International Journal for Quality in Health Care最新文献

Background: High-quality discharge information is important to promote patient safety when patients are transferred from hospital to primary care. Patients with multiple long-term conditions are especially vulnerable to insufficient transfer of medication information, as they use many medications and have complex interactions with the healthcare services. The aim of this study was to investigate the effect of integrated medicines management provided to hospitalized multimorbid patients on the quality of the discharge medication information.

Methods: Multimorbid patients ≥18 years, using a minimum of four regular medications from a minimum of two therapeutic medication classes were recruited from the Internal Medicine ward, Oslo University Hospital, Norway, from August 2014 to March 2016 and randomly assigned, 1:1, to the intervention or control group. Intervention patients received integrated medicines management throughout the hospital stay. Control patients received standard care. This paper reports the results of a pre-specified secondary endpoint analysis of a randomized controlled trial; the difference between the intervention and control group in the quality of discharge medication information.

Results: The analysis population comprised 384 patients. Integrated medicines management improved the discharge summary quality score of the medication information from 5.8 ± 1.5 to 8.6 ± 2.6 (mean difference 2.7, 95% CI 2.3-3.2, p < 0.001). In total 171 intervention patients (89%) received a patient discharge information letter, compared to 66 control patients (35%), p < 0.001. The quality score of the medication information in the patient discharge information letter was improved from 6.0 ± 1.8 in the control group to 10.0 ± 1.3 in the intervention group (mean difference 4.0, 95% CI 3.6-4.4, p < 0.001).

Conclusion: Integrated medicines management delivered to multimorbid patients during a hospital stay improved the quality of the medication information in discharge summaries as well as patient discharge information letters and ensured that a discharge information letter in lay language was prepared for almost all patients who were involved in the management of their medications after discharge.

Background: Iron deficiency is the leading cause of anaemia worldwide and is increasingly treated with intravenous (IV) iron therapy. Staining from IV iron therapy is a rare but significant and preventable adverse event. To mitigate patient harm, a health-service-wide quality improvement project was implemented. This study aimed to determine the real-world impact of a quality improvement project on IV iron staining incidents and preventability.

Methods: A retrospective chart audit was undertaken for all IV iron staining episodes reported in a directorate-wide clinical incident reporting database (RiskMan) between 2016 and 2022. Incidence rates of IV iron staining, preventability, and stain severity were compared pre- and post-implementation of a standardized IV iron procedure.

Results: Over 7 years, 103 IV iron stains were identified, resulting in a staining rate of 0.31 stains per 100 infusions (pre 0.27% and post 0.34%, P = .25). Implementation of the standardized IV iron procedure resulted in improvements in pharmacist review of the medication order (61.8% versus 89.7%, P < .01), use of the statewide IV iron infusion consent form (27.3% versus 76.9%, P < .01), and appropriate cannula site (14.3% versus 52.5%, P < .01). Smaller stain sizes were associated with cessation of the infusion at identification of extravasation (312 cm2 versus 35 cm2) (P = .04). Preventability was assigned to 86% of stains.

Conclusion: The incidence rate of IV iron staining in a real-world clinical setting is 0.31%. There was increased compliance with several best practice principles and 86% of stains were preventable. Early identification and intervention of potential staining incidents results in smaller iron stains for patients. Quality improvement tools developed for this project can contribute to patient outcomes internationally.

Background: Integrated care can be broadly defined as the delivery of high-quality and safe care for patients as they cross organizational boundaries or when care is delivered with multiple health care teams, professions, or organizations. Successful integration of care services is contingent on multiple and complex factors across macro, meso, and micro levels of health and social care systems in lower-, middle-, and higher-income countries. Previous priorities for the future development of integrated care have focused on designing and implementing models or approaches to integrated care rather than establishing the research needed to underpin them. This study aimed to address this evidence gap by developing a consensus on international research priorities related to integration of care and cross-boundary working.

Methods: We conducted a sequential electronic Delphi (eDelphi) study from September 2023 to December 2023. The eDelphi process consisted of initial priority generation followed by two rounds of consensus development via an online survey. Sixty-six priorities were generated by 19 delegates at an international conference workshop titled, 'Priority setting for future research on integration of care and cross-boundary working'. Workshop delegates then identified other experts in integrated care and cross-boundary working from their networks. In each eDelphi round, participants then provided item-by-item responses using a seven-point Likert scale, with consensus defined a priori as ≥80% agreement (strongly agree or agree). Priorities that reached consensus were conceptually grouped into topics.

Results: Twenty-five of 66 unique (37.9%) research priorities achieved consensus after two eDelphi rounds. In Round 1, 63/85 (74.1%) experts from 10 countries across 4 continents achieved consensus on 12/66 (18.2%) priorities. In Round 2, 51/63 (81.0%) experts achieved consensus on a further 13/54 (24.1%) priorities. From the 25 priorities, we derived six conceptual groupings that represent broad topics for future research on integrated care and cross-boundary working: (i) access to care, (ii) data sharing and technology, (iii) measurement of care quality, (iv) patient experience and satisfaction, (v) service design, integration and governance, and (vi) teamwork and leadership.

Conclusion: Integrating care services and improving cross-boundary working is important for improving the quality of care provided to patients, regardless of country. Therefore, the conceptual topics and individual priorities identified in this study can inform policymakers, practitioners, and researchers when designing or evaluating integrated care services across the world in pursuit of improved integrated care systems.

Background: The closure of a pharmacy-led anticoagulation clinic, which provided point-of-care (POC) international normalized ratio (INR) testing and face-to-face visits, coupled with the transition to an academic physician-led clinic without POC INR testing and reliance on telephone communication, created significant challenges for warfarin management during the Coronavirus disease 2019 pandemic. The aim of this quality control project was to increase the percentage of patients on warfarin within the optimal time in therapeutic range (TTR) from 52.30% to 65.00%, sustain baseline quarterly cumulative percentage TTR to 59.00%, and transition 20% of eligible patients from warfarin to dual oral anticoagulation (DOAC) within 12 months.

Methods: A multidisciplinary team employed a Fishbone diagram, stakeholder analysis, process flow map, and a driver diagram. Significant barriers included knowledge gaps, fear of blood draws, lack of POC INR testing, and noninteroperable electronic health records (EHRs). Primary outcome measures included quarterly cumulative percentage TTR, 2-monthly percentage TTR, and the percentage of eligible patients switched to DOAC. Process measures included INR completion rates. Key interventions involved educating patients and the care team, transitioning patients to DOAC, improving EHRs, and optimizing processes. Data analysis utilized run charts.

Results: Monthly INR completion rates rose from 63% to 87% within 12 months and reached 92% during the 6 months post-project period. Among 143 patients, 40.55% (58) were eligible for a DOAC switch, with 51.72% (30/58) successfully transitioning during the project and the 6-month post-project period. Two-monthly TTR rates improved from the baseline of 52.30% to 62.00% during the study period and remained sustainable at 62.80% in the post-project phase. Quarterly cumulative TTR rates remained stable at 59.20% during the study period in 2021. The quarterly cumulative TTR rates continued to increase at 60.50% and 64.40% in 2022 and 2023, respectively, during the post-project period. No bleeding episodes occurred during the 15-month post-project period.

Conclusion: Multi-faceted strategies significantly improved warfarin safety during the project and maintained these improvements for 24 months. Transitioning from warfarin to DOACs was crucial for optimizing anticoagulation management with limited resources. The lead physician and team used various tools to address barriers to effective warfarin management, ensure appropriate DOAC prescribing, and enhance practices for DOAC prescriptions. This project effectively addressed barriers, improved population health, and provided a model for anticoagulation management in primary care settings.

There have been growing concerns about the well-being of staff in inpatient mental health settings, with studies suggesting that they have higher burnout and greater work-related stress levels than staff in other healthcare sectors. When addressing staff well-being, psychological safety can be a useful concept. However, there is no measure of psychological safety that is suitable for use in inpatient mental health settings. Edmondson (1999) is the most commonly used measure of psychological safety, but it was designed for use in general physical healthcare settings. As inpatient mental health settings are unique environments, transferability of knowledge from physical to mental healthcare settings cannot be assumed. We sought to develop questionnaire items that capture psychological safety among healthcare staff working in acute inpatient mental healthcare settings. We used the nominal group technique, a consensus method involving rounds of discussion, idea generation, and item rating/ranking to identify priorities. Twenty-eight stakeholders participated, including 4 who had lived experience of mental health problems, 11 academics and 18 healthcare professionals (8 participants identified with more than 1 category). The study involved a workshop with three parts: (i) an overview of current research and limitations of the Edmondson (1999) measure as outlined above, (ii) discussion on what items should be retained from the Edmondson (1999) measure, and (iii) discussion on what items should be added to the Edmondson (1999) measure. Twenty-one items were generated and retained to capture psychological safety in inpatient mental health settings. These measure professionals' sense of being valued by their team and organization, feeling supported at work, feeling physically safe and protected from physical harm, and knowing they can raise concerns about risk and safety. This is the first study to generate questionnaire items suitable for measuring staff psychological safety in mental health settings. These have been generated via a consensus method to ensure stakeholders' views are reflected. Further research is needed to evaluate factor structure, internal reliability, and convergent validity.

Health inequity between Indigenous (First Nations, Inuit, and Métis) peoples and other citizens is an important policy concern in Canada, as in other colonial countries. Racism in healthcare has been identified as contributing to poorer care and to worse outcomes. Despite a large literature regarding racism in other healthcare contexts, the dimensions of the existing literature on anti-Indigenous racism in Canadian healthcare are unclear. A scoping review examined the evidence of anti-Indigenous racist experiences in healthcare in the research literature, including the types of racist behaviours identified, settings studied, and Indigenous populations and geographic regions included. We identified English and French language journal articles on anti-Indigenous racism in Canadian healthcare settings in Scopus, PubMed, CINAHL, and the Bibliography of Indigenous Peoples in North America, and grey literature reports. A total of 2250 journal articles and 9 grey literature reports published since 2000 were included in screening, and 66 studies were included in the final review. Most used qualitative interviews with patients, but a large proportion included healthcare providers. Most were conducted in urban settings, a majority in Ontario or British Columbia, with mixed Indigenous populations. The largest proportion focussed on patient experiences with healthcare in general, rather than specific clinical contexts. Most racist experiences identified were 'covert' racism, including patients feeling treated differently from non-Indigenous patients, being ignored, treated more slowly, or not believed. Stereotyping of Indigenous peoples as substance users, poor patients, or poor parents was also commonly reported. 'Overt racism', including the use of racist slurs, was not widely found. Some quantitative studies did use standardized or validated instruments to capture racist experiences, but most did not result in generalizable estimates of their prevalence. The few studies linking racism to health outcomes found that experiencing racism was related to reluctance to seek healthcare, potentially leading to higher unmet healthcare needs. Gender was the intersecting dimension most identified as shaping healthcare experiences, with Indigenous women and girls at risk to specific stereotypes. Some papers suggested that socio-economically disadvantaged Indigenous people were at the highest risk to experiencing racism. Types of anti-Indigenous racism identified in Canadian healthcare appear similar to those reported in other jurisdictions. Indigenous peoples facing multiple dimensions of disadvantage, especially gender and social class, may be the most likely to experience racism. It is likely that the experience of racism in healthcare has implications for Indigenous peoples' health, mainly by reducing healthcare access.

Adverse events (AEs), and particularly adverse drug events (ADEs), represent a health problem as they can cause permanent damage or death. Understanding the frequency, location, and causes of ADEs can prevent harm to patients. The Global Trigger Tool, produced by the Institute for Healthcare Improvement (GTT/IHI), is widely used to identify AEs. Recognizing the profile of patients who suffer ADEs can reveal clinical or individual characteristics that predispose to the occurrence of AEs. A cross-sectional study was carried out through a retrospective analysis of 120 medical charts of patients discharged from hospital between October 2020 and April 2021. Patients over 18 years old, with a length of stay of more than 24 h, were included. The list of triggers used was from the medication module of the GTT/IHI, which was adapted for use in the institution. Two primary reviewers and a medical reviewer applied this tool. The primary reviewers independently assessed the randomized charts. A meeting to achieve consensus among the reviewers was held every 2 weeks to validate the identified ADEs; classifications were based on harm severity. Multivariate logistic regression was utilized to assess the variables that predicted the occurrence of ADEs, using the backward stepwise method. A total of 43 ADEs were identified, with a frequency of 36 per 100 admissions (43/120). Of these, five ADEs (12%) were responsible for patients being admitted to hospital. In the case of in-hospital ADEs, there were 42.2 per 1000 patients/day. The clinical manifestation of altered kidney function (16%) and the anatomical drug group of the nervous system (33%) were the most frequent ADEs. The multivariate logistic regression model was significant (×2 = 44.960, P < .001), indicating that factors such as: known drug allergy [odds ratio 5.728; 95% confidence interval (CI): 1.249, 26.274, P = .025]; being clinically hospitalized (odds ratio 7.504; 95% CI: 1.654, 34.037; P = .009); number of medicines used (odds ratio 1.100; 95% CI: 1.054, 1.148; P < .001); and being under the care of internal medicine (odds ratio 3.633; 95% CI: 1.257, 10.511; P = .017) were predictor variables associated with the occurrence of ADEs. A significant percentage of hospitalized patients experienced at least one ADE, with rates surpassing those found in similar studies. The GTT/IHI effectively assessed medication-related harm, emphasizing the need for tailored triggers based on population characteristics. Predictor variables can inform preventive strategies. Overall, the tool facilitated a localized risk assessment of medication use.