International Journal for Quality in Health Care最新文献

Background: Stroke, a leading cause of global disability, where timely thrombolysis is crucial for favorable outcomes. Despite initiatives like Acute Stroke Care Maps (ASCaMs) in China aiming to improve care continuity and thrombolysis rates, the long-term effectiveness of these interventions in urban settings remains underexplored.

Methods: This retrospective cohort study investigates the role of the Shenyang ASCaM in improving the thrombolysis rate with tissue plasminogen activator within 4.5 hours of ischemic stroke onset in 30 hospitals. Using interrupted time series (ITS) analysis, it compares outcomes before and after ASCaM's implementation from April 2019 to December 2021. The ASCaM strategy, featuring EMS prenotification, rapid triage, and immediate neuroimaging, is assessed. Regression models, adjusted for patient demographics and clinical scores, evaluate the intervention's impact, controlling for potential confounders.

Results: In the study, 2676 patients were evaluated before the implementation of the Shenyang ASCaM, and 8277 patients were assessed during its implementation. Thrombolysis rates within the vital 4.5-hour window rose significantly from 59% before ASCaM to 72% during its implementation (P < .001), and door-to-needle time (DNT) decreased significantly by 12.269 minutes (P < .0001). Early neurological deterioration (END) incidents decreased significantly from 44% to 39.2% (adjusted OR = 0.820, P = .001), indicating improved stroke care efficiency and outcomes. ITS analysis showed a pre-implementation monthly decrease in thrombolysis rates of 0.95%, countered by a post-implementation immediate surge of 6.21% and a sustained improvement at a rate of 0.13% per month. Furthermore, Post-ASCaM, DNT reduced to 52.42 minutes, thrombolysis rates increased to 72.3%, and END incidence decreased (adjusted OR = 0.820, P = .001), indicating improved stroke care efficiency and outcomes.

Conclusion: Our findings confirm that China's ASCaMs significantly enhance thrombolysis rates and ensure care continuity in managing acute stroke, indicating their long-term effectiveness in urban settings. This contributes to global stroke care improvements, emphasizing the potential for wider application and further research on sustained interventions.

Background: Care in the dying phase is often suboptimal in hospitals outside specialized palliative care. Studies of the implementation of recommendations for care in the dying phase are rare. Medical records can provide information in this regard.

Methods: A retrospective analysis of medical records was conducted for 400 patients who died in six intensive care units (ICUs) and four general wards (GWs) at two German medical centres. To evaluate the care in the dying phase, we descriptively analysed 37 variables reflecting recommendations of the German Palliative Care Guideline. To identify factors associated with important aspects of care, seven of these variables were determined as appropriate for multiple logistic regression.

Results: In 299/400 (74.8%) patients, recognition of the dying phase was documented. Patients with the ability to communicate were informed about the impending death in 46/121 (38.0%) and informal caregivers (ICs) in 282/390 (72.3%). Patients' wishes regarding care were documented in 33/122 (27.1%). Monitoring was rarely stopped before death, with significantly lower percentages in ICUs: e.g. vital signs in 30% [14.9% in ICUs vs. 52.9% in GWs; confidence interval (28.4, 47.6)]. Validated symptom assessment tools were used in 272/400 (68.0%), mainly for pain (66.3%). Logistic regression analysis identified setting (ICUs vs. GWs), recognition of the dying phase, patient age, communication ability, and malignant neoplasm as factors significantly associated with aspects of care.

Conclusion: The dying phase was not consistently documented, many presumably nonbeneficial interventions continued until death, systematic symptom assessment beyond pain was lacking, and communication with patients and ICs was poorly documented. Findings suggest a need for setting-specific strengthening of healthcare professionals in these settings.

Background: Intra- and postoperative adverse events (AEs) are devastating to patients and costly for healthcare systems. In 2008, the World Health Organization Surgical Safety Checklist was introduced to minimize morbidity and mortality and to enhance team performance. It consists of three parts whereof the third part, the sign-out at the end of surgery, is generally performed poorly. Addressing intraoperative AEs and discussion of the consecutive postoperative management should take place during this often-omitted sign-out. To address this issue, a national, multicentre quality improvement project (CIBOSurg-ClassIntra® for Better Outcomes in Surgery) is currently being conducted in Switzerland. This project evaluates the effectiveness and implementation of systematic recording of intraoperative AEs using ClassIntra® (a generic classification system for intraoperative AEs) and an interdisciplinary discussion during the sign-out. The current study, conducted in the preimplementation phase of CIBOSurg, aims to assess existing practices and determinants concerning the future implementation of systematic recording of intraoperative AEs, perceptions surrounding ClassIntra®, and its implementation during sign-out.

Methods: A qualitative context analysis was conducted across eight hospitals in Switzerland and one in the Netherlands. Nearly 100 semistructured interviews were conducted with interdisciplinary staff from different surgical disciplines. Data were analysed using rapid analysis and concept-structuring qualitative content analysis guided by the Consolidated Framework for Implementation Research and the Expert Recommendations for Implementing Change.

Results: Findings indicate that the sign-out is not yet implemented consistently at every participating hospital. Currently, intraoperative AEs are not being systematically recorded and discussed, despite recognition of their importance. Most interviewees considered the application and implementation of ClassIntra® to be feasible and were convinced that a systematic recording of intraoperative AEs and interdisciplinary discussion among the operative team during sign-out is particularly useful for learning and postoperative patient care. Several barriers and facilitators to the successful recording and discussion of intraoperative AEs were identified.

Conclusion: The study results provide important information about current practices, while also generating insights on how to better discuss and systematically record intraoperative AEs and improve sign-out performance. Future implementation of ClassIntra® is generally perceived positively. The findings address a critical gap in surgical safety practice and provide a basis for developing multifaceted implementation strategies.

Background: This study aimed to systematically evaluate apps with temporomandibular disorder (TMD) self-management content available in Australia for quality, clinical safety, self-management support functions, and contributors to app development.

Methods: A systematic search of the App Store (iOS) and Google Play (Android) was conducted on 18 April 2023 (and updated 26 July 2023) to identify apps that had TMD self-management content. Two raters independently assessed app quality, clinical safety, self-management support, and contributors to app development for the involvement of people living with TMD and clinicians. Quality was evaluated using the Mobile App Rating Scale (MARS) for engagement, functionality, aesthetics, and information quality scored using a 5-point Likert scale. App clinical safety was assessed using MARS functionality (item 6) and information quality items for accuracy/relevance (item 15), scope (item 16), and visual information accuracy/clarity (item 17) (scored on a Likert scale), and the M-Health Index and Navigation Database framework questions: does the app provide any warning for use? Does the app have a crisis management feature? Can the app cause harm? (scored yes/no). Self-management support was evaluated using the Self-Management Support (SMS-14) checklist (scored yes/no). Included apps, app store descriptions, and linked websites were qualitatively evaluated to determine the contributors to app development.

Results: Seven apps with TMD self-management content were available in Australia. Overall, the included apps were of acceptable quality (mean = 3.25/5) but scored poorly for engagement (2.71/5) and information (2.92/5). Clinical safety limitations identified were the inability to identify and/or direct users to support services in a crisis and inconsistent TMD information. One app (Do I Grind or Snore) was deemed potentially harmful as sleep sounds suggestive of obstructive sleep apnoea were interpreted as snoring by the app. Overall, the inclusion of self-management support functions was variable (range 1-9; mean = 4.71/14), with pain/TMD education (71%) and self-monitoring (71%) the most common. Only one app had development input from a person with lived experience of TMD.

Conclusion: The quality and self-management support of apps with TMD self-management content is variable. TMD apps with activating self-management strategies and higher engagement scores are more likely to be effective. Concerningly, one app was found to be potentially harmful, and overall apps lacked user safeguards. Only one app involved a person with TMD in its development, and the authors recommend using co-design in future TMD app development to improve app quality, clinical safety, and impact.

Background: The quality and equitable accessibility of health services represent basic priorities for health systems. In Mexico, three quarters of patients with diabetes are treated at public health services shown to be heterogeneous as regards the quality of the health-care processes. This notwithstanding, no information has been published on the quality of care provided to patients with diabetes according to their socioeconomic characteristics and ethnicity. Accordingly, the objective of this study was to identify disparities in the quality of care provided to adults medically diagnosed with type 2 diabetes (T2D), according to their socioeconomic levels and ethnicity.

Methods: Cross-sectional analysis based on data drawn from the 2018-19 National Health and Nutrition Survey. Quality of care was assessed from the patients' perspective. Analysis included a nationally representative sample of 4,555 adults aged ≥20 years, with a diagnosis of diabetes, and a subsample of 1,586 adults with Hb1Ac measurements. Two multiple linear regression models were fitted to assess the relationship between the overall quality of care provided vs. the socioeconomic levels and ethnicity of patients, adjusted for covariates.

Results: Nearly one third of adults with diabetes belonged to low socioeconomic levels, 7% were indigenous, 92% were ≥40 years old, and 50% had experienced diabetes-related complications. Respondents had been diagnosed with diabetes for 11 years on average. Patients of low socioeconomic levels showed a higher frequency of complications and inadequate glycemic control than did those of higher levels. After adjusting for covariates, the quality of care received was poorer among T2D patients of low (-4.8 pp, 95% CI: -6.5, -3.0) and medium (-1.5 pp, 95% CI: -3.1,0.1) socioeconomic levels compared to those in the high tier, and among indigenous (-2.7 pp, 95% CI -5.3, -0.1) vs. non-indigenous individuals.

Conclusions: Overall, adults with diabetes receive poor-quality health care. Furthermore, disparities exist by socioeconomic level and ethnicity in the quality of care provided. It is essential to strengthen and renew health-care policies with a view to improving outpatient care for individuals with diabetes, one of the most prevalent chronic diseases in Mexico and around the world. It is vital that efforts to ensure the health and well-being of the most socially vulnerable populations be rooted in an equity approach.

Background: Medication safety remains a global concern, with governments and organizations striving to mitigate preventable patient harm across healthcare systems. Look-alike, sound-alike medication incidents and the safety culture are widely acknowledged as a contributor to medication errors, particularly within the high-risk perioperative environment. The Medication Safety Culture Indicator Matrix (MedSCIM) is a novel tool developed by the Canadian Institute for Safe Medication Practices to assess the maturity of the medication safety culture. This study aims to delineate look-alike sound-alike (LASA) medication incidents reported in the pharmacy and perioperative settings of an Australian hospital and assess the maturity of the medication safety culture.

Methods: The study setting is within a large regional hospital in Australia, servicing both adult and paediatric populations. Medication incidents from 1 April 2018 to 1 April 2023 were retrospectively gathered from the Clinical Incident Management System, Riskman®. Data and statistical analyses were carried out using Microsoft Excel®. The necessary approvals were secured from the Heath Service Human Research and Ethics Committee.

Results: During the 5-year period, a total of 246 (4.1%) of the 6002 medication incidents within the health service were identified as meeting the inclusion criteria. Of the 246 medication incidents, 63.0% were identified from the Pharmacy Department, while 22.0% and 15.0% were from the Post Anaesthetic Care Unit and Anaesthetics Department, respectively. The most frequently reported incident classification in both the Anaesthetics Department and Post Anaesthetic Care Unit was 'incorrect dose', followed by 'incorrect medication'. Throughout the 5-year period, 46 (18.7%) of the 246 medication incidents were attributed to look-alike, sound-alike sources of error, predominantly identified in the Pharmacy Department (73.9%), followed by the Anaesthetics Department (17.4%) and the Post Anaesthetic Care Unit (8.7%). High-risk medications were most frequently reported to the Anaesthetics Department. Packaging (packaging alone, naming and packaging, and syringe swaps) was determined to be a contributing factor in 30 (65.2%) of the 46 LASA medication incidents. MedSCIM assessment revealed a reactive medication safety culture. Additionally, the medication incident report documentation was found to be mostly complete or semi-complete.

Conclusion: Our analysis delineated medication incidents occurring across the entire medication management cycle and identified incidents related to LASA medications as a contributor to medication incidents across these clinical settings. This novel medication safety culture tool assessment highlighted opportunities for improvement with clinical incident documentation.