Cardiac surgical outcomes are some of the most scrutinised results in medicine, both by the public as well as the surgeons themselves. This has resulted in an extraordinary push for quality, and the result has been improvement year over year.1 We now recognise that complex operations have high potential for error, and that no single individual should be relied on to ensure safe care. Indeed, even for high-quality cardiac surgery programmes with excellent outcomes errors still occur, and only about 10% of patients will experience zero error or near misses after open heart surgery.2 Creating the teams and care delivery systems to minimise errors and mitigate their impact drives quality improvement. One new area of investigation that has received attention relates to variation in operative and postoperative care delivery systems with a focus on off-peak (evenings, nights and weekends) performance.3 4

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A dominant trend over the past few decades has been the reconfiguration of acute hospital services to provide more centralised and specialised care, particularly for complex conditions, resulting in fewer hospitals each serving a higher volume of patients. Centralisation is usually framed as a response to concerns about the safety of care in smaller hospitals. In this issue of the journal, Flojstrup and colleagues report on the impact of a hospital reconfiguration programme for emergency and acute care in Denmark.1 The ongoing programme, which began in 2008, involves closure of most small, rural hospitals and halving the number of acute hospitals. The quality of Danish registry data allows for the survival outcomes (adjusted in-hospital and 30-day mortality rates) of a large cohort (11 367 655 unplanned non-psychiatric episodes) to be described throughout the centralisation programme and across different diagnoses and arrival times. The use of a unique patient identifier...

Adverse drug events (ADEs) raise major concerns in hospital care by causing morbidity and mortality in patients despite active attention to medication safety.1–3 However, less attention has been paid to ADEs that lead to medication-related rapid response team (RRT) or medical emergency team (MET) activations, even though this kind of data can be very valuable for learning from incidents and understanding the variety of its contributing factors. In this issue of BMJ Quality & Safety, Levkovich4 estimated the incidence and preventability of medication-related MET activations and described the associated adverse medication events. In this editorial, we summarise the key findings from the study, comment on its strengths and recommend further developments in this field of research.

New insights into ADEs leading to MET activations

Levkovich4 analysed 146 medication-related MET activations in two academic teaching hospitals in Australia. Levkovich...

Background

With increasing surgical workload, it is common for cardiac surgeons to perform coronary artery bypass grafting (CABG) after other procedures in a workday. To investigate whether prior procedures performed by the surgeon impact the outcomes, we compared the outcomes between CABGs performed first versus those performed after prior procedures, separately for on-pump and off-pump CABGs as they differed in technical complexity.

Methods

We conducted a retrospective cohort study of patients undergoing isolated CABG in China from January 2013 to December 2018. Patients were categorised as undergoing on-pump and off-pump CABGs. Outcomes of the procedures performed first in primary surgeons’ daily schedule (first procedure) were compared with subsequent ones (non-first procedure). The primary outcome was an adverse events composite (AEC) defined as the number of adverse events, including in-hospital mortality, myocardial infarction, stroke, acute kidney injury and reoperation. Secondary outcomes were the individual components of the primary outcome, presented as binary variables. Mixed-effects models were used, adjusting for patient and surgeon-level characteristics and year of surgery.

Results

Among 21 866 patients, 10 109 (16.1% as non-first) underwent on-pump and 11 757 (29.6% as non-first) off-pump CABG. In the on-pump cohort, there was no significant association between procedure order and the outcomes (all p>0.05). In the off-pump cohort, non-first procedures were associated with an increased number of AEC (adjusted rate ratio 1.29, 95% CI 1.13 to 1.47, p<0.001), myocardial infarction (adjusted OR (ORadj) 1.43, 95% CI 1.13 to 1.81, p=0.003) and stroke (ORadj 1.73, 95% CI 1.18 to 2.53, p=0.005) compared with first procedures. These increases were only found to be statistically significant when the procedure was performed by surgeons with <20 years’ practice or surgeons with a preindex volume <700 cases.

Conclusions

For a technically challenging surgical procedure like off-pump CABG, prior workload adversely affected patient outcomes.

Objectives

The study aimed to investigate how the ‘natural experiment’ of reconfiguring the emergency healthcare system in Denmark affected in-hospital and 30-day mortality on a national level. The reconfiguration included the centralisation of hospitals and the establishment of emergency departments with specialists present around the clock.

Design

Hospital-based cohort study.

Setting

All public hospitals in Denmark.

Participants

Patients with an unplanned contact from 1 January 2007 until 31 December 2016.

Interventions

Stepped-wedge reconfiguration of the Danish emergency healthcare system.

Main outcome measures

We determined the adjusted ORs for in-hospital mortality and HRs for 30-day mortality using logistic and Cox regression analysis adjusted for sex, age, Charlson Comorbidity Index, income, education, mandatory referral and the changes in the out of hours system in the Capital Region. The main outcomes were stratified by the time of arrival. We performed subgroup analyses on selected diagnoses: myocardial infarction, stroke, pneumonia, aortic aneurysm, bowel perforation, hip fracture and major trauma.

Results

We included 11 367 655 unplanned hospital contacts. The adjusted OR for overall in-hospital mortality after reconfiguration of the emergency healthcare system was 0.998 (95% CI 0.968 to 1.010; p=0.285), and the adjusted OR for 30-day mortality was 1.004 (95% CI 1.000 to 1.008; p=0.045)). Subgroup analyses showed some possible benefits of the reconfiguration such as a reduction in-hospital and 30-day mortality for myocardial infarction, stroke, aortic aneurysm and major trauma.

Conclusions

The Danish emergency care reconfiguration programme was not associated with an improvement in overall in-hospital mortality trends and was associated with a slight slowing of prior improvements in 30-day mortality trends.

Objectives

Despite recognition of clinical deterioration and medication-related harm as patient safety risks, the frequency of medication-related Rapid Response System activations is undefined. We aimed to estimate the incidence and preventability of medication-related Medical Emergency Team (MET) activations and describe the associated adverse medication events.

Methods

A case review study of consecutive MET activations at two acute, academic teaching hospitals in Melbourne, Australia with mature Rapid Response Systems was conducted. All MET activations during a 3-week study period were assessed for a medication cause including identification of the contributing adverse medication event and its preventability, using validated tools and recognised classification systems.

Results

There were 9439 admissions and 628 MET activations during the study period. Of these, 146 (23.2%) MET activations were medication related: an incidence of 15.5 medication-related MET activation per 1000 admissions. Medication-related MET activations occurred a median of 46.6 hours earlier (IQR 22–165) in an admission than non-medication-related activations (p=0.001). Furthermore, this group also had more repeat MET activations during their admission (p=0.021, OR=1.68, 95% CI 1.09 to 2.59). A total of 92 of 146 (63%) medication-related MET activations were potentially preventable. Tachycardia due to omission of beta-blocking agents (10.9%, n=10 of 92) and hypotension due to cumulative toxicity (9.8%, n=9 of 92) or inappropriate use (10.9%, n=10 of 92) of antihypertensives were the most common adverse medication events leading to potentially preventable medication-related MET activations.

Conclusions

Medications contributed to almost a quarter of MET activations, often early in a patient’s admission. One in seven MET activations were due to potentially preventable adverse medication events. The most common of these were omission of beta-blockers and clinically inappropriate antihypertensive use. Strategies to prevent these events would increase patient safety and reduce burden on the MET.

Background

Burnout threatens intensive care unit (ICU) professionals’ capacity to provide high-quality care. Moral distress is previously considered a root cause of burnout, but there are other risk factors of burnout such as personality, work–life balance and culture. This study aimed to disentangle the associations of ICU professionals’ moral distress and other risk factors with the components of burnout—emotional exhaustion, depersonalisation and personal accomplishment—suggesting informed burnout prevention strategies.

Methods

Cross-sectional survey completed in 2019 of ICU professionals in two Dutch hospitals. The survey included validated measure for burnout (the Dutch Maslach Burnout Inventory), moral distress (Moral Distress Scale), personality (short Big Five Inventory), work–home balance (Survey Work–Home Interaction Nijmegen) and organisational culture (Culture of Care Barometer). Each of the three components of burnout was analysed as a separate outcome, and for each of the components, a separate regression analysis was carried out.

Results

251 ICU professionals responded to the survey (response rate: 53.3%). Burnout prevalence was 22.7%. Findings showed that moral distress was associated with emotional exhaustion (β=0.18, 95% CI 0.9 to 0.26) and depersonalisation (β=0.19, 95% CI 0.10 to 0.28) and with increased emotional exhaustion mediated by negative work-to-home spillover (β=0.09, 95% CI 0.04 to 0.13). Support from direct supervisors mitigates the association between moral distress and emotional exhaustion (β=0.16, 95% CI 0.04 to 0.27).

Conclusions

Understanding moral distress as a root cause of burnout is too simplified. There is an important interplay between moral distress and work–home imbalance. Interventions that support individual coping with moral distress and a work–home imbalance, and the support of direct supervisors, are paramount to prevent burnout in physicians and nurses.

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

In older patients with diabetes mellitus and risk of cardiovascular events, the addition of a clinical decision support system to team-based care compared with team-based care alone resulted in modest reductions in glycosylated haemoglobin, low-density lipoprotein cholesterol levels and systolic blood pressure after 18 months of follow-up, although there was no difference in all-cause mortality at 36 months. Ann Intern Med. 6 December 2022.

The use of a validated point-of-care risk stratification tool to assist emergency department providers in...

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Improving Public Health and Health Care for Older Adults: The Three Keys to Cross-Sector Age-Friendly Work Implementation Guide and Workbook contains resources to improve how public health and health care organizations work across the care continuum to reliably provide evidence-based care and services to every older adult at every interaction, with a foundational focus on equity.

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The FDA updates information on reports of squamous cell carcinoma in the capsule around breast implants.

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The FDA expanded its evaluation of the potential risk of exposure to toxic compounds when using hemodialysis and peritoneal dialysis systems

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Phoenix, Arizona, USA; Pharmedica USA LLC is voluntarily recalling two lots of Purely Soothing, 15% MSM Drops to the consumer level. This product is being recalled due to non-sterility.