre rising from the 40th percentile in 2001 to the 49th percentile in 2003, the other rising from the 37th percentile in 2003 to the 45th percentile in 2004. These centres have also maintained improved nutritional outcomes, so that they were at the 60th and 55th percentiles, respectively, in 2011. Sustained improvement was accomplished through QI methodology, use of data as a driver for improvement and a change in culture.

CONCLUSIONS

Participation in collaboratives led to improved nutrition outcomes while a strong culture of QI facilitated sustained improvement.

From harm to hope and purposeful action: what could we do after Francis?

Responses to the reports on the inquiry into Mid Staffordshire have resulted in calls from politicians, NHS leaders and the public to improve care across the NHS in England. However, the substance of what needs to be done remains unclear. In this paper, we offer seven key 'ingredients' required to sustain improvement of care, supported by evidence drawn from published literature. We believe that empowering and upskilling the front-line workforce in understanding and implementing improvement techniques, supported by changes at system and policy level and reinforced by what leaders say and do, will result in sustainable benefit for patients and families, as well as greater satisfaction for staff.

Governance of quality of care: a qualitative study of health service boards in Victoria, Australia

Objectives

To describe the engagement of health service boards with quality-of-care issues and to identify factors that influence boards’ activities in this area.

Methods

We conducted semistructured interviews with 35 board members and executives from 13 public health services in Victoria, Australia. Interviews focused on the role currently played by boards in overseeing quality of care. We also elicited interviewees’ perceptions of factors that have influenced their current approach to governance in this area. Thematic analysis was used to identify key themes from interview transcripts.

Results

Virtually all interviewees believed boards had substantial opportunities to influence the quality of care delivered within the service, chiefly through setting priorities, monitoring progress, holding staff to account and shaping culture. Perceived barriers to leveraging this influence included insufficient resources, gaps in skills and experience among board members, inadequate information on performance and regulatory requirements that miss the mark. Interviewees converged on four enablers of more effective quality governance: stronger regional collaborations; more tailored board training on quality issues; smarter use of reporting and accreditation requirements; and better access to data that was reliable, longitudinal and allowed for benchmarking against peer organisations.

Conclusions

Although health service boards are eager to establish quality of care as a governance priority, several obstacles are blocking progress. The result is a gap between the rhetoric of quality governance and the reality of month-to-month activities at the board level. The imperative for effective board-level engagement in this area cannot be met until these barriers are addressed.

Staffing and resource adequacy strongly related to RNs' assessment of patient safety: a national study of RNs working in acute-care hospitals in Sweden

Introduction

Although registered nurses (RNs) are central in patient care, we have not found prior research that specifically addresses how RNs assess the safety of patient care at their workplace and how factors in RNs’ work environment are related to their assessments. This study aims to address these issues.

Methods

9236 RNs working with inpatient care in 79 acute-care hospitals in Sweden completed a national population-based survey, including Practice Environment Scale of the Nursing Work Index—Revised and items from Agency for Healthcare Research and Quality's Hospital Survey on Patient Safety Culture. Correlation coefficients (Pearson and Spearman) and proportional odds regression were used for analysis.

Results

Nursing work environment factors were strongly related to RNs’ assessments of patient safety. RNs’ perception of having adequate staffing and resources improved their assessment of patient safety by at least two and a half times (OR 2.74 CI 2.52 to 2.97). RNs with a higher level of involvement in direct patient care gave a better patient safety grade than RNs with a more supervisory role. Most, but not all, patient safety culture items were related to RNs’ assessed patient safety grade. We found that work experience seemed to have no influence on RNs’ patient safety assessment.

Conclusions

While previous research emphasises patient-to-nurse ratios in strengthening patient safety practices, this study complements this by emphasising RNs’ own perception of having enough staff and resources to provide quality nursing care, as well as having good collegial nurse–physician relations and the presence of visible and competent nursing leadership—all factors highly related to RNs’ assessment of the safety of patient care at their workplace.

A system-wide approach to explaining variation in potentially avoidable emergency admissions: national ecological study

Background

Some emergency admissions can be avoided if acute exacerbations of health problems are managed by the range of health services providing emergency and urgent care.

Aim

To identify system-wide factors explaining variation in age sex adjusted admission rates for conditions rich in avoidable admissions.

Design

National ecological study.

Setting

152 emergency and urgent care systems in England.

Methods

Hospital Episode Statistics data on emergency admissions were used to calculate an age sex adjusted admission rate for conditions rich in avoidable admissions for each emergency and urgent care system in England for 2008–2011.

Results

There were 3 273 395 relevant admissions in 2008–2011, accounting for 22% of all emergency admissions. The mean age sex adjusted admission rate was 2258 per year per 100 000 population, with a 3.4-fold variation between systems (1268 and 4359). Factors beyond the control of health services explained the majority of variation: unemployment rates explained 72%, with urban/rural status explaining further variation (R²=75%). Factors related to emergency departments, hospitals, emergency ambulance services and general practice explained further variation (R²=85%): the attendance rate at emergency departments, percentage of emergency department attendances converted to admissions, percentage of emergency admissions staying less than a day, percentage of emergency ambulance calls not transported to hospital and perceived access to general practice within 48 h.

Conclusions

Interventions to reduce avoidable admissions should be targeted at deprived communities. Better use of emergency departments, ambulance services and primary care could further reduce avoidable emergency admissions.