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Inter-hospital transfer and patient outcomes: a retrospective cohort study

Quality and Safety in Health Care Journal -

Background

Inter-hospital transfer (IHT, the transfer of patients between hospitals) occurs regularly and exposes patients to risks of discontinuity of care, though outcomes of transferred patients remains largely understudied.

Objective

To evaluate the association between IHT and healthcare utilisation and clinical outcomes.

Design

Retrospective cohort.

Setting

CMS 2013 100 % Master Beneficiary Summary and Inpatient claims files merged with 2013 American Hospital Association data.

Participants

Beneficiaries≥age 65 enrolled in Medicare A and B, with an acute care hospitalisation claim in 2013 and 1 of 15 top disease categories.

Main outcome measures

Cost of hospitalisation, length of stay (LOS) (of entire hospitalisation), discharge home, 3 -day and 30- day mortality, in transferred vs non-transferred patients.

Results

The final cohort consisted of 53 420 transferred patients and 53 420 propensity-score matched non-transferred patients. Across all 15 disease categories, IHT was associated with significantly higher costs, longer LOS and lower odds of discharge home. Additionally, IHT was associated with lower propensity-matched odds of 3-day and/or 30- day mortality for some disease categories (acute myocardial infarction, stroke, sepsis, respiratory disease) and higher propensity-matched odds of mortality for other disease categories (oesophageal/gastrointestinal disease, renal failure, congestive heart failure, pneumonia, renal failure, chronic obstructivepulmonary disease, hip fracture/dislocation, urinary tract infection and metabolic disease).

Conclusions

In this nationally representative study of Medicare beneficiaries, IHT was associated with higher costs, longer LOS and lower odds of discharge home, but was differentially associated with odds of early death and 30 -day mortality depending on patients’ disease category. These findings demonstrate heterogeneity among transferred patients depending on the diagnosis, presenting a nuanced assessment of this complex care transition.

Correction: Local emergency medical response after a terrorist attack in Norway: a qualitative study

Quality and Safety in Health Care Journal -

Brandrud AS, Bretthauer M, Brattebø G, et al. Local emergency medical response after a terrorist attack in Norway: a qualitative study. BMJQualSaf 2017;26:806–16. doi: 10.1136/bmjqs-2017-006517.

The authors want to alert readers on the below error identified in the published version.

At the bottom of page 807 under the headline: "Focus group participants" the corrected text should be: "In total, 260 individuals were eligible for interviews. Of these, 20 had moved from the area or were no longer in service, leaving 240 individuals we invited to participate in the study".

Language, culture and preventable readmissions: pragmatic, intervention studies needed

Quality and Safety in Health Care Journal -

Preventable hospital readmissions are considered a marker of care quality. Readmissions burden patients and their families and are a significant driver of healthcare costs.1 2 In the USA (where we are based), readmission penalties have resulted in an array of interventions, ranging from the relatively simple (eg, ensuring a timely follow-up appointment) to bundled interventions with multiple components (eg, medication reconciliation plus phone follow-up plus structured handoff to outpatient clinicians).3 Evaluation results, however, have been mixed and progress in reducing readmissions difficult. Studies generally have provided limited details about interventions and the patient groups involved, making it impossible to know what worked for whom.3 4 Complicating the practical implications of this research is that bundled interventions, which tend to be more successful, require greater investment of clinical and financial resources and at times result in net financial loss, significantly...

Connecting simulation and quality improvement: how can healthcare simulation really improve patient care?

Quality and Safety in Health Care Journal -

Simulation has an established role in the education and training of healthcare professionals, but its function as a healthcare quality improvement (QI) tool is more emergent. In this edition of the journal, Ajmi and colleagues report on a simulation-based intervention that improved door-to-needle times and patient outcomes in acute ischaemic stroke.1 This prompts reflection on the positioning of simulation-based methods within QI programmes, the role of trained simulation experts as part of QI-focused teams and the directions for future scholarly enquiry that supports integration of these fields.

The improvement report by Ajmi et al is a comprehensive and thoughtful example among many reports of simulation-based interventions to improve care processes and patient outcomes. Improved time-based targets in trauma,2 stroke and cardiac care are frequently cited in the literature, as are better resuscitation outcomes3 and compliance with practice guidelines.4 The identification of...

Association between cultural factors and readmissions: the mediating effect of hospital discharge practices and care-transition preparedness

Quality and Safety in Health Care Journal -

Objectives

The study examines whether hospital discharge practices and care-transition preparedness mediate the association between patients’ cultural factors and readmissions.

Methods

A prospective study of internal medicine patients (n=599) examining a culturally diverse cohort, at a tertiary medical centre in Israel. The in-hospital baseline questionnaire included sociodemographic, cultural factors (Multidimensional Health Locus of Control, family collectivism, health literacy and minority status) and physical, mental and functional health status. A follow-up telephone survey assessed hospital discharge practices: use of the teach-back method, providers’ cultural competence, at-discharge language concordance and caregiver presence and care-transition preparedness using the care transition measure (CTM). Clinical and administrative data, including 30-day readmissions to any hospital, were retrieved from the healthcare organisation’s data warehouse. Multiple mediation was tested using Hayes’s PROCESS procedure, model 80.

Results

A total of 101 patients (17%) were readmitted within 30 days. Multiple logistic regressions indicated that all cultural factors, except for minority status, were associated with 30-day readmission when no mediators were included (p<0.05). Multiple mediation analysis indicated significant indirect effects of the cultural factors on readmission through the hospital discharge practices and CTM. Finally, when the mediators were included, strong direct and indirect effects between minority status and readmission were found (B coefficient=–0.95; p=0.021).

Conclusions

The results show that the association between patients’ cultural factors and 30-day readmission is mediated by the hospital discharge practices and care transition. Providing high-quality discharge planning tailored to patients’ cultural characteristics is associated with better care-transition preparedness, which, in turn, is associated with reduced 30-day readmissions.

Patients perspective on how to improve the care of people with chronic conditions in France: a citizen science study within the ComPaRe e-cohort

Quality and Safety in Health Care Journal -

Background

This study aimed to involve patients with chronic conditions in generating ideas for improving their care.

Methods

We performed a citizen science study. Participants were adult patients with chronic conditions recruited in Community of Patients for Research ‘ComPaRe,’ a French e-cohort of patients with chronic conditions. Participants generated ideas to improve their care in answer to the open-ended question, ‘If you had a magic wand, what would you change in your healthcare?’ Three researchers and two patients independently extracted ideas from open-ended answers by using thematic analysis. Ideas were grouped into areas for improvement at the consultation, hospital/clinic and health system levels. Findings were validated and enriched by a second sample of participants recruited in ComPaRe.

Results

Between May 2017 and April 2018, a total of 1636 patients provided 3613 ideas to improve consultations (1701 ideas related to 58 areas for improvement), hospitals/clinics (928 ideas related to 41 areas for improvement) and the health system (984 ideas related to 48 areas for improvement). At the consultation level, most ideas were related to improving physician–patient discussions, informing patients about their own care, and adapting treatment to patient preferences and context. At the hospital/clinic level, most ideas aimed at improving the coordination and collaboration in care. At the health system level, most ideas were related to decreasing the administrative burden imposed on patients, improving access to care and reducing the costs of care.

Conclusion

Patients have many ideas to improve their care, from the content of consultations to the organisation of hospitals. Our study provides the proof of concept for a method to leverage patients’ practical knowledge of the care system to improve it.

Can a patient-directed video improve inpatient advance care planning? A prospective pre-post cohort study

Quality and Safety in Health Care Journal -

Background

Patients and their families often have an inadequate understanding of the risks and benefits of their advance care planning (ACP) options. Improving patients’ knowledge of therapeutic interventions allows them to better select treatments they believe are most appropriate for their condition.

Objectives

To determine if a video aimed at educating and engaging hospitalised patients on a standardised ACP order set can improve (1) inpatient understanding of key ACP concepts, (2) ACP documentation within 48 hours of hospital admission, (3) concordance between a patient’s expressed and chart-documented care preferences, (4) patient satisfaction with decision-making, and (5) patient’s decisional confidence.

Methods

A prospective, non-randomised, pre-post intervention study of 252 inpatients in a 215-bed community-based hospital in Comox, British Columbia, Canada.

Results

Our video decision support tool was associated with significant improvements in (1) patient understanding of key ACP concepts (70%–100%; p<0.0001), (2) ACP documentation within 48 hours of hospital admission (81%–92%; p=0.01), (3) concordance between patients’ expressed wishes and chart documentation (69%–89%; p<0.0001), (4) patient satisfaction with decision-making (Canadian Health Care Evaluation Project Lite score: 4.3–4.5, p=0.001), and (5) patient’s decisional confidence (patients with no decisional conflict, increased from 72% to 93%; p<0.0001).

Conclusion

A 13 min video aimed at educating and engaging inpatients on ACP concepts improved patient understanding of key ACP concepts, rates of ACP documentation and patient satisfaction with decision-making.

Putting out fires: a qualitative study exploring the use of patient complaints to drive improvement at three academic hospitals

Quality and Safety in Health Care Journal -

Background and objectives

Recent years have seen increasing calls for more proactive use of patient complaints to develop effective system-wide changes, analogous to the intended functions of incident reporting and root cause analysis (RCA) to improve patient safety. Given recent questions regarding the impact of RCAs on patient safety, we sought to explore the degree to which current patient complaints processes generate solutions to recurring quality problems.

Design/setting

Qualitative analysis of semistructured interviews with 21 patient relations personnel (PRP), nursing and physician leaders at three teaching hospitals (Toronto, Canada).

Results

Challenges to using the patient complaints process to drive hospital-wide improvement included: (1) Complaints often reflect recalcitrant system-wide issues (eg, wait times) or well-known problems which require intensive efforts to address (eg, poor communication). (2) The use of weak change strategies (eg, one-off educational sessions). (3) The handling of complaints by unit managers so they never reach the patient relations office. PRP identified giving patients a voice as their primary goal. Yet their daily work, which they described as ‘putting out fires’, focused primarily on placating patients in order to resolve complaints as quickly as possible, which may in effect suppress the patient voice.

Conclusions

Using patient complaints to drive improvement faces many of the challenges affecting incident reporting and RCA. The emphasis on ‘putting out fires’ may further detract from efforts to improve care for future patients. Systemically incorporating patients’ voices in clinical operations, as with co-design and other forms of authentic patient engagement, may hold greater promise for meaningful improvements in the patient experience than do RCA-like analyses of patient complaints.

Home care nursing after elective vascular surgery: an opportunity to reduce emergency department visits and hospital readmission

Quality and Safety in Health Care Journal -

Background

Events occurring outside the hospital setting are underevaluated in surgical quality improvement initiatives and research.

Objective

To quantify regional variation in home care nursing following vascular surgery and explore its impact on emergency department (ED) visits and hospital readmission.

Methods

Patients who underwent elective vascular surgery and were discharged directly home were identified from population-based administrative databases for the province of Ontario, Canada, 2006–2015. The index surgeries included carotid endarterectomy, open and endovascular aortic aneurysm repair and bypass for lower extremity peripheral arterial disease. Home care nursing within 30 days of discharge was captured and compared across regions. Using multilevel logistic regression, we characterised the association between home care nursing and the risk of an ED visit or hospital readmission within 30 days of discharge.

Results

The cohort included 23 617 patients, of whom 9002 (38%) received home care nursing within 30 days of discharge home. Receipt of nursing care after discharge home varied widely across Ontario’s 14 administrative health regions (range 16%–84%), even after accounting for differences in patient case mix. A lower likelihood of an ED visit or hospital readmission within 30 days of discharge was observed among patients who received home care nursing following three of four index surgeries: carotid endarterectomy OR 0.74, 95% CI 0.61 to 0.91; endovascular aortic aneurysm repair OR 0.85, 95% CI 0.72 to 0.99; open aortic aneurysm repair OR 1.06, 95% CI 0.91 to 1.23; bypass for lower extremity peripheral arterial disease OR 0.81, 95% CI 0.72 to 0.92.

Conclusion

Home care nursing may contribute to reducing ED visits and hospital readmission and is variably prescribed after vascular surgery.

Automated detection of wrong-drug prescribing errors

Quality and Safety in Health Care Journal -

Background

To assess the specificity of an algorithm designed to detect look-alike/sound-alike (LASA) medication prescribing errors in electronic health record (EHR) data.

Setting

Urban, academic medical centre, comprising a 495-bed hospital and outpatient clinic running on the Cerner EHR. We extracted 8 years of medication orders and diagnostic claims. We licensed a database of medication indications, refined it and merged it with the medication data. We developed an algorithm that triggered for LASA errors based on name similarity, the frequency with which a patient received a medication and whether the medication was justified by a diagnostic claim. We stratified triggers by similarity. Two clinicians reviewed a sample of charts for the presence of a true error, with disagreements resolved by a third reviewer. We computed specificity, positive predictive value (PPV) and yield.

Results

The algorithm analysed 488 481 orders and generated 2404 triggers (0.5% rate). Clinicians reviewed 506 cases and confirmed the presence of 61 errors, for an overall PPV of 12.1% (95% CI 10.7% to 13.5%). It was not possible to measure sensitivity or the false-negative rate. The specificity of the algorithm varied as a function of name similarity and whether the intended and dispensed drugs shared the same route of administration.

Conclusion

Automated detection of LASA medication errors is feasible and can reveal errors not currently detected by other means. Real-time error detection is not possible with the current system, the main barrier being the real-time availability of accurate diagnostic information. Further development should replicate this analysis in other health systems and on a larger set of medications and should decrease clinician time spent reviewing false-positive triggers by increasing specificity.

Nursing roles for in-hospital cardiac arrest response: higher versus lower performing hospitals

Quality and Safety in Health Care Journal -

Background

Good outcomes for in-hospital cardiac arrest (IHCA) depend on a skilled resuscitation team, prompt initiation of high-quality cardiopulmonary resuscitation and defibrillation, and organisational structures to support IHCA response. We examined the role of nurses in resuscitation, contrasting higher versus lower performing hospitals in IHCA survival.

Methods

We conducted a descriptive qualitative study at nine hospitals in the American Heart Association’s Get With The Guidelines-Resuscitation registry, purposefully sampling hospitals that varied in geography, academic status, and risk-standardised IHCA survival. We conducted 158 semistructured interviews with nurses, physicians, respiratory therapists, pharmacists, quality improvement staff, and administrators. Qualitative thematic text analysis followed by type-building text analysis identified distinct nursing roles in IHCA care and support for roles.

Results

Nurses played three major roles in IHCA response: bedside first responder, resuscitation team member, and clinical or administrative leader. We found distinctions between higher and lower performing hospitals in support for nurses. Higher performing hospitals emphasised training and competency of nurses at all levels; provided organisational flexibility and responsiveness with nursing roles; and empowered nurses to operate at a higher scope of clinical practice (eg, bedside defibrillation). Higher performing hospitals promoted nurses as leaders—administrators supporting nurses in resuscitation care at the institution, resuscitation team leaders during resuscitation and clinical champions for resuscitation care. Lower performing hospitals had more restrictive nurse roles with less emphasis on systematically identifying improvement needs.

Conclusion

Hospitals that excelled in IHCA survival emphasised mentoring and empowering front-line nurses and ensured clinical competency and adequate nursing training for IHCA care. Though not proof of causation, nurses appear to be critical to effective IHCA response, and how to support their role to optimise outcomes warrants further investigation.

Validity evidence for Quality Improvement Knowledge Application Tool Revised (QIKAT-R) scores: consequences of rater number and type using neurology cases

Quality and Safety in Health Care Journal -

Objectives

To develop neurology scenarios for use with the Quality Improvement Knowledge Application Tool Revised (QIKAT-R), gather and evaluate validity evidence, and project the impact of scenario number, rater number and rater type on score reliability.

Methods

Six neurological case scenarios were developed. Residents were randomly assigned three scenarios before and after a quality improvement (QI) course in 2015 and 2016. For each scenario, residents crafted an aim statement, selected a measure and proposed a change to address a quality gap. Responses were scored by six faculty raters (two with and four without QI expertise) using the QIKAT-R. Validity evidence from content, response process, internal structure, relations to other variables and consequences was collected. A generalisability (G) study examined sources of score variability, and decision analyses estimated projected reliability for different numbers of raters and scenarios and raters with and without QI expertise.

Results

Raters scored 163 responses from 28 residents. The mean QIKAT-R score was 5.69 (SD 1.06). G-coefficient and Phi-coefficient were 0.65 and 0.60, respectively. Interrater reliability was fair for raters without QI expertise (intraclass correlation = 0.53, 95% CI 0.30 to 0.72) and acceptable for raters with QI expertise (intraclass correlation = 0.66, 95% CI 0.02 to 0.88). Postcourse scores were significantly higher than precourse scores (6.05, SD 1.48 vs 5.22, SD 1.5; p < 0.001). Sufficient reliability for formative assessment (G-coefficient > 0.60) could be achieved by three raters scoring six scenarios or two raters scoring eight scenarios, regardless of rater QI expertise.

Conclusions

Validity evidence was sufficient to support the use of the QIKAT-R with multiple scenarios and raters to assess resident QI knowledge application for formative or low-stakes summative purposes. The results provide practical information for educators to guide implementation decisions.

Patient safety superheroes in training: using a comic book to teach patient safety to residents

Quality and Safety in Health Care Journal -

Problem

Medical errors are a health burden. Residents must be aware of patient safety threats and have confidence reporting concerns. Creative modalities for teaching such content (eg, simulation) are resource intensive, while lectures do not assimilate clinical practice. Therefore, the objective of this project was to assess the use of a comic book to train Internal Medicine residents to identify patient safety issues. We report acceptability of the teaching tool and awareness and confidence in identifying patient safety issues using a comic book.

Approach

Residents from the Medical College of Wisconsin participated in a 1-hour session to identify 24 safety topics in a comic book. The primary outcomes were awareness and confidence. Engagement and enjoyment were also measured as forms of acceptability of the tool. Comparisons were made using Fisher’s exact tests and paired t-tests for awareness questions and Fisher’s exact tests for confidence questions. Analyses were performed using SAS V.9.4.

Outcomes

Fifty participants were included in the analyses. Proportions in each awareness category were significantly different on post-test in 21 of 24 topics included. The confidence in both identifying safety topics (55.1% precourse to 96% postcourse) and reporting them (35.42%–90%) increased significantly after the curriculum. 90% found the tool enjoyable and 98% found the tool engaging.

Next steps

This curriculum was successful in increasing resident awareness and confidence regarding patient safety. The use of a comic book was acceptable to residents. Future directions include digital conversion of the curriculum and expansion to include multiple settings within the hospital.

Reducing door-to-needle times in stroke thrombolysis to 13 min through protocol revision and simulation training: a quality improvement project in a Norwegian stroke centre

Quality and Safety in Health Care Journal -

Background

In eligible patients with acute ischaemic stroke, rapid revascularisation is crucial for good outcome. At our treatment centre, we had achieved and sustained a median door-to-needle time of under 30 min. We hypothesised that further improvement could be achieved through implementing a revised treatment protocol and in situ simulation-based team training sessions. This report describes a quality improvement project aiming to reduce door-to-needle times in stroke thrombolysis.

Methods

All members of the acute stroke treatment team were surveyed to tailor the interventions to local conditions. Through a review of responses and available literature, the improvement team suggested changes to streamline the protocol and designed in situ simulation-based team training sessions. Implementation of interventions started in February 2017. We completed 14 simulation sessions from February to June 2017 and an additional 12 sessions from November 2017 to March 2018. Applying Kirkpatrick’s four-level training evaluation model, participant reactions, clinical behaviour and patient outcomes were measured. Statistical process control charts were used to demonstrate changes in treatment times and patient outcomes.

Results

A total of 650 consecutive patients, including a 3-year baseline, treated with intravenous thrombolysis were assessed. Median door to needle times were significantly reduced from 27 to 13 min and remained consistent after 13 months. Risk-adjusted cumulative sum charts indicate a reduced proportion of patients deceased or bedridden after 90 days. There was no significant change in balancing measures (stroke mimics, fatal intracranial haemorrhage and prehospital times).

Conclusions

Implementing a revised treatment protocol in combination with in situ simulation-based team training sessions for stroke thrombolysis was followed by a considerable reduction in door-to-needle times and improved patient outcomes. Additional work is needed to assess sustainability and generalisability of the interventions.

Quality and safety in the literature: November 2019

Quality and Safety in Health Care Journal -

Healthcare quality and safety span multiple topics across the spectrum of academic andclinical 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 lastseveral months. Some articles will focus on a particular theme, while others will highlight unique publications from high-impact medical journals.

Key points

  • A single dose of intravenous amoxicillin and clavulanic acid nearly halves the risk of of maternal infection in women after operative vaginal delivery. The Lancet. 15 June 2019

  • Hospital-acquired complications are common during hospitalisations for low-value procedures, and when present, result in prolonged length of stay. JAMA Int Med. 25 February 2019

  • A model utilising computerised order entry events for postoperative complication surveillance has a high negative predictive value and may allow for more targeted manual chart review. JAMA Surg. 1...

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