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Correction: Its time to consider national culture when designing team training initiatives in healthcare

Quality and Safety in Health Care Journal -

Rice J, Daouk-Öyry L, Hitti EI. It’s time to consider national culture when designing team training initiatives in healthcare. BMJ Qual Saf 2021;30:412–7. doi: 10.1136/bmjqs-2020-010918

This article has been corrected since it first published. The provenance and peer review statement has been included.

Correction: Comparing peripherally inserted central catheter-related practices across hospitals with different insertion models: a multisite qualitative study

Quality and Safety in Health Care Journal -

Krein SL, Harrod M, Weston LE, et al. Comparing peripherally inserted central catheter-related practices across hospitals with different insertion models: a multisite qualitative study. BMJ Qual Saf 2021;30:628–38.

This article has been corrected since it first published. The provenance and peer review statement has been included.

Correction: The Irish National Adverse Event Study-2 (INAES-2): longitudinal trends in adverse event rates in the Irish healthcare system

Quality and Safety in Health Care Journal -

Connolly W, Rafter N, Conroy RM, et al. The Irish National Adverse Event Study-2 (INAES-2): longitudinal trends in adverse event rates in the Irish healthcare system. BMJ Qual Saf 2021;30:547–558. doi:10.1136/bmjqs-2020-011122

This article has been corrected since it first published. The provenance and peer review statement has been included.

Accreditation in health care: does it make any difference to patient outcomes?

Quality and Safety in Health Care Journal -

Over the past few decades, a growing number of organisations have begun offering accreditation and certification services to healthcare facilities. As an example, in the USA, a comprehensive and facility-wide accreditation with a designated organisation is required to contract with Medicare and Medicaid, two large government-sponsored health insurance programmes and often the largest single payers for any given facility. In addition, facilities have the option to pursue voluntary specialty-specific accreditations for nursing excellence, radiology and imaging, trauma, chest pain and more. However, one of the perennial questions about these accolades is, does accreditation mean that patient outcomes are better? Accreditation methods are heterogeneous, typically rely on facility-generated documentation of processes and policies and do not guarantee best practices will be followed on a day-to-day basis. As a result, the published literature shows mixed evidence on its effectiveness.1

What remains unclear at this point is how accreditation achieves...

Sustaining quality improvement efforts: emerging principles and practice

Quality and Safety in Health Care Journal -

Do we care if a quality improvement (QI) innovation is effective, if it is not sustained? This uncomfortable question is increasingly important as healthcare is judged (and reimbursed) on ‘quality’ and ‘value’. Often, a sentinel safety event or dip in performance on a quality measure tied to reimbursement spurs a ‘quick fix’ mentality. However, considering how to ‘fix the problem’ in such a way that it is permanently fixed—in other words—that the ‘fix’ becomes part of everyday practice routines, is essential. This is not easy. Reviews of the extant literature point out how little we know about how to do this successfully1–4 and conceptual models drawing on this literature also vary widely in what they consider to be important key contributors to sustainability.5–9 When empirical literature does exist, it often demonstrates...

Impact of trauma centre accreditation on mortality and complications in a Canadian trauma system: an interrupted time series analysis

Quality and Safety in Health Care Journal -

Background

Periodic external accreditation visits aiming to determine whether trauma centres are fulfilling the criteria for optimal care are part of most trauma systems. However, despite the growing trend towards accreditation of trauma centres, its impact on patient outcomes remains unclear. In addition, a recent systematic review found inconsistent results on the association between accreditation and patient outcomes, mostly due to the lack of robust controls. We aim to address these gaps by assessing the impact of trauma centre accreditation on patient outcomes, specifically in-hospital mortality and complications, using an interrupted time series (ITS) design.

Methods

We included all major trauma admissions to five level I and four level II trauma centres in Quebec, Canada between 2008 and 2017. In order to perform ITS, we first obtained monthly and quarterly estimates of the proportions of in-hospital mortality and complications, respectively, for level I and level II centres. Prognostic scores were used to standardise these proportions to account for changes in patient case mix and segmented regressions with autocorrelated errors were used to estimate changes in levels and trends in both outcomes following accreditation.

Results

There were 51 035 admissions, including 20 165 for major trauma during the study period. After accounting for changes in patient case mix and secular trend in studied outcomes, we globally did not observe an association between accreditation and patient outcomes. However, associations were heterogeneous across centres. For example, in a level II centre with worsening preaccreditation outcomes, accreditation led to –9.08 (95% CI –13.29 to –4.87) and –9.60 (95% CI –15.77 to –3.43) percentage point reductions in mortality and complications, respectively.

Conclusion

Accreditation seemed to be beneficial for centres that were experiencing a decrease in performance preceding accreditation.

Effectiveness of chest pain centre accreditation on the management of acute coronary syndrome: a retrospective study using a national database

Quality and Safety in Health Care Journal -

Background

Large-scale real-world data to evaluate the impact of chest pain centre (CPC) accreditation on acute coronary syndrome (ACS) emergency care in heavy-burden developing countries like China are rare.

Methods

This study is a retrospective study based on data from the Hospital Quality Monitoring System (HQMS) database. This study included emergency patients admitted with ACS to hospitals that uploaded clinical data continuously to the database from 2013 to 2016. Propensity score matching was used to compare hospitals with and without CPC accreditation during this period. A longitudinal self-contrast comparison design with mixed-effects models was used to compare management of ACS before and after accreditation.

Results

A total of 798 008 patients with ACS from 746 hospitals were included in the analysis. After matching admission date, hospital levels and types and adjusting for possible covariates, patients with ACS admitted to accredited CPCs had lower in-hospital mortality (OR=0.70, 95% CI 0.53 to 0.93), shorter length of stay (LOS; adjusted multiplicative effect=0.89, 95% CI 0.84 to 0.94) and more percutaneous coronary intervention (PCI) procedures (OR=3.53, 95% CI 2.20 to 5.66) than patients admitted in hospitals without applying for CPC accreditation. Furthermore, when compared with the ‘before accreditation’ group only in accredited CPCs, the in-hospital mortality and LOS decreased and the usage of PCI were increased in both ‘accreditation’ (for in-hospital mortality: OR=0.86, 95% CI 0.79 to 0.93; for LOS: 0.94, 95% CI 0.93 to 0.95; for PCI: OR=1.22, 95% CI 1.18 to 1.26) and ‘after accreditation’ groups (for in-hospital mortality: OR=0.90, 95% CI 0.84 to 0.97; for LOS: 0.89, 95% CI 0.89 to 0.90; for PCI: OR=1.36, 95% CI 1.33 to 1.39). The significant benefits of decreased in-hospital mortality, reduced LOS and increased PCI usage were also observed for patients with acute myocardial infarction.

Conclusions

CPC accreditation is associated with better management and in-hospital clinical outcomes of patients with ACS. CPC establishment and accreditation should be promoted and implemented in countries with high levels of ACS.

Sustainability of paediatric asthma care quality in community hospitals after ending a national quality improvement collaborative

Quality and Safety in Health Care Journal -

Background

Community hospitals, which care for most hospitalised children in the USA, may be vulnerable to declines in paediatric care quality when quality improvement (QI) initiatives end. We aimed to evaluate changes in care quality in community hospitals after the end of the Pathways for Improving Paediatric Asthma Care (PIPA) national QI collaborative.

Methods

We conducted a longitudinal cohort study during and after PIPA. PIPA included 45 community hospitals, of which 34 completed the 12-month collaborative and were invited for extended sustainability monitoring (total of 21–24 months from collaborative start). PIPA provided paediatric asthma pathways, educational materials/seminars, QI mentorship, monthly data reports, a mobile application and peer-to-peer learning opportunities. Access to pathways, educational materials and the mobile application remained during sustainability monitoring. Charts were reviewed for children aged 2–17 years old hospitalised with a primary diagnosis of asthma (maximum 20 monthly per hospital). Outcomes included measures of guideline adherence (early bronchodilator administration via metered-dose inhaler (MDI), secondhand smoke screening and referral to smoking cessation resources) and length of stay (LOS). We evaluated outcomes using multilevel regression models adjusted for patient mix, using an interrupted time-series approach.

Results

We analysed 2159 hospitalisations from 23 hospitals (68% of eligible). Participating hospitals were structurally similar to those that dropped out but had more improvement in guideline adherence during the collaborative (29% vs 15%, p=0.02). The end of the collaborative was associated with a significant initial decrease in early MDI administration (81%–68%) (adjusted OR (aOR) 0.26 (95% CI 0.15 to 0.42)) and decreased rate of referral to smoking cessation resources (2.2% per month increase to 0.3% per month decrease) (aOR 0.86 (95% CI 0.75 to 0.98)) but no significant changes in LOS or secondhand smoke screening.

Conclusions

The end of a paediatric asthma QI collaborative was associated with concerning declines in guideline adherence in community hospitals.

How sensitive are avoidable emergency department attendances to primary care quality? Retrospective observational study

Quality and Safety in Health Care Journal -

Background

Improvements in primary care quality are often proposed as a solution to rises in emergency department (ED) attendances. However, there is little agreement on what constitutes an avoidable attendance, and the relationship between primary care quality and ED demand remains poorly understood.

Objective

To estimate the size of the associations between primary care quality and volumes of ED attendances classified as avoidable.

Methods

Retrospective observational study of all attendances at EDs in England during 2015/2016, applying three definitions of avoidable attendance. We linked practice-level counts of attendances to seven measures of primary care access, patient experience and clinical quality for 7521 practices. We used count data regressions to associate attendance counts with levels of quality. We then calculated proportions of attendances associated with levels of primary care quality below the national average.

Results

Attendance volumes were negatively related to three of the seven quality measures. Incidence rate ratios (IRRs) for all attendances associated with 10 percentage-point differences in quality were 0.987 for clinical quality and 0.987 for easy telephone access and 0.978 for ability to get an appointment. These associations were relatively stronger for narrower definitions of avoidable attendances (for the narrowest definition, IRRs=0.966, 0.976 and 0.934, respectively) but represented fewer attendances in absolute terms. 341 000 (2.4%) attendances were associated with levels of primary care quality below the national average in 2015/2016.

Conclusion

ED attendances are sensitive to primary care quality, but magnitudes of these associations are small. Attendances are much less responsive to differences in primary care quality than indicated by estimates of the prevalence of avoidable attendances. This may explain the failure of initiatives to reduce attendances through primary care improvements.

Smart agent system for insulin infusion protocol management: a simulation-based human factors evaluation study

Quality and Safety in Health Care Journal -

Objective

To compare the insulin infusion management of critically ill patients by nurses using either a common standard (ie, human completion of insulin infusion protocol steps) or smart agent (SA) system that integrates the electronic health record and infusion pump and automates insulin dose selection.

Design

A within subjects design where participants completed 12 simulation scenarios, in 4 blocks of 3 scenarios each. Each block was performed with either the manual standard or the SA system. The initial starting condition was randomised to manual standard or SA and alternated thereafter.

Setting

A simulation-based human factors evaluation conducted at a large academic medical centre.

Subjects

Twenty critical care nurses.

Interventions

A systems engineering intervention, the SA, for insulin infusion management.

Measurements

The primary study outcomes were error rates and task completion times. Secondary study outcomes were perceived workload, trust in automation and system usability, all measured with previously validated scales.

Main results

The SA system produced significantly fewer dose errors compared with manual calculation (17% (n=20) vs 0, p<0.001). Participants were significantly faster, completing the protocol using the SA system (p<0.001). Overall ratings of workload for the SA system were significantly lower than with the manual system (p<0.001). For trust ratings, there was a significant interaction between time (first or second exposure) and the system used, such that after their second exposure to the two systems, participants had significantly more trust in the SA system. Participants rated the usability of the SA system significantly higher than the manual system (p<0.001).

Conclusions

A systems engineering approach jointly optimised safety, efficiency and workload considerations.

SEIPS 101 and seven simple SEIPS tools

Quality and Safety in Health Care Journal -

In the past 15 years, SEIPS (Systems Engineering Initiative for Patient Safety)1–3 and related conceptual models4 5 were developed to study and improve healthcare. These theoretical models depict how work systems affect health-related outcomes, such as patient safety, and can be used to guide research and improvement efforts. Various versions of the SEIPS model have been used by academics and practitioners, but a recent review argued that broader use and benefits can be achieved through ‘an easy-to-use version of the model and simplified tools for model application’.6 This concords with repeated requests we have received for simple, practical tools to apply SEIPS and with the general critique regarding the dearth of easy to use systems engineering tools.7

Accordingly, we offer SEIPS 101, a simplified, practice-oriented SEIPS model meant for easy use by practitioners, researchers and...

Improving timeliness of hepatitis B vaccine administration in an urban safety net level III NICU

Quality and Safety in Health Care Journal -

Objective

To avoid preventable consequences of perinatal hepatitis B infection, all infants should be given hepatitis B vaccine (HBV) within 24 hours of birth if birth weight is ≥2 kg and at 30 days of life or at discharge if <2 kg, to provide highest seroprotection rates while ensuring universal vaccination prior to discharge. We aimed to achieve timely HBV administration in >80% of eligible infants in both birthweight groups and decrease infants discharged home without receiving HBV to <1% over an 18-month period and sustain results for an additional 15 months.

Methods

Data were collected from June 2016 to May 2020 in a level III neonatal intensive care unit. A multidisciplinary team identified barriers and interventions through Plan-Do-Study-Act cycles from September 2017 to February 2019: using pharmacists as champions, overcoming legal barriers, staff education and best practice alerts (BPAs) embedded in electronic health records. Statistical process control (SPC) p charts were used to evaluate the primary outcome measure, monthly percentage of infants receiving timely HBV administration stratified by birthweight categories (≥2 and <2 kg). For infants receiving HBV outside the time frame, absolute difference of timeliness was calculated.

Results

Mean timely HBV administration improved from 45% to 95% (≥2 kg) and from 45% to 85% (<2 kg) with special cause variation in SPC charts. Infants discharged without receiving HBV decreased from 4.6% to 0.22%. Of those given HBV outside the recommended time frame, median absolute time between recommended and actual administration time decreased significantly: from 3.5 days (IQR 1.6, 8.6) to 0.3 day (IQR 0.1, 0.8) (p<0.001) in ≥2 kg group and from 6 days (IQR 1, 15) to 1 day (IQR 1, 6.5) (p=0.009) in <2 kg group.

Conclusions

Using a multidisciplinary approach, we significantly improved and sustained timely HBV administration and nearly eliminated infants discharged home without receiving HBV. Pharmacists as champions and BPAs were critical to our success.

Quality and Safety in the Literature: November 2021

Quality and Safety in Health Care Journal -

Healthcare quality and safety span multiple topics across the spectrum of academic and clinical disciplines. Keeping abreast of the rapidly growing body of work can be challenging. In this series, we provide succinct summaries of selected relevant studies published in the last several months. Some articles will focus on a particular theme, whereas others will highlight unique publications from high-impact medical journals.

Key points

  • A randomised, controlled, multicentre trial in Switzerland found that there was no difference in subjective or objective measures of patient knowledge between bedside and outside the room rounding strategies. Ann Intern Med. 29 June 2021.

  • Use of clear face masks improves patients’ perceptions of surgeons’ communication skills, empathy and trustworthiness when compared with use of standard face masks. JAMA Surg. 1 April 2021.

  • Queensland’s minimum nurse-to-patient ratio policy resulted in significantly improved nurse staffing, hospital length of stay...

  • Merck Issues Voluntary Nationwide Recall of CUBICIN® (Daptomycin for Injection) 500 mg, Lot 934778, Due to Presence of Particulate Matter Identified as Glass Particles

    FDA MedWatch -

    Merck (NYSE: MRK), known as MSD outside the United States and Canada, is voluntarily recalling one lot of CUBICIN® (daptomycin for injection) 500mg for intravenous use, Lot 934778, Exp June 2022. Because treatment with CUBICIN is likely to be initiated at a hospital or other monitored healthcare se

    Bryant Ranch Prepack Issues Voluntary Nationwide Recall of Methocarbamol 500mg Bottles Due to Mislabeling With the Incorrect Strength

    FDA MedWatch -

    Burbank, CA, Bryant Ranch Prepack is voluntarily recalling 1 lot of Methocarbamol 500mg, Tablets to the consumer level. The bottles labeled as Methocarbamol 500mg Tablets have been found to contain Methocarbamol 750mg Tablets. If a patient takes a 750mg Tablet of Methocarbamol instead of the prescri

    Lupin Pharmaceuticals, Inc. Issues Voluntarily Nationwide Recall of All Irbesartan Tablets and Irbesartan and Hydrochlorothiazide Tablets Due to Potential Presence of N-nitrosoirbesartan Impurity

    FDA MedWatch -

    Baltimore, Maryland, October 14, 2021: Lupin Pharmaceuticals Inc. is voluntarily recalling the below-mentioned batches of Irbesartan Tablets and Irbesartan and Hydrochlorothiazide Tablets to the consumer level. As part of Lupin’s ongoing assessment, analysis revealed that certain tested API batches

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