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Reaching 95%: decision support tools are the surest way to improve diagnosis now

Quality and Safety in Health Care Journal -

Rory Staunton, a 12 year-old boy, presented with fever, vomiting and mottled skin. Was this gastroenteritis?

Thomas Duncan’s symptoms were headache, dizziness, nausea, abdominal pain and fever after recent travel from West Africa. Was this sinusitis?

These two classic cases of diagnostic error beg the question of why the correct diagnosis was missed, and in his classic paper, George Bordage provided a very plausible answer: ‘I just didn’t think of it.’1 That is where clinical decision support tools for diagnosis (CDS-Dx), the so-called ‘symptom checkers’, come in. They work, and would likely have helped the clinicians consider the correct diagnosis in these cases: Rory Staunton’s streptococcal sepsis2 or Thomas Duncan’s Ebola infection,3 both of which had a fatal outcome.

CDS-Dx work

The report by Sibbald et al published in this issue of BMJ Quality & Safety adds to the growing evidence that...

Mental health services: quality, safety and suicide

Quality and Safety in Health Care Journal -

Suicide is a major global challenge with an estimated 700 000 people taking their lives each year.1 Each of these deaths is an individual tragedy affecting families, friends, communities and health and social care teams. As clinicians and researchers working in suicide prevention, we are sometimes contacted by people whose loved ones have died by suicide while under the care of mental health services. Although we hear about examples of high-quality care, there are also accounts of poor continuity, failed communication, diagnostic or therapeutic errors, poorly trained or resourced clinical teams or a lack of family involvement. Suicide is a complex phenomenon and many of its drivers are economic and social,2 but its prevention should be a priority for health services in general and for mental health services in particular. Specifically, mental health patients represent a group at greatly elevated risk of suicide who are accessible...

Beyond improvement skills: what do clinicians, managers, patients and others need to do to make improvement happen?

Quality and Safety in Health Care Journal -

In this issue of the journal, Wright et al offer an in-depth examination of the implementation of six improvement projects in three English hospitals to elucidate the work that matters most to those directly involved. The framework they inductively derive from their analysis—a set of ‘socio-organisational functional and facilitative tasks’, or SOFFTs—gives substance to the activities undertaken by practitioners at the sharp end of improvement projects, beyond the technical skills involved in delivering quality improvement methods.1 The notion that this class of activity may be important to the success of improvement work is not new: previous researchers, the authors of this study among them, have drawn attention to the range of organising activities that are central to success or failure of improvement efforts, for example, in engaging colleagues and ensuring fit with organisational processes, structures and culture.2–5 Research in...

Should electronic differential diagnosis support be used early or late in the diagnostic process? A multicentre experimental study of Isabel

Quality and Safety in Health Care Journal -

Background

Diagnostic errors unfortunately remain common. Electronic differential diagnostic support (EDS) systems may help, but it is unclear when and how they ought to be integrated into the diagnostic process.

Objective

To explore how much EDS improves diagnostic accuracy, and whether EDS should be used early or late in the diagnostic process.

Setting

6 Canadian medical schools. A volunteer sample of 67 medical students, 62 residents in internal medicine or emergency medicine, and 61 practising internists or emergency medicine physicians were recruited in May through June 2020.

Intervention

Participants were randomised to make use of EDS either early (after the chief complaint) or late (after the complete history and physical is available) in the diagnostic process while solving each of 16 written cases. For each case, we measured the number of diagnoses proposed in the differential diagnosis and how often the correct diagnosis was present within the differential.

Results

EDS increased the number of diagnostic hypotheses by 2.32 (95% CI 2.10 to 2.49) when used early in the process and 0.89 (95% CI 0.69 to 1.10) when used late in the process (both p<0.001). Both early and late use of EDS increased the likelihood of the correct diagnosis being present in the differential (7% and 8%, respectively, both p<0.001). Whereas early use increased the number of diagnostic hypotheses (most notably for students and residents), late use increased the likelihood of the correct diagnosis being present in the differential regardless of one’s experience level.

Conclusions and relevance

EDS increased the number of diagnostic hypotheses and the likelihood of the correct diagnosis appearing in the differential, and these effects persisted irrespective of whether EDS was used early or late in the diagnostic process.

National cross-sectional cohort study of the relationship between quality of mental healthcare and death by suicide

Quality and Safety in Health Care Journal -

Background

Patient safety-based interventions aimed at lethal means restriction are effective at reducing death by suicide in inpatient mental health settings but are more challenging in the outpatient arena. As an alternative approach, we examined the association between quality of mental healthcare and suicide in a national healthcare system.

Methods

We calculated regional suicide rates for Department of Veterans Affairs (VA) Healthcare users from 2013 to 2017. To control for underlying variation in suicide risk in each of our 115 mental health referral regions (MHRRs), we calculated standardised rate ratios (SRRs) for VA users compared with the general population. We calculated quality metrics for outpatient mental healthcare in each MHRR using individual metrics as well as an Overall Quality Index. We assessed the correlation between quality metrics and suicide rates.

Results

Among the 115 VA MHRRs, the age-adjusted, sex-adjusted and race-adjusted annual suicide rates varied from 6.8 to 92.9 per 100 000 VA users, and the SRRs varied between 0.7 and 5.7. Mean regional-level adherence to each of our quality metrics ranged from a low of 7.7% for subspecialty care access to a high of 58.9% for care transitions. While there was substantial regional variation in quality, there was no correlation between an overall index of mental healthcare quality and SRR.

Conclusion

There was no correlation between overall quality of outpatient mental healthcare and rates of suicide in a national healthcare system. Although it is possible that quality was not high enough anywhere to prevent suicide at the population level or that we were unable to adequately measure quality, this examination of core mental health services in a well-resourced system raises doubts that a quality-based approach alone can lower population-level suicide rates.

Association between acute psychiatric bed availability in the Veterans Health Administration and veteran suicide risk: a retrospective cohort study

Quality and Safety in Health Care Journal -

Background

Veteran suicides have increased despite mental health investments by the Veterans Health Administration (VHA).

Objective

To examine relationships between suicide and acute inpatient psychiatric bed occupancy and other community, hospital and patient factors.

Methods

Retrospective cohort study using administrative and publicly available data for contextual community factors. The study sample included all veterans enrolled in VHA primary care in 2011–2016 associated with 111 VHA hospitals with acute inpatient psychiatric units. Acute psychiatric bed occupancy, as a measure of access to care, was the main exposure of interest and was categorised by quarter as per cent occupied using thresholds of ≤85%, 85.1%–90%, 90.1%–95% and >95%. Hospital-level analyses were conducted using generalised linear mixed models with random intercepts for hospital, modelling number of suicides by quarter with a negative binomial distribution.

Results

From 2011 to 2016, the national incidence of suicide among enrolled veterans increased from 39.7 to 41.6 per 100 000 person-years. VHA psychiatric bed occupancy decreased from a mean of 68.2% (IQR 56.5%–82.2%) to 65.4% (IQR 53.9%–79.9%). VHA hospitals with the highest occupancy (>95%) in a quarter compared with ≤85% had an adjusted incident rate ratio (IRR) for suicide of 1.10 (95% CI 1.01 to 1.19); no increased risk was observed for 85.1%–90% (IRR 0.96; 95% CI 0.89 to 1.03) or 90.1%–95% (IRR 0.96; 95% CI 0.89 to 1.04) compared with ≤85% occupancy. Of hospital and community variables, suicide risk was not associated with number of VHA or non-VHA psychiatric beds or amount spent on community mental health. Suicide risk increased by age categories, seasons, geographic regions and over time.

Conclusions

High VHA hospital occupancy (>95%) was associated with a 10% increased suicide risk for veterans whereas absolute number of beds was not, suggesting occupancy is an important access measure. Future work should clarify optimal bed occupancy to meet acute psychiatric needs and ensure adequate bed distribution.

Determining the skills needed by frontline NHS staff to deliver quality improvement: findings from six case studies

Quality and Safety in Health Care Journal -

Background

Previous studies have detailed the technical, learning and soft skills healthcare staff deploy to deliver quality improvement (QI). However, research has mainly focused on management and leadership skills, overlooking the skills frontline staff use to improve care. Our research explored which skills mattered to frontline health practitioners delivering QI projects.

Study design

We used a theory-driven approach, informed by communities of practice, knowledge-in-practice-in-context and positive deviance theory. We used case studies to examine skill use in three pseudonymised English hospital Trusts, selected on the basis of Care Quality Commission rating. Seventy-three senior staff orientation interviews led to the selection of two QI projects at each site. Snowball sampling obtained a maximally varied range of 87 staff with whom we held 122 semistructured interviews at different stages of QI delivery, analysed thematically.

Results

Six overarching ‘Socio-Organisational Functional and Facilitative Tasks’ (SOFFTs) were deployed by frontline staff. Several of these had to be enacted to address challenges faced. The SOFFTs included: (1) adopting and promulgating the appropriate organisational environment; (2) managing the QI rollercoaster; (3) getting the problem right; (4) getting the right message to the right people; (5) enabling learning to occur; and (6) contextualising experience. Each task had its own inherent skills.

Conclusion

Our case studies provide a nuanced understanding of the skills used by healthcare staff. While technical skills are important, the ability to judge when and how to use wider skills was paramount. The provision of QI training and fidelity to the improvement programme may be less of a priority than the deployment of SOFFT skills used to overcome barriers. QI projects will fail if such skills and resources are not accessed.

Effect of the surgical safety checklist on provider and patient outcomes: a systematic review

Quality and Safety in Health Care Journal -

Background

Despite being implemented for over a decade, literature describing how the surgical safety checklist (SSC) is completed by operating room (OR) teams and how this relates to its effectiveness is scarce. This systematic review aimed to: (1) quantify how many studies reported SSC completion versus described how the SSC was completed; (2) evaluate the impact of the SSC on provider outcomes (Communication, case Understanding, Safety Culture, CUSC), patient outcomes (complications, mortality rates) and moderators of these relationships.

Methods

A systematic literature search was conducted using Medline, CINAHL, Embase, PsycINFO, PubMed, Scopus and Web of Science on 10 January 2020. We included providers who treat human patients and completed any type of SSC in any OR or simulation centre. Statistical directional findings were extracted for provider and patient outcomes and key factors (eg, attentiveness) were used to determine moderating effects.

Results

300 studies were included in the analysis comprising over 7 302 674 operations and 2 480 748 providers and patients. Thirty-eight per cent of studies provided at least some description of how the SSC was completed. Of the studies that described SSC completion, a clearer positive relationship was observed concerning the SSC’s influence on provider outcomes (CUSC) compared with patient outcomes (complications and mortality), as well as related moderators.

Conclusion

There is a scarcity of research that examines how the SSC is completed and how this influences safety outcomes. Examining how a checklist is completed is critical for understanding why the checklist is successful in some instances and not others.

IHI Adds Renowned Leaders in Patient Safety, Public Health to Board of Directors

Institute for Healthcare Improvement -

The Institute for Healthcare Improvement (IHI) has added two new members to its Board of Directors. Rear Admiral retired Sylvia Trent-Adams has a legacy of work in federal service and public health and has served as Deputy Surgeon General and Acting Surgeon General. Beth Daley Ullem is a life-long patient safety advocate with deep expertise working with health system leaders and boards to improve the quality and safety of patient care.

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