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Are increases in emergency use and hospitalisation always a bad thing? Reflections on unintended consequences and apparent backfires

Quality and Safety in Health Care Journal -

Verschlimmbessern: German word meaning to make something worse in an effort to improve it

In this issue of BMJ Quality & Safety, Snooks et al1 report a stepped-wedge trial involving 32 general practices in Wales. A web-based software program presented clinicians with estimates of patients’ risk of future emergency attendance on the basis of clinical characteristics, past health services use and socioeconomic factors. Clinicians could then develop management plans which would avoid acute deteriorations necessitating emergency department attendance. Surprisingly, the intervention caused a small but statistically significant increase in hospital admissions and use of other National Health Service services.

The authors deserve congratulations here because they undertook this evaluation precisely because policies intended to improve care or reduce costs often presume the effectiveness of a certain approach when little evidence exists to support it. Targeting high-cost users of healthcare is a widely recommend approach which is harder...

To catch a killer: electronic sepsis alert tools reaching a fever pitch?

Quality and Safety in Health Care Journal -

Sepsis is a global health priority of staggering impact, resulting in at least 6 million deaths worldwide each year and contributing to as many one half of all hospital deaths in the USA.1–4 Sepsis is also tremendously costly, as reflected in total healthcare expenditures,5 6 short-term and long-term morbidity and mortality7–9 and the heavy burden placed on caregivers and society.10 11 Large-scale efforts, including those of the WHO and the Global Sepsis Alliance, have helped to elevate sepsis to a highly prominent concern visible to ‘the public, political leaders and leaders of healthcare systems’.1 12 Emerging public awareness campaigns—for example, the Sepsis Alliance’s ‘It’s About TIME’ motto emphasises Temperature, Infection, Mental decline and Extreme illness as concerning patient symptoms13—further drive home...

Effects and costs of implementing predictive risk stratification in primary care: a randomised stepped wedge trial

Quality and Safety in Health Care Journal -

Aim

We evaluated the introduction of a predictive risk stratification model (PRISM) into primary care. Contemporaneously National Health Service (NHS) Wales introduced Quality and Outcomes Framework payments to general practices to focus care on those at highest risk of emergency admission to hospital. The aim of this study was to evaluate the costs and effects of introducing PRISM into primary care.

Methods

Randomised stepped wedge trial with 32 general practices in one Welsh health board. The intervention comprised: PRISM software; practice-based training; clinical support through two ‘general practitioner (GP) champions’ and technical support. The primary outcome was emergency hospital admissions.

Results

Across 230 099 participants, PRISM implementation increased use of health services: emergency hospital admission rates by 1 % when untransformed (while change in log-transformed rate L=0.011, 95% CI 0.010 to 0.013); emergency department (ED) attendance rates by untransformed 3 % (while L=0.030, 95% CI 0.028 to 0.032); outpatient visit rates by untransformed 5 % (while L=0.055, 95% CI 0.051 to 0.058); the proportion of days with recorded GP activity by untransformed 1 % (while L=0.011, 95% CI 0.007 to 0.014) and time in hospital by untransformed 3 % (while L=0.029, 95% CI 0.026 to 0.031). Thus NHS costs per participant increased by £76 (95% CI £46 to £106).

Conclusions

Introduction of PRISM resulted in a statistically significant increase in emergency hospital admissions and use of other NHS services without evidence of benefits to patients or the NHS.

Hospital nurse staffing and staff-patient interactions: an observational study

Quality and Safety in Health Care Journal -

Background

Existing evidence indicates that reducing nurse staffing and/or skill mix adversely affects care quality. Nursing shortages may lead managers to dilute nursing team skill mix, substituting assistant personnel for registered nurses (RNs). However, no previous studies have described the relationship between nurse staffing and staff–patient interactions.

Setting

Six wards at two English National Health Service hospitals.

Methods

We observed 238 hours of care (n=270 patients). Staff–patient interactions were rated using the Quality of Interactions Schedule. RN, healthcare assistant (HCA) and patient numbers were used to calculate patient-to-staff ratios. Multilevel regression models explored the association between staffing levels, skill mix and the chance of an interaction being rated as ‘negative’ quality, rate at which patients experienced interactions and total amount of time patients spent interacting with staff per observed hour.

Results

10% of the 3076 observed interactions were rated as negative. The odds of a negative interaction increased significantly as the number of patients per RN increased (p=0.035, OR of 2.82 for ≥8 patients/RN compared with >6 to <8 patients/RN). A similar pattern was observed for HCA staffing but the relationship was not significant (p=0.056). When RN staffing was low, the odds of a negative interaction increased with higher HCA staffing. Rate of interactions per patient hour, but not total amount of interaction time, was related to RN and HCA staffing levels.

Conclusion

Low RN staffing levels are associated with changes in quality and quantity of staff–patient interactions. When RN staffing is low, increases in assistant staff levels are not associated with improved quality of staff–patient interactions. Beneficial effects from adding assistant staff are likely to be dependent on having sufficient RNs to supervise, limiting the scope for substitution.

Variation in use and outcomes related to midline catheters: results from a multicentre pilot study

Quality and Safety in Health Care Journal -

Background

While midline vascular catheters are gaining popularity in clinical practice, patterns of use and outcomes related to these devices are not well known.

Methods

Trained abstractors collected data from medical records of hospitalised patients who received midline catheters in 12 hospitals. Device characteristics, patterns of use and outcomes were assessed at device removal or at 30 days. Rates of major (upper-extremity deep vein thrombosis [DVT], bloodstream infection [BSI] and catheter occlusion) and minor complications were assessed. 2 tests were used to examine differences in rates of complication by number of lumens, reasons for catheter removal l, and hospital-level differences in rates of midline use.

Results

Complete data on 1161 midlines representing 5%–72% of all midlines placed in participating hospitals between 1 January 2017 and 1 March 2018 were available. Most (70.8%) midlines were placed in general ward settings for difficult intravenous access (61.4%). The median dwell time of midlines across hospitals was 6 days; almost half (49%) were removed within 5 days of insertion. A major or minor complication occurred in 10.3% of midlines, with minor complications such as dislodgement, leaking and infiltration accounting for 71% of all adverse events. While rates of major complications including occlusion, upper-extremity DVT and BSI were low (2.2%, 1.4% and 0.3%, respectively), they were just as likely to lead to midline removal as minor complications (53.8% vs 52.5%, p=0.90). Across hospitals, absolute volume of midlines placed varied from 100 to 1837 devices, with corresponding utilisation rates of 0.97%–12.92% (p<0.001).

Conclusion

Midline use and outcomes vary widely across hospitals. Although rates of major complications are low, device removal as a result of adverse events is common.

Use of performance reports among trauma medical directors and programme managers in the American College of Surgeons Trauma Quality Improvement Program: a qualitative analysis

Quality and Safety in Health Care Journal -

Background

The American College of Surgeons’ Trauma Quality Improvement Program (TQIP) provides trauma centres with performance reports on their processes and outcomes of care relative to their peers. This study explored how performance reports are used by trauma centre leaders to engage in performance improvement and perceived barriers to use.

Study design

Qualitative focus group study with trauma medical directors (TMDs) and trauma programme managers (TPMs) in US trauma centres. Consistent with qualitative descriptive analysis, data collection and interpretation were inductively and iteratively completed. Major themes were derived using a constant comparative technique.

Results

Six focus groups were conducted involving 22 TMDs and 22 TPMs. Three major themes were captured: (1) technical uses of performance reports; (2) cultural uses of performance reports; (3) opportunities to enhance the role and value of TQIP. First, technical uses included using reports to assess data collection procedures, data quality and areas of poor performance relative to peers. In this domain, barriers to report use included not trusting others’ data quality and challenges with report interpretation. Second, reports were used to influence practice change by fostering inter-specialty discussions, leveraging resources for quality improvement, community engagement and regional collaboratives. Perceived lack of specialist engagement was viewed as an impediment in this domain. Lastly, identified opportunities for TQIP to support report use involved clarifying the relationship between verification and performance reports, and increasing partnerships with nursing associations.

Conclusion

Trauma centre improvement leaders indicated practical and social uses of performance reports that can affect intention and ability to change. Recommendations to optimise programme participation include a focus on data quality, adequate resource provision and enhanced support for regional collaboratives.

Can universal patient-held health booklets promote continuity of care and patient-centred care in low-resource countries? The case of Mongolia

Quality and Safety in Health Care Journal -

Background

A system of clinical records accessible by both patients and their attending healthcare professionals facilitates continuity of care and patient-centred care, thereby improving clinical outcomes. The need for such a system has become greater as the proportion of patients with chronic non-communicable diseases (NCDs) requiring ongoing care increases. This is particularly true in low-income and middle-income countries where the burden of these diseases is greatest.

Objective

To describe a nationwide patient-held health booklet (PHHB) system and investigate its use and completeness for clinical information transfer during chronic NCD outpatient visits in Ulaanbaatar, Mongolia.

Methods

Qualitative and quantitative methodologies were employed in this mixed-methods study. Structured interviews were used to study a sample of adult patients with chronic NCDs attending the outpatient departments (OPDs) of two large, public secondary care hospitals ; artefact reviews were used to analyse the content of the written documents relating to their clinical care; and snowball methodology was used to identify policy and training documents.

Results

96% (379/395) brought handover documentation from previous provider/s: 94% had PHHBs, 27% other additional documents and 4% had nothing. 67% were referred from primary care and 44% referred back for follow-up. On leaving the OPD, irrespective of requirements for computer data entry, doctors provided written clinical information in the PHHB for 93% of patients. 84% of patients recalled being given verbal information. However, only 41% of the consultation with written information included all three key handover information items (diagnosis, management/treatment and follow-up). The PHHBs were the best completed type of document, with evidence that they were consulted by patients (80%), public (95%) and private (77%) providers. Living >1 hour away (OR=0.28; 95% CI 0.13 to 0.61) decreased the likelihood of receiving written management/treatment information; living >1 hour away (OR=0.48; 95% CI 0.27 to 0.87), comorbidity (OR=0.55; 95% CI 0.35 to 0.87) and returning to secondary care (OR=0.52; 95% CI 0.33 to 0.80) all independently decreased the likelihood of receiving written follow-up information. A Ministry order mandates the use of the booklet, but there were no other related policies, guidelines or clinician training.

Conclusion

The universal PHHBs were well accepted, well used and the best completed handover documentation. The PHHBs provided a successful handover option for patients with chronic NCDs in Mongolia, but their completeness needs improving. There is potential for global application.

What US hospitals are currently doing to prevent common device-associated infections: results from a national survey

Quality and Safety in Health Care Journal -

Background

Despite focused initiatives to reduce device-associated infection among hospitalised patients, the practices US hospitals are currently using are unknown. We thus used a national survey to ascertain the use of several established and novel practices to prevent device-associated infections.

Methods

We mailed surveys to infection preventionists in a random sample of nearly 900 US acute care hospitals in 2017. Our survey asked about the use of practices to prevent three common device-associated infections: catheter-associated urinary tract infection (CAUTI), central line-associated bloodstream infection (CLABSI) and ventilator-associated pneumonia (VAP). Using sample weights, we estimated the percentage of hospitals reporting regular use of each practice. We also conducted multivariable regression to determine associations between selected hospital characteristics (eg, perceived support from leadership) and use of CAUTI, CLABSI and VAP prevention practices.

Results

The response rate was 59%. Several practices are reportedly used in over 90% of US hospitals: aseptic technique during indwelling urethral catheter insertion and maintenance (to prevent CAUTI); maximum sterile barrier precautions during central catheter insertion and alcohol-containing chlorhexidine gluconate for insertion site antisepsis (to prevent CLABSI); and semirecumbent positioning of the patient (to prevent VAP). Antimicrobial devices are used in the minority of hospitals for these three device-associated infections.

Conclusions

We provide an updated snapshot of the practices US hospitals are currently using to prevent device-associated infections. Compared with previous studies using a similar design and questions, we found that the use of recommended practices increased in US hospitals, especially for CAUTI prevention.

Exposure to incivility hinders clinical performance in a simulated operative crisis

Quality and Safety in Health Care Journal -

Background

Effective communication is critical for patient safety. One potential threat to communication in the operating room is incivility. Although examined in other industries, little has been done to examine how incivility impacts the ability to deliver safe care in a crisis. We therefore sought to determine how incivility influenced anaesthesiology resident performance during a standardised simulation scenario of occult haemorrhage.

Methods

This is a multicentre, prospective, randomised control trial from three academic centres. Anaesthesiology residents were randomly assigned to either a normal or ‘rude’ environment and subjected to a validated simulated operating room crisis. Technical and non-technical performance domains including vigilance, diagnosis, communication and patient management were graded on survey with Likert scales by blinded raters and compared between groups.

Results

76 participants underwent randomisation with 67 encounters included for analysis (34 control, 33 intervention). Those exposed to incivility scored lower on every performance metric, including a binary measurement of overall performance with 91.2% (control) versus 63.6% (rude) obtaining a passing score (p=0.009). Binary logistic regression to predict this outcome was performed to assess impact of confounders. Only the presence of incivility reached statistical significance (OR 0.110, 95% CI 0.022 to 0.544, p=0.007). 65% of the rude group believed the surgical environment negatively impacted performance; however, self-reported performance assessment on a Likert scale was similar between groups (p=0.112).

Conclusion

Although self-assessment scores were similar, incivility had a negative impact on performance. Multiple areas were impacted including vigilance, diagnosis, communication and patient management even though participants were not aware of these effects. It is imperative that these behaviours be eliminated from operating room culture and that interpersonal communication in high-stress environments be incorporated into medical training.

Sepsis and antimicrobial stewardship: two sides of the same coin

Quality and Safety in Health Care Journal -

Introduction

Sepsis and antimicrobial stewardship programmes coexist in tension, as they can appear to have apparently opposing messages around antimicrobial prescribing. In the era of increasing antimicrobial resistance (AMR), there is a need for greater alignment between sepsis and antimicrobial stewardship governance and management programmes. Antimicrobial therapy is an essential part of sepsis management with a focus on time-dependent recognition and resuscitation pathways.1 Sepsis is a clinical diagnosis, and delay to first-dose antimicrobial is associated with increasing mortality.1 To avoid potential unintended consequences from inappropriate antimicrobial prescribing, including increased AMR and healthcare-associated infections such as Clostridioides difficile infection, antimicrobial stewardship strategies including de-escalation protocols and stopping antimicrobials in non-infective cases should be a fundamental component of sepsis quality improvement initiatives.2 Perceived tensions remain, however, between managing sepsis and effective antimicrobial stewardship, and these perceptions are likely to be heightened by media reporting...

Electronic health record-based clinical decision support alert for severe sepsis: a randomised evaluation

Quality and Safety in Health Care Journal -

Background

Sepsis remains the top cause of morbidity and mortality of hospitalised patients despite concerted efforts. Clinical decision support for sepsis has shown mixed results reflecting heterogeneous populations, methodologies and interventions.

Objectives

To determine whether the addition of a real-time electronic health record (EHR)-based clinical decision support alert improves adherence to treatment guidelines and clinical outcomes in hospitalised patients with suspected severe sepsis.

Design

Patient-level randomisation, single blinded.

Setting

Medical and surgical inpatient units of an academic, tertiary care medical centre.

Patients

1123 adults over the age of 18 admitted to inpatient wards (intensive care units (ICU) excluded) at an academic teaching hospital between November 2014 and March 2015.

Interventions

Patients were randomised to either usual care or the addition of an EHR-generated alert in response to a set of modified severe sepsis criteria that included vital signs, laboratory values and physician orders.

Measurements and main results

There was no significant difference between the intervention and control groups in primary outcome of the percentage of patients with new antibiotic orders at 3 hours after the alert (35% vs 37%, p=0.53). There was no difference in secondary outcomes of in-hospital mortality at 30 days, length of stay greater than 72 hours, rate of transfer to ICU within 48 hours of alert, or proportion of patients receiving at least 30 mL/kg of intravenous fluids.

Conclusions

An EHR-based severe sepsis alert did not result in a statistically significant improvement in several sepsis treatment performance measures.

Quality and safety in the literature: September 2019

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

  • Increased flexibility in shift duration while maintaining a maximum weekly amount of duty hours for US internal medicine residents was non-inferior to standard duty-hour rules with regard to 30-day mortality, readmissions and various patient safety indicators. N Engl J Med. 7 Mar 2019

  • A significant amount of antibiotics prescribed for common acute indications in English primary care exceeded durations recommended by guidelines. This was especially true for respiratory tract indications and women with acute cystitis. BMJ. 27 Feb 2019

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