American journal of medical quality : the official journal of the American College of Medical Quality最新文献

Guidelines for diagnosing pulmonary embolism (PE) start with a risk assessment using a pretest probability (PTP) tool, followed by D-dimer testing or computed tomography pulmonary angiography (CTPA) depending on risk. The project aimed to develop an electronic clinical quality measure (eCQM) to encourage broader use of a validated PTP scoring tool in emergency departments (EDs) to more accurately diagnose PE and to reduce unnecessary CTPAs. To identify a value set to accurately identify CTPA and abnormal D-dimer tests using standard classification systems and clinical vocabularies (ie, Current Procedural Terminology [CPT], Logical Observation Identifiers Names and Codes [LOINC], systematized nomenclature of medicine clinical terms [SNOMED CT]) across 3 academic United States health care systems. A comprehensive value set to identify CTPAs was selected, which contained 31 codes. Additionally, each health care system had unique, site-specific codes to more granularly identify CTPAs. Three health care systems representing 38 EDs from across the country submitted data from all ED encounters between September 12, 2022, and January 11, 2023. Imaging types were reviewed from each of the CPT codes and LOINC. The project evaluated whether a D-dimer was obtained using CPT and LOINC and whether the D-dimer result was elevated using SNOMED CT. The number of ED encounters, PTP use, and diagnosis of PE using different codes were determined. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value for selected codes were calculated. Over a 4-month study period, 270,214 encounters were included from 38 EDs. 11,794 ED encounters with CTPAs during the study period, using the site-specific codes were identified. The comprehensive value set had a PPV of 63.4%. Restricting the CTPA value set to CPT code 71275 or LOINC 88322-3 improved the PPV to 82% with 100% sensitivity and 99% specificity. The restricted value set captured the highest proportion of relevant site-specific codes. D-dimer values were identified using LOINC codes 48065-7 and 91556-1 at Site 1 and 48067-3 at Site 2. SNOMED CT codes were not used at any site to identify elevated D-dimer results. Different D-dimer tests with different normal ranges were used at each site, and only one site provided an abnormal flag for D-dimer results. Heterogeneity in the use of nationally standardized codes for labs and imaging tests limits the ability to measure and compare quality across health care organizations for CTPA and D-dimer results. Restricting the identification of CTPA to CPT Code 71275 or LOINC 88322-3 resulted in high sensitivity and specificity, but false positives remain. Additionally, coding for an abnormal D-dimer test result is not standardized across institutions. Therefore, the currently available value sets cannot be used to develop eCQMs whose aim is to evaluate whether CTPA is ordered appropriately based on the PTP risk level and laboratory testing.

Ambulatory procedures performed electively in hospital outpatient departments are of increasing complexity and constitute a growing share of total procedure volume. Despite their importance, little is known of the prevalence of complications from routine procedures once patients are discharged. This study utilizes a 100% Medicare Fee-for-Service claims data file for the years 2019-2022 to assess the relative frequency of hospital-based ambulatory procedures and 30-day patient postprocedure emergency room and hospitalization complication rates utilizing the Ambulatory Potentially Preventable Complication (AM-PPC) classification method. AM-PPC is a claims-based method designed to calculate comparative provider rates of complication exclusively for elective ambulatory procedures excluding procedures performed in hospital emergency departments. The authors calculated the mean rate of ambulatory complications by procedure across hospitals and then compared them for variation in hospital-specific procedure complication rates to the mean rate. About 2.1% of patients receiving a procedure performed in a hospital outpatient department had an emergency room or inpatient hospitalization visit within 30 days. Complication event rates varied widely across hospital outpatient departments and within specific procedures. Hip arthroplasty complication rates varied from 0.0% to 7.6% while those for upper genitourinary procedures varied from 1.7% to 14.2%. In conclusion, the complication rate for ambulatory procedures is seen to vary substantially across hospital outpatient departments for well-established, routine procedures. This study provides a baseline of complication rates for ambulatory procedures, which will be essential for future efforts to improve patient safety.

Research on dashboard adoption has focused on technical and design requirements. Evidence on social mechanisms for successful dashboard adoption is scarce. This study examined 2 quality dashboards in a similar organizational context with different outcomes. The research question was: How do social mechanisms influence the adoption of dashboards in practice? This embedded case study within one Dutch hospital in 2 phases: (1) interviews and observations to identify social mechanisms in the end-user's team and (2) expert focus groups to validate identified mechanisms. Data were transcribed verbatim and analyzed thematically, resulting in the identification of 3 social mechanisms within the team of end-users influencing dashboard adoption: cultivating a supportive team climate, trust, and leadership behavior in end-users' teams. These mechanisms stimulate a learning environment for discussing and improving care quality. They require action from individuals and teams, so dashboards can be used for collective understanding, learning, and improving. Without these social mechanisms, dashboards remain an unadopted "materiality."

Narrow therapeutic time windows and delays in assessing acute ischemic stroke patients limit the access to and effectiveness of reperfusion therapies. A 2-year quality improvement project codesigned and tested a checklist for quicker evaluation of suspected stroke cases in 2 emergency departments (EDs). Utility, feasibility, and implementation barriers were assessed through semistructured interviews. The impact on stroke quality metrics was analyzed using bivariate and multivariate regression models with data from the American Heart Association's Get With the Guidelines registry. Implementing the checklist was significantly associated with higher odds of receiving intravenous thrombolytics within 60 minutes of ED arrival (odds ratio: 6.4, 95% confidence interval: 1.1-68.7, P = 0.03). Users felt the checklist improved the standardization of stroke care and promoted teamwork, especially in a time of higher staff turnover. An ED-based stroke checklist resulted in timelier stroke care for acute ischemic stroke patients, meriting further testing in larger, more diverse settings.

Small-bore feeding tubes (SBFT) in vulnerable patients carry a risk of iatrogenic pneumothorax by misplacement into the lung. This institution noted a series of iatrogenic pneumothoraxes caused by the placement of these devices. A resident-led, multidisciplinary team developed a hospital guideline through a consensus-driven process. The guideline mandated SBFT placement by approved "super-users" via the CORTRAK Enteral Access System or via non-CORTRAK Methods, including the 2-step X-ray Method, fluoroscopy, or direct visualization techniques. A "super-user" Program for the CORTRAK Enteral Access System was developed to assure competency and consistency. With the development of the guideline and "super-user" program, the authors observed a decrease in the number of SBFT-related iatrogenic pneumothoraxes. Following a brief period of adoption, the three-hospital organization has had no SBFT-related iatrogenic pneumothoraxes. This project demonstrates the effectiveness of developing a resident-driven, evidence-based hospital guideline for the safe passage of SBFTs.