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Impact of a national QI programme on reducing electronic health record notifications to clinicians

Quality and Safety in Health Care Journal -

Background

Emerging evidence suggests electronic health record (EHR)-related information overload is a risk to patient safety. In the US Department of Veterans Affairs (VA), EHR-based ‘inbox’ notifications originally intended for communicating important clinical information are now cited by 70% of primary care practitioners (PCPs) to be of unmanageable volume. We evaluated the impact of a national, multicomponent, quality improvement (QI) programme to reduce low-value EHR notifications.

Methods

The programme involved three steps: (1) accessing daily PCP notification load data at all 148 facilities operated nationally by the VA; (2) standardising and restricting mandatory notification types at all facilities to a recommended list; and (3) hands-on training for all PCPs on customising and processing notifications more effectively. Designated leaders at each of VA’s 18 regional networks led programme implementation using a nationally developed toolkit. Each network supervised technical requirements and data collection, ensuring consistency. Coaching calls and emails allowed the national team to address implementation challenges and monitor effects. We analysed notification load and mandatory notifications preintervention (March 2017) and immediately postintervention (June–July 2017) to assess programme impact.

Results

Median number of mandatory notification types at each facility decreased significantly from 15 (IQR: 13–19) to 10 (IQR: 10–11) preintervention to postintervention, respectively (P<0.001). Mean daily notifications per PCP decreased significantly from 128 (SEM=4) to 116 (SEM=4; P<0.001). Heterogeneity in implementation across sites led to differences in observed programme impact, including potentially beneficial carryover effects.

Conclusions

Based on prior estimates on time to process notifications, a national QI programme potentially saved 1.5 hours per week per PCP to enable higher value work. The number of daily notifications remained high, suggesting the need for additional multifaceted interventions and protected clinical time to help manage them. Nevertheless, our project suggests feasibility of using large-scale ‘de-implementation’ interventions to reduce unintended safety or efficiency consequences of well-intended electronic communication systems.

Fluoroquinolone Antibiotics: Safety Communication - Increased Risk of Ruptures or Tears in the Aorta Blood Vessel in Certain Patients

FDA MedWatch -

FDA review found that fluoroquinolone antibiotics can increase the occurrence of rare but serious events of ruptures or tears in the main artery of the body, called the aorta. These tears, called aortic dissections, or ruptures of an aortic aneurysm can lead to dangerous bleeding or even death. They can occur with fluoroquinolones for systemic use given by mouth or through an injection.

WIHI: Women in Action - Paving the Way For Better Care

Institute for Healthcare Improvement -

December 20, 2018 | Whether it’s blowing the whistle on the dangerous levels of lead in drinking water in Flint, Michigan, championing the healing powers of dance and movement in hospitals, or shining a human spotlight on disease outbreaks throughout the world, this special edition of WIHI features a panel of outstanding women who are creatively and effectively reshaping caregiving.

Putting Patients at the Center of Prescribing

Institute for Healthcare Improvement -

Each year in the US, more than 700,000 emergency department visits and 100,000 hospitalizations result from adverse drug events, studies show, making medication safety one of the most pressing challenges in health care. To better understand the causes of harm from medication and develop potential solutions, the Institute for Healthcare Improvement (IHI), a leader in health and health care improvement worldwide, is leading a project in which clinical teams will test methods to improve and work through with patients the myriad of problems that may arise when medications are prescribed. This Learning and Action Network is an initiative of the Pfizer Global Medical Grants Medication Optimization Learning and Change Project.

10 Principles of Radical Redesign of the Healthcare System

Institute for Healthcare Improvement -

The current environment for clinicians is “a tough time”, according to Donald Berwick, MD, MPP, president emeritus and senior fellow at the Institute for Healthcare Improvement, who spoke at the annual RSNA conference in Chicago on Nov. 26. Under pressure to convert to a value-based care system with heightened regulation, clinicians can still be at the forefront of leading a radical redesign to meet the goals of the triple aim.

Medication reconciliation: ineffective or hard to implement?

Quality and Safety in Health Care Journal -

In this issue of BMJ Quality & Safety, Schnipper et al evaluate the implementation of a multifaceted medication reconciliation intervention at six hospitals using the MARQUIS medication reconciliation implementation toolkit.1 The planned intervention included the following elements: hiring or reallocating new staff to obtain medication histories, performing both admission and discharge medication reconciliation, improving access to preadmission medication sources, introducing policy, training staff on obtaining medication histories and patient counselling, implementing a gold standard medication reconciliation process including targeting of high-risk patients, improving healthcare information technology and utilising social marketing and community engagement. The study had many methodological strengths, including independent observers for outcome verification, clinical assessment of medication discrepancies, pragmatic implementation in both community and teaching hospitals, mentored implementation and a large randomly selected patient sample with controls and temporal trending. The main result was that potentially harmful discrepancies did not decrease over time beyond baseline...

Mortality alerts, actions taken and declining mortality: true effect or regression to the mean?

Quality and Safety in Health Care Journal -

Alerts have become a routine part of our daily lives—from the apps on our phones to an increasing number of ‘wearables’ (eg, fitness trackers) and household devices. Within healthcare, frontline clinicians have become all too familiar with a barrage of alerts and alarms from electronic medical records and medical devices.

Somewhat less familiar to most clinicians, however, are the alerts received by institutions from regulators and other regional or national bodies monitoring healthcare performance. After the Bristol inquiry in 2001 in the UK,1 research showed that given the available data Bristol could have been detected as an outlier and that it was not simply a matter of the low volume of cases.2 3 Had the cumulative excess mortality been monitored using these routinely collected data, then an alarm could have given for Bristol after the publication of the 1991 Cardiac Surgical Register and...

Effects of a multifaceted medication reconciliation quality improvement intervention on patient safety: final results of the MARQUIS study

Quality and Safety in Health Care Journal -

Background

Unintentional discrepancies across care settings are a common form of medication error and can contribute to patient harm. Medication reconciliation can reduce discrepancies; however, effective implementation in real-world settings is challenging.

Methods

We conducted a pragmatic quality improvement (QI) study at five US hospitals, two of which included concurrent controls. The intervention consisted of local implementation of medication reconciliation best practices, utilising an evidence-based toolkit with 11 intervention components. Trained QI mentors conducted monthly site phone calls and two site visits during the intervention, which lasted from December 2011 through June 2014. The primary outcome was number of potentially harmful unintentional medication discrepancies per patient; secondary outcome was total discrepancies regardless of potential for harm. Time series analysis used multivariable Poisson regression.

Results

Across five sites, 1648 patients were sampled: 613 during baseline and 1035 during the implementation period. Overall, potentially harmful discrepancies did not decrease over time beyond baseline temporal trends, adjusted incidence rate ratio (IRR) 0.97 per month (95% CI 0.86 to 1.08), p=0.53. The intervention was associated with a reduction in total medication discrepancies, IRR 0.92 per month (95% CI 0.87 to 0.97), p=0.002. Of the four sites that implemented interventions, three had reductions in potentially harmful discrepancies. The fourth site, which implemented interventions and installed a new electronic health record (EHR), saw an increase in discrepancies, as did the fifth site, which did not implement any interventions but also installed a new EHR.

Conclusions

Mentored implementation of a multifaceted medication reconciliation QI initiative was associated with a reduction in total, but not potentially harmful, medication discrepancies. The effect of EHR implementation on medication discrepancies warrants further study.

Trial registration number

NCT01337063.

Investigating the association of alerts from a national mortality surveillance system with subsequent hospital mortality in England: an interrupted time series analysis

Quality and Safety in Health Care Journal -

Objective

To investigate the association between alerts from a national hospital mortality surveillance system and subsequent trends in relative risk of mortality.

Background

There is increasing interest in performance monitoring in the NHS. Since 2007, Imperial College London has generated monthly mortality alerts, based on statistical process control charts and using routinely collected hospital administrative data, for all English acute NHS hospital trusts. The impact of this system has not yet been studied.

Methods

We investigated alerts sent to Acute National Health Service hospital trusts in England in 2011–2013. We examined risk-adjusted mortality (relative risk) for all monitored diagnosis and procedure groups at a hospital trust level for 12 months prior to an alert and 23 months post alert. We used an interrupted time series design with a 9-month lag to estimate a trend prior to a mortality alert and the change in trend after, using generalised estimating equations.

Results

On average there was a 5% monthly increase in relative risk of mortality during the 12 months prior to an alert (95% CI 4% to 5%). Mortality risk fell, on average by 61% (95% CI 56% to 65%), during the 9-month period immediately following an alert, then levelled to a slow decline, reaching on average the level of expected mortality within 18 months of the alert.

Conclusions

Our results suggest an association between an alert notification and a reduction in the risk of mortality, although with less lag time than expected. It is difficult to determine any causal association. A proportion of alerts may be triggered by random variation alone and subsequent falls could simply reflect regression to the mean. Findings could also indicate that some hospitals are monitoring their own mortality statistics or other performance information, taking action prior to alert notification.

National hospital mortality surveillance system: a descriptive analysis

Quality and Safety in Health Care Journal -

Objective

To provide a description of the Imperial College Mortality Surveillance System and subsequent investigations by the Care Quality Commission (CQC) in National Health Service (NHS) hospitals receiving mortality alerts.

Background

The mortality surveillance system has generated monthly mortality alerts since 2007, on 122 individual diagnosis and surgical procedure groups, using routinely collected hospital administrative data for all English acute NHS hospital trusts. The CQC, the English national regulator, is notified of each alert. This study describes the findings of CQC investigations of alerting trusts.

Methods

We carried out (1) a descriptive analysis of alerts (2007–2016) and (2) an audit of CQC investigations in a subset of alerts (2011–2013).

Results

Between April 2007 and October 2016, 860 alerts were generated and 76% (654 alerts) were sent to trusts. Alert volumes varied over time (range: 40–101). Septicaemia (except in labour) was the most commonly alerting group (11.5% alerts sent). We reviewed CQC communications in a subset of 204 alerts from 96 trusts. The CQC investigated 75% (154/204) of alerts. In 90% of these pursued alerts, trusts returned evidence of local case note reviews (140/154). These reviews found areas of care that could be improved in 69% (106/154) of alerts. In 25% (38/154) trusts considered that identified failings in care could have impacted on patient outcomes. The CQC investigations resulted in full trust action plans in 77% (118/154) of all pursued alerts.

Conclusion

The mortality surveillance system has generated a large number of alerts since 2007. Quality of care problems were found in 69% of alerts with CQC investigations, and one in four trusts reported that failings in care may have an impact on patient outcomes. Identifying whether mortality alerts are the most efficient means to highlight areas of substandard care will require further investigation.

Incidence and trends of central line associated pneumothorax using radiograph report text search versus administrative database codes

Quality and Safety in Health Care Journal -

Background

Central line associated pneumothorax (CLAP) could be a good quality of care indicator because they are objectively measured, clearly undesirable and possibly avoidable. We measured the incidence and trends of CLAP using radiograph report text search with manual review and compared them with measures using routinely collected health administrative data.

Methods

For each hospitalisation to a tertiary care teaching hospital between 2002 and 2015, we searched all chest radiography reports for a central line with a sensitive computer algorithm. Screen positive reports were manually reviewed to confirm central lines. The index and subsequent chest radiography reports were screened for pneumothorax followed by manual confirmation. Diagnostic and procedural codes were used to identify CLAP in administrative data.

Results

In 685 044 hospitalisations, 10 819 underwent central line insertion (1.6%) with CLAP occurring 181 times (1.7%). CLAP risk did not change over time. Codes for CLAP were inaccurate (sensitivity 13.8%, positive predictive value 6.6%). However, overall code-based CLAP risk (1.8%) was almost identical to actual values possibly because patient strata with inflated CLAP risk were balanced by more common strata having underestimated CLAP risk. Code-based methods inflated central line incidence 2.2 times and erroneously concluded that CLAP risk decreased significantly over time.

Conclusions

Using valid methods, CLAP incidence was similar to those in the literature but has not changed over time. Although administrative database codes for CLAP were very inaccurate, they generated CLAP risks very similar to actual values because of offsetting errors. In contrast to those from radiograph report text search with manual review, CLAP trends decreased significantly using administrative data. Hospital CLAP risk should not be measured using administrative data.

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