Handoffs have become integral to almost all aspects of hospital-based care. Realities such as duty hour limitations and shift work mean that patients are cared for by numerous individuals each day in an inpatient unit. Furthermore, the specialisation of modern medicine now means that patients transfer between units and care teams as their healthcare needs evolve. This changing of personnel and patient location necessitates handoffs, where clinicians communicate information about the patient, transferring responsibility for care from one person to another. For example, a patient in the hospital might receive care from two separate physician teams (night and day coverage) and three nursing teams (each working an 8-hour shift). This means their care is passed through at least five handoffs in a 24-hour period, not counting potential handoffs to procedural teams, escalations of care or handoffs for break coverage. The number of handoffs in a day for each patient...

Overuse of medical devices such as urinary and vascular catheters remains a pervasive problem contributing to preventable hospital-associated infections and other complications. There is not much mystery remaining about why this happens and how to address it. Nearly two decades of quality improvement studies show us that standardising the indications for catheter insertion, integrating their reassessment into clinical workflow and empowering nurses all lead to more judicious catheter use.1–3

 Despite this evidence, replicating these interventions across institutions, commonly known as spread, is extremely hard. In some countries, national implementation toolkits were created to support hospitals interested in adopting these strategies, like the Comprehensive Unit-based Safety Programme (CUSP) of the Agency for Healthcare Research and Quality (AHRQ) or Choosing Wisely Canada’s ‘Lose the Tube’.4 5 In the USA, CUSP resulted in reduced urinary catheter use in over 10% of hospitals.

Background

Patient-reported experience measures (PREMs) are valuable tools to evaluate patient-centredness (PC) from the patients’ perspective. Despite their utility, a comprehensive PREM addressing PC has been lacking. To bridge this gap, we developed the preliminary version of the Experienced Patient-Centeredness Questionnaire (EPAT), a disease-generic tool based on the integrative model of PC comprising 16 dimensions. It demonstrated content validity. This study aimed to test its psychometric properties and to develop a final 64-item version (EPAT-64).

Methods

In this cross-sectional study, we included adult patients treated for cardiovascular diseases, cancer, musculoskeletal diseases and mental disorders in inpatient or outpatient settings in Germany. For each dimension of PC, we selected four items based on item characteristics such as item difficulty and corrected item–total correlation. We tested structural validity using confirmatory factor analysis, examined reliability by McDonald’s Omega and tested construct validity by examining correlations with general health status and satisfaction with care.

Results

Analysis of data from 2.024 patients showed excellent acceptance and acceptable item–total correlations for all EPAT-64 items, with few items demonstrating ceiling effects. The confirmatory factor analysis indicated the best fit for a bifactor model, where each item loaded on both a general factor and a dimension-specific factor. Omega showed high reliability for the general factor, while varying for specific dimensions. Construct validity was confirmed by absence of strong correlations with general health status and a strong correlation of the general factor with satisfaction with care.

Conclusions

EPAT-64 demonstrated commendable psychometric properties. This tool allows comprehensive assessment of PC, offering flexibility to users who can measure each dimension with a four-item module or choose modules based on their needs. EPAT-64 serves multiple purposes, including quality improvement and evaluation of interventions aiming to enhance PC. Its versatility empowers users in diverse healthcare settings.

Background

A substantial number of people experiencing self-harm or suicidal ideation present to hospital emergency departments (EDs). In 2014, a National Clinical Programme was introduced in EDs in Ireland to standardise care provision. Internationally, there has been limited research on the factors affecting the implementation of care for people who present with mental health crises in EDs.

Methods

This qualitative study examined factors influencing the implementation of the National Clinical Programme for Self-harm and Suicide-related Ideation in 15 hospitals in Ireland from early (2015–2017) through to later implementation (2019–2022). Semi-structured interviews were conducted with staff involved in programme delivery, with the topic guide and thematic analysis informed by the Consolidated Framework for Implementation Research.

Results

A total of 30 participants completed interviews: nurse specialists (n=16), consultant psychiatrists (n=6), nursing managers (n=2), emergency medicine staff (n=2) and members of the national programme team (n=4). Enablers of implementation included the introduction of national, standardised guidance for EDs; implementation strategies led by the national programme team; and training and support for nurse specialists. The following inner-setting factors were perceived as barriers to implementation in some hospitals: limited access to a designated assessment room, delayed access to clinical input and poor collaboration with ED staff. Overall, these barriers dissipated over time, owing to implementation strategies at national and local levels. The varied availability of aftercare impacted providers’ ability to deliver the programme and the adaptability of programme delivery had a mixed impact across hospitals.

Conclusions

The perceived value of the programme and national leadership helped to advance implementation. Strategies related to ongoing training and education, developing stakeholder interrelationships and evaluation and monitoring have helped address implementation barriers and promote continued sustainment of the programme. Continued efforts are needed to support nurse specialists delivering the programme and foster partnerships with community providers to improve the transition to aftercare.

Objective

To assess the association of county-level bias about black and white people with patient experience, influenza immunisation, and quality of clinical care for black and white older US adults (age 65+ years).

Design

Linear multivariable regression measured the cross-sectional association of county-level estimates of implicit and explicit bias about black and white people with patient experiences, influenza immunisation, and clinical quality-of-care for black and white older US adults.

Participants

We used data from 1.9 million white adults who completed implicit and explicit bias measures during 2003–2018, patient experience and influenza immunisation data from respondents to the 2009–2017 Medicare Consumer Assessment of Healthcare Providers and Systems (MCAHPS) Surveys, and clinical quality-of-care data from patients whose records were included in 2009–2017 Healthcare Effectiveness Data and Information Set (HEDIS) submissions (n=0.8–2.9 million per measure).

Main outcome measures

Three patient experience measures and patient-reported influenza immunisation from the MCAHPS Survey; five HEDIS measures.

Results

In county-level models, higher pro-white implicit bias was associated with lower immunisation rates and worse scores for some patient experience measures for black and white adults as well as larger-magnitude black-white disparities. Higher pro-white implicit bias was associated with worse scores for some HEDIS measures for black and white adults but not with black-white disparities in clinical quality of care. Most significant associations were small in magnitude (effect sizes of 0.2–0.3 or less).

Conclusions

To the extent that county-level pro-white implicit bias is indicative of bias among healthcare providers, there may be a need for interventions designed to prevent such bias from adversely affecting the experiences and preventive care of black patients and the clinical quality of care for all patients.

Background

Handoffs are a weak link in the chain of clinical care of inpatients. Within-unit handoffs are increasing in frequency due to changes in duty hours. There are strong rationales for standardising the reporting of critical information between providers, and such practices have been adopted by other industries.

Objectives

As part of Making Healthcare Safer IV we reviewed the evidence from the last 10 years that the use of structured handoff protocols influences patient safety outcomes within acute care hospital units.

Methods

We searched four databases for systematic reviews and original research studies of any design that assessed structured handoff protocols and reported patient safety outcomes. Screening and eligibility were done in duplicate, while data extraction was done by one reviewer and checked by a second reviewer. The synthesis of results is narrative. Certainty of evidence was based on the Grading of Recommendations Assessment, Development and Evaluation framework as modified for Making Healthcare Safer IV.

Results

We searched for evidence on 12 handoff tools. Two systematic reviews of Situation, Background, Assessment, Recommendation (SBAR) (including 11 and 28 original research studies; 5 and 15 were about the use in handoffs) and two newer original research studies provided low certainty evidence that the SBAR tool improves patient safety outcomes. Ten original research studies (about nine implementations) provided moderate certainty evidence that the I-PASS tool (Illness severity, Patient summary, Action list, Situation awareness, Synthesis to receiver) reduces medical errors and adverse events. No other structured handoff tool was assessed in more than one study or one setting.

Conclusion

The SBAR and I-PASS structured tools for within-unit handoffs probably improve patient safety, with I-PASS having a stronger certainty of evidence. Other published tools lack sufficient evidence to draw conclusions.

PROSPERO registration number

CRD42024576324.

Purpose

This systematic review aims to identify the implementation strategies of financial navigation and systematically synthesise its effects on mitigating financial toxicity among cancer survivors, based on the theoretical framework of implementation science.

Methods

Medline, Web of Science Core Collection, ScienceDirect and ProQuest Health & Medical Collection databases were searched for studies published before 22 August 2023. We sought original research on financial navigation interventions among adult cancer survivors with financial toxicity in healthcare settings. The Revised Cochrane risk-of-bias tool for randomised trials, 2.0 and the Risk Of Bias In Non-randomised Studies of Interventions-I were used to assess the risk of bias in included studies. In addition, the implementation strategies of the included studies were categorised and collated based on Expert Recommendations for Implementing Change, and the Consolidated Framework for Implementation Research was adopted to explain barriers and facilities for implementation.

Results

In total, 6855 records were screened, yielding 14 full-text articles, which were included (3 randomised clinical trials and 11 non-randomised studies). ‘Train and educate stakeholders’ (n=13 (92.9%)) and ‘use evaluative and iterative strategies’ (n=12 (85.7%)) were the most common implementation strategies in financial navigation. The feasibility of financial navigation is relatively high, but generally hindered by the health condition of cancer survivors, low willingness to participate and insufficient number of navigators to cover all participants. After the intervention, three of seven studies reported statistically significant mitigations in patient-reported financial toxicity. In studies reporting statistically significant outcomes, ‘adapt and tailor to the context’ and ‘change infrastructure’ were proposed as key corresponding recommendations.

Conclusions

Financial navigation is a potentially beneficial intervention for lessening the financial toxicity of cancer survivors, but more high-level evidence is needed for further validation. Financial navigation combined with the theoretical framework of implementation science provides a foundation for the future realisation of the leap from knowledge to practice.

PROSPERO registration number

CRD42023469114.

Many successful implementation studies fail to be sustained and spread after the publication. We aimed to spread a successful deimplementation strategy that reduced inappropriate peripheral venous catheter and urinary catheter use and evaluated the spread, adoption and effects of this strategy in clinical practice.

We adapted the original successful study into a more accessible project, creating a toolkit called Better without catheter. We recruited 39 hospitals (more than half of all Dutch hospitals) across the Netherlands, which participated in regular online meetings. After 21 months, we sent an online survey to the project leaders of the participating hospitals to assess progress, barriers and facilitators to adopting the project.

Widespread promotion and targeted emails were key factors in spreading Better without catheter. There was considerable variation in the hospitals’ progress; five had not yet started, six had completed the project and the others were at various stages in between. Major barriers included lack of time and resources, organisational facilities and the composition of local project teams. Key facilitators were organisational support and the involvement of physicians and nurse leaders. Project leaders valued the toolkit, the flexibility to tailor the project and the online meetings.

Overall, the spread and adoption of this deimplementation strategy showed encouraging results, with 39 hospitals joining the network within 2 years. Although reach and engagement were high, the hospitals’ progress in the project was frequently hindered by organisational and management factors. Four elements supported the uptake: widespread promotion, the translation of the original study into an accessible improvement project with practical tools, the flexibility to tailor the approach locally and participation in a peer network.

Prusaczyk B, Burke RE. It’s time for the field of geriatrics to invest in implementation science. BMJ Qual Saf 2023;32:700-703.

In this article, the affiliation ‘Central and North West London NHS foundation Trust’ has been added to Simon Conroy and the funding statement has been updated to acknowledge the funding from the NHS Elect and Central and North West London NHS foundation Trust.

doi: 10.1136/bmjqs-2023-016263corr1

Tackling overuse in healthcare is now more necessary than ever. Movements such as Choosing Wisely and Preventing Overdiagnosis have highlighted that some healthcare services offer no added value and may even cause harm to patients. Estimates of overdiagnosis and overtreatment vary widely between services, providers and regions.1 2 Overuse is a persistent challenge in high-income countries and is increasingly recognised in low-income settings.3 Action is needed to prevent patient harm, reduce resource waste and preserve the limited time of healthcare professionals. In addition, since healthcare services have a significant environmental impact, minimising overuse can contribute to achieving climate goals.

De-implementation science

To accelerate the reduction of overuse, robust de-implementation science is essential.4 This field studies the drivers, strategies and processes involved in reducing or eliminating ineffective, unnecessary or harmful healthcare practices, and in replacing them with evidence-based, high-value alternatives. Rigorous...

Sepsis remains a leading cause of morbidity and mortality worldwide.1 The use of artificial intelligence (AI), and particularly machine-learning (ML) approaches, to predict which patients are at risk for sepsis in the hospital may improve patient-centred outcomes through early recognition and timely antibiotics. Yet, despite major interest in the use of ML applications in sepsis care, there are only a handful of successful examples of model implementation that save lives through early detection.2 3 The high cost and extensive system architecture required to test and implement novel ML applications have limited many institutions’ abilities to bring these models to the bedside. Unfortunately, this has resulted in a preponderance of studies on model development rather than implementation and reliance on proprietary models disseminated to health systems without validation or testing. One well-known sepsis predictive model developed by an electronic health record vendor (Epic Systems,...

Background

Low-value care (LVC) describes practices that persist in healthcare, despite being ineffective, inefficient or causing harm. Several determinants for the provision of LVC have been identified, but understanding how these factors influence professionals’ decisions, individually and jointly, is a necessary next step to guide deimplementation.

Methods

A factorial survey experiment was employed using vignettes that presented hypothetical medical scenarios among 593 Swedish primary care physicians. Each vignette varied systematically by factors such as patient age, patient request for the LVC, physician’s perception of this practice, practice cost to the primary care centre and time taken to deliver it. For each scenario, we measured the reported likelihood of providing the LVC. We collected information on the physician’s worry about missing a serious illness.

Results

Patient requests and physicians’ positive perceptions of the practice were the factors that increased the reported likelihood of providing LVC the most (by 14 and 13 percentage points (pp), respectively). When the LVC was low in cost or not time-consuming, patient requests further boosted the likelihood of provision by 29 and 18 pp. In contrast, credible evidence against the LVC reduced the role of patient requests by 11 pp. Physicians’ fear of missing a serious illness was linked with higher reported probability of providing LVC, and the credibility of the evidence against the LVC reduced the role of this concern.

Conclusions

The findings highlight that patient requests enhance the role of many determinants, while the credibility of evidence diminishes the impact of others. Overall, these findings point to the relevance of increased clinician knowledge about LVC, tools for patient communication and the use of decision support tools to reduce the uncertainty in decision-making.

Objective

To identify bias in using a single machine learning (ML) sepsis prediction model across multiple hospitals and care locations; evaluate the impact of six different bias mitigation strategies and propose a generic modelling approach for developing best-performing models.

Methods

We developed a baseline ML model to predict sepsis using retrospective data on patients in emergency departments (EDs) and wards across nine hospitals. We set model sensitivity at 70% and determined the number of alerts required to be evaluated (number needed to evaluate (NNE), 95% CI) for each case of true sepsis and the number of hours between the first alert and timestamped outcomes meeting sepsis-3 reference criteria (HTS3). Six bias mitigation models were compared with the baseline model for impact on NNE and HTS3.

Results

Across 969 292 admissions, mean NNE for the baseline model was significantly lower for EDs (6.1 patients, 95% CI 6 to 6.2) than for wards (7.5 patients, 95% CI 7.4 to 7.5). Across all sites, median HTS3 was 20 hours (20–21) for wards vs 5 (5–5) for EDs. Bias mitigation models significantly impacted NNE but not HTS3. Compared with the baseline model, the best-performing models for NNE with reduced interhospital variance were those trained separately on data from ED patients or from ward patients across all sites. These models generated the lowest NNE results for all care locations in seven of nine hospitals.

Conclusions

Implementing a single sepsis prediction model across all sites and care locations within multihospital systems may be unacceptable given large variances in NNE across multiple sites. Bias mitigation methods can identify models demonstrating improved performance across most sites in reducing alert burden but with no impact on the length of the prediction window.

Background

There is limited evidence from antimicrobial stewardship programmes in less-resourced settings. This study aimed to improve the quality of antibacterial prescriptions by mitigating overuse and promoting the use of narrow-spectrum agents in intensive care units (ICUs) in a middle-income country.

Methods

We established a quality improvement collaborative (QIC) model involving nine Argentine ICUs over 11 months with a 16-week baseline period (BP) and a 32-week implementation period (IP). Our intervention package included audits and feedback on antibacterial use, facility-specific treatment guidelines, antibacterial timeouts, pharmacy-based interventions and education. The intervention was delivered in two learning sessions with three action periods along with coaching support and basic quality improvement training.

Results

We included 912 patients, 357 in BP and 555 in IP. The latter had higher APACHE II (17 (95% CI: 12 to 21) vs 15 (95% CI: 11 to 20), p=0.036), SOFA scores (6 (95% CI: 4 to 9) vs 5 (95% CI: 3 to 8), p=0.006), renal failure (41.6% vs 33.1%, p=0.009), sepsis (36.1% vs 31.6%, p<0.001) and septic shock (40.0% vs 33.8%, p<0.001). The days of antibacterial therapy (DOT) were similar between the groups (change in the slope from BP to IP 28.1 (95% CI: –17.4 to 73.5), p=0.2405). There were no differences in the antibacterial defined daily dose (DDD) between the groups (change in the slope from BP to IP 43.9, (95% CI: –12.3 to 100.0), p=0.1413).

The rate of antibacterial de-escalation based on microbiological culture was higher during the IP (62.0% vs 45.3%, p<0.001).

The infection prevention control (IPC) assessment framework was increased in eight ICUs.

Conclusion

Implementing an antimicrobial stewardship program in ICUs in a middle-income country via a QIC demonstrated success in improving antibacterial de-escalation based on microbiological culture results, but not on DOT or DDD. In addition, eight out of nine ICUs improved their IPC Assessment Framework Score.

Background

Early mobilisation of intensive care unit (ICU) patients has been recommended in clinical practice guidelines. Therefore, the Japanese universal health insurance system introduced an additional fee for early mobilisation and/or rehabilitation, which can be claimed by hospitals when starting rehabilitation of ICU patients within 48 hours after their ICU admission. However, the effect of this fee is unknown.

Objective

To measure the proportion of ICU patients who received early rehabilitation and the impact on length of ICU stay, the length of hospital stay and discharged to home after the introduction of the financial incentive (additional fee for early mobilisation and/or rehabilitation).

Design/methods

We included patients who were admitted to ICU within 2 days of hospitalisation between April 2016 and January 2020. We conducted interrupted time series analyses to assess the effects of the introduction of the financial incentive.

Results

The proportion of patients who received early rehabilitation immediately increased after the introduction of the financial incentive (rate ratio (RR) 1.293, 95% CI 1.240 to 1.349). The RR for proportion of patients received early rehabilitation was 1.008 (95% CI 1.005 to 1.011) in the period after the introduction of the financial incentive compared with period before its introduction. There was no statistically significant change in the mean length of ICU stay, the mean length of hospital stay and the proportion of patients who were discharged to home.

Conclusion

After the introduction of the financial incentive, the proportion of ICU patients who received early rehabilitation increased. However, the effects of the financial incentive on the length of ICU stay, the length of hospital stay and the proportion of patients who were discharged to home were limited.

Background

Creating and sustaining an institutional climate conducive to patient and health worker safety is a critical element of successful multimodal hand hygiene improvement strategies aimed at achieving best practices. Repeated WHO global surveys indicate that the institutional safety climate consistently ranks the lowest among various interventions.

Methods

To develop an international expert consensus on research agenda priorities related to the role of institutional safety climate within the context of a multimodal hand hygiene improvement strategy, we conducted a structured consensus process involving a purposive sample of international experts. A preliminary list of research priorities was formulated following evidence mapping, and subsequently refined through a modified Delphi consensus process involving two rounds. In round 1, survey respondents were asked to rate the importance of each research priority. In round 2, experts reviewed round 1 ratings to reach a consensus (defined as ≥70% agreement) on the final prioritised items to be included in the research agenda. The research priorities were then reviewed and finalised by members of the WHO Technical Advisory Group on Hand Hygiene Research in Healthcare.

Results

Of the 57 invited participants, 50 completed Delphi round 1 (88%), and 48 completed round 2 (96%). Thirty-six research priority statements were included in round 1 across five thematic categories: (1) safety climate; (2) personal accountability for hand hygiene; (3) leadership; (4) patient participation and empowerment and (5) religion and traditions. In round 1, 75% of the items achieved consensus, with 9 statements carried forward to round 2, leading to a final set of 31 prioritised research statements.

Conclusion

This research agenda can be used by researchers, clinicians, policy-makers and funding bodies to address gaps in hand hygiene improvement within the context of an institutional safety climate, thereby enhancing patient and health worker safety globally.

Background

The way that data are presented can influence quality and safety initiatives. Time-series charts highlight changes but do not clarify whether data lie outside expected variation. Statistical process control (SPC) charts make this distinction and have been demonstrated to be effective in supporting hospital initiatives. To improve the uptake of the SPC methodology by hospitals in England, a training intervention was created. The current study evaluates the effectiveness of that training against the background of a wider national initiative to encourage the adoption of SPC charts.

Methods

A parallel cluster randomised trial was conducted with 16 English NHS hospitals. Half were randomised to the training intervention and half to the control. The primary analysis compares the difference in use of SPC charts within hospital board papers in a postrandomisation period (adjusting for baseline use). Trainees completed feedback forms with Likert scale and open-ended items.

Results

Fifteen hospitals participated across the study arms. SPC chart use increased in both intervention and control hospitals between the baseline and postrandomisation period (29 and 30 percentage points, respectively). There was no statistically significant difference between the intervention and control hospitals in use of SPC charts in the postrandomisation period (average absolute difference 9% (95% CI –34% to 52%). In the feedback forms, 93.9% (n=31/33) of trainees affirmed learning and 97.0% (n=32/33) had formed an intention to change their behaviour.

Conclusions

Control chart use increased in both intervention and control hospitals. This is consistent with a rising tide and/or contamination effect, such that the culture of control chart use is spreading across hospitals in England. Further research is needed to support hospitals implementing SPC training initiatives and to link SPC implementation to quality and safety outcomes. Such research could support future quality and safety initiatives nationally and internationally.

Trial registration number

NCT04977414.

The stepped-wedge cluster randomised trial is a popular design in implementation and health services research. All clusters, such as clinics or hospitals, start in the control state, and gradually switch over to treatment in a random order until all clusters have received the intervention. The design allows for the incorporation of an experiment into the gradual roll-out of an intervention across clusters. However, the traditional stepped-wedge layout may not be the best choice in many scenarios. In this article, we discuss modifications to the stepped-wedge design that maintain a staggered roll-out, but which may improve some key characteristics. We consider improving the timing of implementation periods, reducing the volume of data collection and allowing for the recruitment of clusters over the course of the trial.

This May, the World Health Assembly (WHA) will vote on re-establishing a mandate for the WHO to address the health consequences of nuclear weapons and war.1 Health professionals and their associations should urge their governments to support such a mandate and support the new United Nations (UN) comprehensive study on the effects of nuclear war.

The first atomic bomb exploded in the New Mexico desert 80 years ago, in July 1945. Three weeks later, two relatively small (by today’s standards), tactical-size nuclear weapons unleashed a cataclysm of radioactive incineration on Hiroshima and Nagasaki. By the end of 1945, about 213 000 people were dead.2 Tens of thousands more have died from late effects of the bombings.

Last December, Nihon Hidankyo, a movement that brings together atomic bomb survivors, was awarded the Nobel Peace Prize for its ‘efforts to achieve a world free of nuclear weapons...

The article by Cho et al1 in the current issue of BMJ Quality and Safety addresses the persistent and debilitating problem of hospital falls, which remain a challenge worldwide. Despite decades of research on hospital falls,2 considerable effort by health professionals,3 and publication of clinical guidelines on falls prevention,4 5 falls and associated injuries continue to be a major threat to patient safety and quality. The reasons why hospital falls continue to be associated with injuries and increased hospital length of stay are incompletely understood and vary across patients and settings. What is known is that patient falls education early after hospital admission helps to prevent falls.6–8 Staff education on how to prevent hospital falls also helps to reduce the risk.9 Exercise, safe footwear, environmental modifications, use of assistive devices such...