In 2018, the HIV pandemic response has transitioned from an emergency approach to one that will be implemented over several decades and likely for our lifetimes. An estimated 37 million people now live with HIV, of whom 21.5 million people are on antiretroviral therapy (ART) including an estimated 17.5 million people who have achieved viral suppression.1 Thus, an estimated 20 million people either require ART or improved regimens and/or adherence interventions.1 Though HIV diagnostic and prevention strategies are improving, stigma, implementation challenges and late diagnoses resulted in 1.8 million people acquiring HIV, indicating that HIV incidence has only been slowly decreasing over the last several years.1 Thus, the numbers of people requiring HIV treatment are likely to continue to increase over the coming years.
Effective support for the lifelong treatment needs of an increasing number of people living with HIV despite decreasing levels...
The earliest contributions of human factors engineering to surgery probably occurred just over a century ago. Already well-known for their pioneering scientific approaches to management, Frank and Lillian Gilbreth turned their expertise in time and motion studies and the psychology of management to optimising the operating room environment (and various aspects of hospital operations).1 Some readers may know this real husband and wife pair of early management gurus as the parents depicted in ‘Cheaper by the Dozen’. Written by two of their 12 children, it humorously depicted the application of the science of efficiency to the lives of this family of 14. The book, first published in 1946, generated a film (1950), a television series and an updated film in 2003. None of the antics in these various productions convey the real-life contributions of either of the Gilbreths. For instance, the modern approach to laying out surgical...
Prediction models hold tremendous promise as a way to improve patient outcomes and healthcare quality more generally by efficiently targeting interventions to those patients most likely to benefit. Most aspects of healthcare (ie, tests, medications and procedures) have associated risks and burdens. Accurate prediction of patients at higher risk for adverse outcomes from their underlying conditions allows for better targeting of interventions, so that only patients for whom the benefits of the intervention outweigh the risks of treatment are provided the intervention. Conversely, accurate prediction of patients at low risk for adverse outcomes (for whom the risks of the intervention outweigh the benefits) can help those patients avoid unnecessary and potentially harmful interventions. Thus, accurate prediction models play a pivotal role in the vision of personalised medicine, where all clinical decisions are tailored to each individual’s unique risk profile.1
In this issue of BMJ Quality & Safety,...
Patients living with HIV infection (PLWH) in sub-Saharan Africa face an important burden of treatment related to everything they do to take care of their health: doctor visits, tests, regular refills, travels, and so on. In this study, we involved PLWH in proposing ideas on how to decrease their burden of treatment and assessed to what extent these propositions could be implemented in care.Methods
Adult PLWH recruited in three HIV care centres in Côte d’Ivoire participated in qualitative interviews starting with ‘What do you believe are the most important things to change in your care to improve your burden of treatment?’ Two independent investigators conducted a thematic analysis to identify and classify patients' propositions to decrease their burden of treatment. A group of experts involving patients, health professionals, hospital leaders and policymakers evaluated each patient proposition to assess its feasibility.Results
Between February and April 2017, 326 participants shared 748 ideas to decrease their burden of treatment. These ideas were grouped into 59 unique patient propositions to improve their personal care and the organisation of their hospital or clinic and/or the health system. Experts considered that 27 (46%), 19 (32%) and 13 (22%) of patients' propositions were easy, moderate and difficult, respectively, to implement. A total of 118 (36%) participants offered at least one proposition considered easily implementable by our experts.Conclusion
Asking PLWH in sub-Saharan Africa about how their care could be improved led to identifying meaningful propositions. According to experts, half of the ideas identified could be implemented easily at low cost for minimally disruptive HIV care.
Studies in operating rooms (OR) show that minor disruptions tend to group together to result in serious adverse events such as surgical errors. Understanding the characteristics of these minor flow disruptions (FD) that impact major events is important in order to proactively design safer systemsObjective
The purpose of this study is to use a systems approach to investigate the aetiology of minor and major FDs in ORs in terms of the people involved, tasks performed and OR traffic, as well as the location of FDs and other environmental characteristics of the OR that may contribute to these disruptions.Methods
Using direct observation and classification of FDs via video recordings of 28 surgical procedures, this study modelled the impact of a range of system factors—location of minor FDs, roles of staff members involved in FDs, type of staff activities as well as OR traffic-related factors—on major FDs in the OR.Results
The rate of major FDs increases as the rate of minor FDs increases, especially in the context of equipment-related FDs, and specific physical locations in the OR. Circulating nurse-related minor FDs and minor FDs that took place in the transitional zone 2, near the foot of the surgical table, were also related to an increase in the rate of major FDs. This study also found that more major and minor FDs took place in the anaesthesia zone compared with all other OR zones. Layout-related disruptions comprised more than half of all observed FDs.Conclusion
Room design and layout issues may create barriers to task performance, potentially contributing to the escalation of FDs in the OR.
Frailty is an important prognostic factor in hospitalised patients but typically requires face-to-face assessment by trained observers to detect. Thus, frail patients are not readily apparent from a systems perspective for those interested in implementing quality improvement measures to optimise their outcomes. This study was designed to externally validate and compare two recently described tools using administrative data as potential markers for frailty: the Hospital Frailty Risk Score (HFRS) and the Hospital-patient One-year Mortality Risk (HOMR) Score.Design
Retrospective cohort study.Setting
All patients over 75 with at least one urgent non-psychiatric hospitalisation between 2004 and 2010.Main outcome measures
Prolonged hospital length of stay (>10 days), 30-day mortality after admission and 30-day postdischarge rates of urgent readmission or emergency department (ED) visits.Results
In 452 785 patients (25.9% with intermediate or high-risk HFRS), increased HFRS was associated with higher Charlson scores, older age and decreased likelihood of baseline independence. Patients with high or intermediate HFRS had significantly increased risks of prolonged hospitalisation (70.0% (OR 8.64, 95% CI 8.30 to 8.99) or 49.7% (OR 3.66, 95% CI 3.60 to 3.71) vs 21.3% in low-risk HFRS group) and 30-day mortality (15.5% (OR 1.27, 95% CI 1.20 to 1.33) or 16.8% (OR 1.39, 95% CI 1.36 to 1.41) vs 12.7% in low-risk), but decreased risks of 30-day readmission (10.0% (OR 0.74, 95% CI 0.69 to 0.79) and 11.2% (OR 0.84, 95% CI 0.82 to 0.86) vs 13.1%) or ED visit (7.3% (OR 0.41, 95% CI 0.38 to 0.45) and 11.1% (OR 0.66, 95% CI 0.38 to 0.45) vs 16.0%). Although only loosely associated (Pearson correlation coefficient 0.265, p<0.0001), both the HFRS and HOMR Score were independently associated with each outcome—HFRS was more strongly associated with prolonged length of stay (C-statistic 0.71) and HOMR Score was more strongly associated with 30-day mortality (C-statistic 0.71). Both poorly predicted 30-day readmissions (C-statistics 0.52 for HFRS and 0.54 for HOMR Score).Conclusions
The HFRS best identified hospitalised older patients at higher risk of prolonged length of stay and the HOMR score better predicted 30-day mortality. However, neither score was suitable for predicting risk of readmission or ED visit in the 30 days after discharge. Thus, a single score is inadequate to prognosticate for all outcomes associated with frailty.
While the concept of collaboration is highly touted in the literature, most descriptions of effective collaboration highlight formal collaborative events; largely ignored are the informal collaborative events and none focusing on the frequent, ‘seemingly’ by chance communication events that arise and their role in supporting patient safety and quality care.Objective
To identify the types of informal communication events that exist in the inpatient setting and better understand the barriers contributing to their necessity.Methods
We undertook a constructivist grounded theory study in an inpatient internal medicine teaching unit in Ontario, Canada. Interview and observational data were collected across two phases; in total, 56 participants were consented for the study. Data collection and analysis occurred iteratively; themes were identified using constant comparison methods.Results
Several types of informal communication events were identified and appeared valuable in three ways: (1) providing a better sense of a patient’s baseline function in comparison to their current function; (2) gaining a more holistic understanding of the patient’s needs; and (3) generating better insight into a patient’s wishes and goals of care. Participants identified a number of organisational and communication challenges leading to the need for informal communication events. These included: scheduling, competing demands and the spatial and temporal organisation of the ward. As a result, nursing staff, allied health professionals and caregivers had to develop strategies for interacting with the physician team.Conclusion
We highlight the importance of informal communication in supporting patient care and the gaps in the system contributing to their necessity. Changes at the system level are needed to ensure we are not leaving important collaborative opportunities to chance alone.
Interruptions are endemic in healthcare work environments. Yet, they can have positive effects in some instances and negative in others, with their net effect on quality of care still poorly understood. We aimed to distinguish beneficial and detrimental forms of interruptions of emergency department (ED) providers using patients’ perceptions of ED care as a quality measure.Methods
An observational design was established. The study setting was an interdisciplinary ED of an academic tertiary referral hospital. Frequencies of interruption sources and contents were identified in systematic expert observations of ED physicians and nurses. Concurrently, patients rated overall quality of care, ED organisation, patient information and waiting times using a standardised survey. Associations were assessed with hierarchical linear models controlling for daily ED workload. Regression results were adjusted for multiple testing. Additionally, analyses were computed for ED physicians and nurses, separately.Results
On 40 days, 160 expert observation sessions were conducted. 1418 patients were surveyed. Frequent interruptions initiated by patients were associated with higher overall quality of care and ED organisation. Interruptions relating to coordination activities were associated with improved ratings of ED waiting times. However, interruptions containing information on previous cases were associated with inferior ratings of ED organisation. Specifically for nurses, overall interruptions were associated with superior patient reports of waiting time.Conclusions
Provider interruptions were differentially associated with patient perceptions of care. Whereas coordination-related and patient-initiated interruptions were beneficial to patient-perceived efficiency of ED operations, interruptions due to case-irrelevant communication were related to inferior patient ratings of ED organisation. The design of resilient healthcare systems requires a thorough consideration of beneficial and harmful effects of interruptions on providers’ workflows and patient safety.
Sepsis is a leading cause of death and suffering, afflicting 1.7 million adults annually in the USA and contributing to over 250 000 deaths.1 The high burden of sepsis has catalysed numerous performance improvement and policy initiatives, including mandatory sepsis protocols in a growing number of US states, the Centers for Medicare and Medicaid Services’ (CMS) ‘SEP-1’ measure, and WHO’s resolution declaring sepsis a global health priority.2 Hospitals around the world are dedicating considerable resources to improving sepsis recognition and compliance with treatment bundles.
However, accurately measuring the impact of sepsis quality improvement efforts is challenging. The core problem is that diagnosing sepsis involves considerable subjectivity.3 Sepsis is a heterogeneous syndrome without a pathological gold standard. It is defined as infection leading to organ dysfunction,4 but it is often unclear whether a patient is infected and whether organ dysfunction is due...
The reporting of adverse events (AE) remains an important part of quality improvement in thoracic surgery. The best methodology for AE reporting in surgery is unclear. An AE reporting system using an electronic discharge summary with embedded data collection fields, specifying surgical procedure and complications, was developed. The data are automatically transferred daily to a web-based reporting system.Methods
We determined the accuracy and sustainability of this electronic real time data collection system (ERD) by comparing the completeness of record capture on procedures and complications with coded discharge data (administrative data), and with the standard of chart audit at two intervals. All surgical procedures performed for 2 consecutive months at initiation (Ti) and 1 year later (T1yr) were audited by an objective trained abstractor. A second abstractor audited 10% of the charts.Results
The ERD captured 71/72 (99%) of charts at Ti and 56/65 (86%) at T1yr. Comparing the presence/absence of complications between ERD and chart audit demonstrated at Ti a high sensitivity and specificity, positive predictive value (PPV) of 95.5%, negative predictive value (NPV) of 93.9% with a kappa of 0.872 (95% CI 0.750 to 0.994), and at T1yr a sensitivity, specificity, PPV and NPV of 100% with a kappa of 1.0 (95% CI 1.0). Comparing the presence/absence of complications between administrative data and chart audit at Ti demonstrated a low sensitivity, high specificity and a kappa of 0.471 (95% CI 0.256 to 0.686), and at T1yr a low sensitivity, high specificity of 85% and a kappa of 0.479 (95% CI 0.245 to 0.714).Conclusions
We found that the ERD can provide accurate real time AE reporting in thoracic surgery, has advantages over previous reporting methodologies and is an alternative system for surgical clinical teams developing AE reporting systems.
Bedside rounds (BR) have been proposed as an ideal method to promote patient-centred hospital care, but there is substantial variation in their implementation and effects. Our objectives were to describe the implementation of BR in hospital settings and determine their effect on patient-centred outcomes.Methods
Data sources included Ovid MEDLINE, Ovid Embase, Scopus and Ovid Cochrane Central Registry of Clinical Trials from database inception through 28 July 2017. We included experimental studies comparing BR to another form of rounds in a hospital-based setting (ie, medical/surgical unit, intensive care unit (ICU)) and reporting a quantitative patient-reported or objectively measured clinical outcome. We used random effects models to calculate pooled Cohen's d effect size estimates for the patient knowledge and patient experience outcome domains.Results
Twenty-nine studies met inclusion criteria, including 20 from adult care (17 non-ICU, 3 ICU), and nine from paediatrics (5 non-ICU, 4 ICU), the majority of which (n=23) were conducted in the USA. Thirteen studies implemented BR with cointerventions as part of a ‘bundle’. Studies most commonly reported outcomes in the domains of patient experience (n=24) and patient knowledge (n=10). We found a small, statistically significant improvement in patient experience with BR (summary Cohen’s d=0.09, 95% CI 0.04 to 0.14, p<0.001, I2=56%), but no significant association between BR and patient knowledge (Cohen’s d=0.21, 95% CI –0.004 to –0.43, p=0.054, I2=92%). Risk of bias was moderate to high, with methodological limitations most often relating to selective reporting, low adherence rates and missing data.Conclusions
BR have been implemented in a variety of hospital settings, often ‘bundled’ with cointerventions. However, BR have demonstrated limited effect on patient-centred outcomes.