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Crisis checklists in emergency medicine: another step forward for cognitive aids

Quality and Safety in Health Care Journal -

A saying often attributed to George Bernard Shaw is ‘The single biggest problem in communication is the illusion that it has taken place.’ While it has been debated who originally made this statement, this expression has been used across several industries in different ways.1–4 Communication is an essential aspect of patient safety. One could argue for expanding this proverb to emphasise the importance of recognising that communication at key moments is intrinsically valuable: the biggest problems in communication are the illusion that it has taken place and the assumption that it is not necessary.

Over the past 100 years, cognitive aids for crisis events during patient care have been called for, developed, refined and examined.5–12 While much of this literature comes from high-risk industries and...

Timely testing: who needs to do what differently to improve adherence to guideline-recommended glycaemic monitoring?

Quality and Safety in Health Care Journal -

The haemoglobin A1c (HbA1c) level has become the standard of care for monitoring type 2 diabetes as it reflects a person’s average blood glucose level over the previous 2–3 months, is correlated with risk of long-term complications and can be measured cheaply and easily. International guidelines recommend testing HbA1c every 6–12 months for those with stable type 2 diabetes, and every 3–6 months in adults with unstable type 2 diabetes until HbA1c is controlled on unchanging therapy.1–3 However, these guidelines are based on expert consensus rather than robust evidence on whether the frequency of HbA1c measurement impacts patient outcomes. To date, most studies have focused on the association between testing frequency and glycaemic control.4–6

In this issue of BMJ Quality & Safety Imai and colleagues go further, demonstrating an association between adherence to guideline-recommended testing frequency and health...

Medical crisis checklists in the emergency department: a simulation-based multi-institutional randomised controlled trial

Quality and Safety in Health Care Journal -

Background

Studies carried out in simulated environments suggest that checklists improve the management of surgical and intensive care crises. Whether checklists improve the management of medical crises simulated in actual emergency departments (EDs) is unknown.

Methods

Eight crises (anaphylactic shock, life-threatening asthma exacerbation, haemorrhagic shock from upper gastrointestinal bleeding, septic shock, calcium channel blocker poisoning, tricyclic antidepressant poisoning, status epilepticus, increased intracranial pressure) were simulated twice (once with and once without checklist access) in each of four EDs—of which two belong to an academic centre—and managed by resuscitation teams during their clinical shifts. A checklist for each crisis listing emergency interventions was derived from current authoritative sources. Checklists were displayed on a screen visible to all team members. Crisis and checklist access were allocated according to permuted block randomisation. No team member managed the same crisis more than once. The primary outcome measure was the percentage of indicated emergency interventions performed.

Results

A total of 138 participants composing 41 resuscitation teams performed 76 simulations (38 with and 38 without checklist access) including 631 interventions. Median percentage of interventions performed was 38.8% (95% CI 35% to 46%) without checklist access and 85.7% (95% CI 80% to 88%) with checklist access (p=7.5x10–8). The benefit of checklist access was similar in the four EDs and independent of senior physician and senior nurse experience, type of crisis and use of usual cognitive aids. On a Likert scale of 1–6, most participants agreed (gave a score of 5 or 6) with the statement ‘I would use the checklist if I got a similar case in reality’.

Conclusion

In this multi-institution study, checklists markedly improved local resuscitation teams’ management of medical crises simulated in situ, and most personnel reported that they would use the checklists if they had a similar case in reality.

Adherence to guideline-recommended HbA1c testing frequency and better outcomes in patients with type 2 diabetes: a 5-year retrospective cohort study in Australian general practice

Quality and Safety in Health Care Journal -

Background

Clinical practice guidelines emphasise the role of regular monitoring of glycated haemoglobin A1c (HbA1c) for patients with type 2 diabetes, with most recommending 6-monthly testing. Nonetheless, there are few in-depth studies evaluating the clinical impact of the recommended testing frequency for patients to underpin the significance of guideline adherence.

Objective

This study aimed to examine associations between patient outcomes and adherence to HbA1c testing frequencies recommended by Australian guidelines (6-monthly for patients with adequate glycaemic control and 3-monthly for patients with inadequate glycaemic control). The primary and secondary outcomes of interest were longitudinal changes in HbA1c values and development of ischaemic heart disease (IHD) and chronic kidney disease (CKD).

Methods

This 5-year retrospective cohort study (July 2013–June 2018) evaluated HbA1c testing frequency in a subset of patients with type 2 diabetes identified within data collected from approximately 250 Australian general practices. The study included patients who were aged ≥18 in 2013 and had a record of HbA1c testing in study practices during the study period. Each patient’s adherence rate was defined by the proportion of HbA1c tests performed within the testing intervals recommended by Australian guidelines. Based on the adherence rate, adherence level was categorised into low (≤33%), moderate (34%–66%) and high (>66%). Generalised additive mixed models were used to examine associations between adherence to the recommended HbA1c testing frequency and patient outcomes.

Results

In the 6424 patients with diabetes, the overall median HbA1c testing frequency was 1.6 tests per year with an adherence rate of 50%. The estimated HbA1c levels among patients with low adherence gradually increased or remained inadequately controlled, while HbA1c values in patients with high adherence remained controlled or improved over time. The risk of developing CKD for patients with high adherence was significantly lower than for patients with low adherence (OR: 0.42, 95% CI 0.18 to 0.99). No association between IHD and adherence to the recommended HbA1c frequency was observed.

Conclusion

Better adherence to guideline-recommended HbA1c testing frequency was associated with better glycaemic control and lower risk of CKD. These findings may provide valuable evidence to support the use of clinical guidelines for better patient outcomes in patients with type 2 diabetes.

Use of telecritical care for family visitation to ICU during the COVID-19 pandemic: an interview study and sentiment analysis

Quality and Safety in Health Care Journal -

Background

When the COVID-19 pandemic restricted visitation between intensive care unit patients and their families, the virtual intensive care unit (vICU) in our large tertiary hospital was adapted to facilitate virtual family visitation. The objective of this paper is to document findings from interviews conducted with family members on three categories: (1) feelings experienced during the visit, (2) barriers, challenges or concerns faced using this service, and (3) opportunities for improvements.

Methods

Family members were interviewed postvisit via phone. For category 1 (feelings), automated analysis in Python using the Valence Aware Dictionary for sentiment Reasoner package produced weighted valence (extent of positive, negative or neutral emotive connotations) of the interviewees’ word choices. Outputs were compared with a manual coder’s valence ratings to assess reliability. Two raters conducted inductive thematic analysis on the notes from these interviews to analyse categories 2 (barriers) and 3 (opportunities).

Results

Valence-based and manual sentiment analysis of 230 comments received on feelings showed over 86% positive sentiments (88.2% and 86.8%, respectively) with some neutral (7.3% and 6.8%) and negative (4.5% and 6.4%) sentiments. The qualitative analysis of data from 57 participants who commented on barriers showed four primary concerns: inability to communicate due to patient status (44% of respondents); technical difficulties (35%); lack of touch and physical presence (11%); and frequency and clarity of communications with the care team (11%). Suggested improvements from 59 participants included: on demand access (51%); improved communication with the care team (17%); improved scheduling processes (10%); and improved system feedback and technical capabilities (17%).

Conclusions

Use of vICU for remote family visitations evoked happiness, joy, gratitude and relief and a sense of closure for those who lost loved ones. Identified areas for concern and improvement should be addressed in future implementations of telecritical care for this purpose.

International recommendations for a vascular access minimum dataset: a Delphi consensus-building study

Quality and Safety in Health Care Journal -

Background

Data regarding vascular access device use and outcomes are limited. In part, this gap reflects the absence of guidance on what variables should be collected to assess patient outcomes. We sought to derive international consensus on a vascular access minimum dataset.

Methods

A modified Delphi study with three rounds (two electronic surveys and a face-to-face consensus panel) was conducted involving international vascular access specialists. In Rounds 1 and 2, electronic surveys were distributed to healthcare professionals specialising in vascular access. Survey respondents were asked to rate the importance of variables, feasibility of data collection and acceptability of items, definitions and response options. In Round 3, a purposive expert panel met to review Round 1 and 2 ratings and reach consensus (defined as ≥70% agreement) on the final items to be included in a minimum dataset for vascular access devices.

Results

A total of 64 of 225 interdisciplinary healthcare professionals from 11 countries responded to Round 1 and 2 surveys (response rate of 34% and 29%, respectively). From the original 52 items, 50 items across five domains emerged from the Delphi procedure.Items related to demographic and clinical characteristics (n=5; eg, age), device characteristics (n=5; eg, device type), insertion (n=16; eg, indication), management (n=9; eg, dressing and securement), and complication and removal (n=15, eg, occlusion) were identified as requirements for a minimum dataset to track and evaluate vascular access device use and outcomes.

Conclusion

We developed and internally validated a minimum dataset for vascular access device research. This study generated new knowledge to enable healthcare systems to collect relevant, useful and meaningful vascular access data. Use of this standardised approach can help benchmark clinical practice and target improvements worldwide.

"Its not just hacking for the sake of it": a qualitative study of health innovators views on patient-driven open innovations, quality and safety

Quality and Safety in Health Care Journal -

Background

Open do-it-yourself (DIY) health innovations raise new dilemmas for patient-oriented and service-oriented scholars and healthcare providers. Our study aimed to generate practical insights into quality and safety issues to patient care raised by two volunteer-run, open DIY solutions: Nightscout Project (patient-driven, open-source software for type 1 diabetes management) and e-NABLE (volunteers who design and three-dimensionally print upper-limb assistive devices). To this end, we examined the views of health innovators who are knowledgeable about medical devices standards and regulations.

Methods

We applied a multimedia-based, data-elicitation technique to conduct indepth interviews with a diversified sample of 31 health innovators practising in two Canadian provinces (Quebec and Ontario). An exploratory thematic analysis approach was used to identify respondents’ reasoning processes and compare their overall judgements of Nightscout and e-NABLE.

Results

Respondents pondered the following quality and safety issues: importance of the need addressed; accessibility; volunteers’ ability to develop and maintain a safe solution of good quality; risks involved for users; consequences of not using the solution; and liability. Overall, innovators see Nightscout as a high-risk DIY solution that requires expert involvement and e-NABLE as a low-risk one that fills a hard-to-meet gap.

Conclusion

Health innovators generally support patient-driven initiatives but also call for the involvement of professionals who possess complementary skills and knowledge. Our findings provide a list of issues healthcare providers may discuss with patients during clinical consultations to document potential risks and benefits of open DIY solutions. To inform new policy approaches, we propose the development of publicly funded umbrella organisations to act as intermediaries between open DIY solutions and regulatory bodies to help them meet quality and safety standards.

Trauma Resuscitation Using in situ Simulation Team Training (TRUST) study: latent safety threat evaluation using framework analysis and video review

Quality and Safety in Health Care Journal -

Introduction

Trauma resuscitation is a complex and time-sensitive endeavour with significant risk for error. These errors can manifest from sequential system, team and knowledge-based failures, defined as latent safety threats (LSTs). In situ simulation (ISS) provides a novel prospective approach to recreate clinical situations that may manifest LSTs. Using ISS coupled with a human factors-based video review and modified framework analysis, we sought to identify and quantify LSTs within trauma resuscitation scenarios.

Methods

At a level 1 trauma centre, we video recorded 12 monthly unannounced ISS to prospectively identify trauma-related LSTs. The on-call multidisciplinary trauma team participated in the study. Using a modified framework analysis, human factors experts transcribed and coded the videos. We identified LST events, categorised them into themes and subthemes and used a hazard matrix to prioritise subthemes requiring intervention.

Results

We identified 843 LST events during 12 simulations, categorised into seven themes and 38 subthemes, of which 23 are considered critical. The seven themes relate to physical workspace, mental model formation, equipment, unclear accountability, demands exceeding individuals’ capacity, infection control and task-specific issues. The physical workspace theme accounted for the largest number of critical LST events (n=152). We observed differences in LST events across the four scenarios; complex scenarios had more LST events.

Conclusions

We identified a diverse set of critical LSTs during trauma resuscitations using ISS coupled with video-based framework analysis. The hazard matrix scoring, in combination with detailed LST subthemes, supported identification of critical LSTs requiring intervention and enhanced efforts intended to improve patient safety. This approach may be useful to others who seek to understand the contributing factors to common LSTs and design interventions to mitigate them.

Factors influencing physician responsiveness to nurse-initiated communication: a qualitative study

Quality and Safety in Health Care Journal -

Background

How quickly physicians respond to communications from bedside nurses is important for the delivery of safe inpatient care. Delays in physician responsiveness can impede care or contribute to patient harm. Understanding contributory factors to physician responsiveness can provide insights to promote timely physician response, possibly improving communication to ensure safe patient care. The purpose of this study was to describe the factors contributing to physician responsiveness to text or numeric pages, telephone calls and face-to-face messages delivered by nurses on adult general care units.

Methods

Using a qualitative design, we collected data through observation, shadowing, interviews and focus groups of bedside registered nurses and physicians who worked in four hospitals in the Midwest USA. We analysed the data using inductive content analysis.

Results

A total of 155 physicians and nurses participated. Eighty-six nurses and 32 physicians participated in focus groups or individual interviews; we shadowed 37 physicians and nurses across all sites. Two major inter-related themes emerged, message and non-message related factors. Message-related factors included the medium nurses used to convey messages, physician preference for notification via one communication medium over another and the clarity of the message, all of which could cause confusion and thus a delayed response. Non-message related factors included trust and interpersonal relationships, and different perspectives between nurses and physicians on the same clinical issue that affected perceptions of urgency, and contributed to delays in responsiveness.

Conclusions

Physician responsiveness to communications from bedside nurses depends on a complex combination of factors related to the message itself and non-message related factors. How quickly physicians respond is a multifactorial phenomenon, and strategies to promote a timely response within the context of a given situation must be directed to both groups.

Association between paediatric intraoperative anaesthesia handover and adverse postoperative outcomes

Quality and Safety in Health Care Journal -

Objective

To determine whether intraoperative handover of patient care from one anaesthesia clinician to another was associated with an increased risk of adverse postoperative outcomes during paediatric surgeries.

Design, setting and participants

A retrospective, population-based cohort study (1 April 2013–1 June 2018) at an academic medical centre.

Exposure

Intraoperative handover of care between pairs of anaesthesia clinicians from one care provider to another compared with no handover of anaesthesia care.

Main outcomes and measures

The primary outcome was a composite of all-cause mortality and major postoperative morbidity within 30 days after surgery. Secondary outcomes included individual components of the primary outcome and 30-day hospital readmission. Inverse probability of exposure weighting using propensity scores for intraoperative handovers was calculated. Weighted logistic regression was used to determine the association between intraoperative anaesthesia handovers and outcomes.

Results

78 321 paediatric surgical cases (n=5411 with handovers) were included for analysis. Patients were predominantly male (56.5%) with a median age of 6.56 (IQR: 2.65–12.53) years and a median anaesthesia duration of 76 (IQR: 55–126) min. In the weighted sample, the odds of the primary outcome (OR: 0.92; 95% CI 0.75 to 1.13; p=0.43), any morbidity (OR: 0.93; 95% CI 0.75 to 1.16; p=0.515), all-cause mortality (OR: 0.8; 95% CI 0.37 to 1.73; p=0.565) or 30-day readmission following surgery (OR: 0.99; 95% CI 0.84 to 1.18; p=0.95) did not significantly differ among surgeries with and without handovers.

Conclusions

Among paediatric patients undergoing surgery, intraoperative anaesthesia handovers were not associated with adverse postoperative outcomes, after accounting for relevant covariates. These findings provide a preliminary perspective on the role of intraoperative handovers as a care-neutral event, with implications for improving safety.

Quality and safety in the literature: September 2021

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

  • The use of time-limited treatment trials for critically ill intensive care unit (ICU) patients with advanced medical illnesses was associated with improvement in quality of family meetings, and reductions in non-beneficial ICU treatments and ICU length of stay, without a change in hospital mortality. JAMA Intern Med. 12 April 2021.

  • Admission avoidance ‘hospital at home’ services, combined with comprehensive geriatric assessment, led to similar outcomes in the proportion of patients living at home 6 months after an acute event...

  • 2021 Safety Communications

    FDA MedWatch -

    The FDA posts Medical Device Safety Communications to describe the FDA's current analysis of an issue and contain specific regulatory approaches and clinical recommendations for patient management.

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