Pub Date : 2024-07-23DOI: 10.1016/j.jcjq.2024.07.005
Kandice Bledsaw PhD, RN (is Director, Quality Outcomes and Analytics, Texas Children's Hospital, Houston.), Zachary D. Prudowsky MD, FAAP (is Pediatric Hematologist/Oncologist, Texas Children's Hospital, and Assistant Professor, Department of Pediatrics, Baylor College of Medicine, Houston.), Mark C. Zobeck MD, MPH (is Pediatric Hematologist/Oncologist, Texas Children's Hospital, and Assistant Professor, Department of Pediatrics, Baylor College of Medicine.), Jenell Robins BSDH, RDH (is Oral Health Educator/Registered Dental Hygienist, Texas Children's Hospital.), Sharon Staton MS-SSEM, BSN, RN (is Clinical Specialist, Texas Children's Hospital.), Janet DeJean MSN, RN (is Clinical Specialist, Texas Children's Hospital.), Esther Yang DDS (is Chief of Service, Department of Dentistry, Texas Children's Hospital, and Assistant Professor, Department of Pediatrics, Baylor College of Medicine.), Claudia X. Harriehausen DDS, MSD (is Pediatric Dentist, Texas Children's Hospital, and Assistant Professor, Department of Pediatrics, Baylor College of Medicine.), Judith R. Campbell MD (is Attending Physician, Texas Children's Hospital, and Professor, Department of Pediatrics, Baylor College of Medicine.), Andrea L. Davis MPH, CIC (is Infection Control Preventionist, Texas Children's Hospital.), Anil George MD (is Pediatric Hematologist/Oncologist, Texas Children's Hospital, and Assistant Professor, Department of Pediatrics, Baylor College of Medicine.), David Steffin MD (is Associate Chief, Cell Therapy and Bone Marrow Transplant Program, Texas Children's Hospital, and Assistant Professor, Department of Pediatrics, Baylor College of Medicine.), Gabriella Llaurador MD (is Pediatric Stem Cell and Transplant Therapy Physician, Texas Children's Hospital, and Assistant Professor, Department of Pediatrics, Baylor College of Medicine.), Alexandra M. Stevens MD, PhD (is Pediatric Hematologist/Oncologist, Texas Children's Hospital, and Assistant Professor, Department of Pediatrics, Baylor College of Medicine. Please address correspondence to Zachary Prudowsky)
Background
Mucosal barrier injury central line–associated bloodstream infections (MBI-CLABSIs) remain a challenge among the pediatric cancer population. These infections commonly occur by oral or gastrointestinal (GI) bacteria translocating through impaired gut or oral mucosa. Although strategies to prevent gut MBI-CLABSIs are well characterized, oral pathogen prevention strategies are lacking.
Methods
The authors’ oncodental collaboration quality improvement project, which included two Plan-Do-Study-Act (PDSA) cycles, aimed to improve MBI-CLABSI rates and oral care adherence on a pediatric hematopoietic stem cell transplant (HSCT) unit. PDSA cycle 1 integrated dental residents into existing rounds every third week to screen for dental, gum, and mucosal disease and provide targeted education to patients and families. PDSA cycle 2 implemented a novel oral health educator (OHE) role in which a trained dental hygienist rounded four days per week. Monthly MBI-CLABSI rates and oral care adherence were followed from December 2020 to May 2021 (baseline), June 2021 to March 2022 (PDSA cycle 1), and April 2022 to December 2022 (PDSA cycle 2). Qualitative surveys captured patient and family perception, and a cost savings analysis was completed.
Results
A 58.8% reduction in MBI-CLABSI rate (events per 1,000 central venous line days) was detected (baseline: 5.1; PDSA cycle 2: 2.1), oral care adherence improved 41.7% (baseline: 60.9%; PDSA cycle 2: 86.3%), 100% of patients found it beneficial to receive oral care demonstrations, and an annual cost savings of $541,000 was estimated.
Conclusion
Direct patient outcomes have measurably improved. This project suggests the implementation of an OHE in pediatric HSCT inpatient units may be valuable to patients and families and may be a cost-effective way to reduce MBI-CLABSIs resulting from oral pathogens.
{"title":"Implementing an Oral Health Educator Contributes to Reduced MBI-CLABSI Rates for Pediatric Hematopoietic Stem Cell Transplant Patients","authors":"Kandice Bledsaw PhD, RN (is Director, Quality Outcomes and Analytics, Texas Children's Hospital, Houston.), Zachary D. Prudowsky MD, FAAP (is Pediatric Hematologist/Oncologist, Texas Children's Hospital, and Assistant Professor, Department of Pediatrics, Baylor College of Medicine, Houston.), Mark C. Zobeck MD, MPH (is Pediatric Hematologist/Oncologist, Texas Children's Hospital, and Assistant Professor, Department of Pediatrics, Baylor College of Medicine.), Jenell Robins BSDH, RDH (is Oral Health Educator/Registered Dental Hygienist, Texas Children's Hospital.), Sharon Staton MS-SSEM, BSN, RN (is Clinical Specialist, Texas Children's Hospital.), Janet DeJean MSN, RN (is Clinical Specialist, Texas Children's Hospital.), Esther Yang DDS (is Chief of Service, Department of Dentistry, Texas Children's Hospital, and Assistant Professor, Department of Pediatrics, Baylor College of Medicine.), Claudia X. Harriehausen DDS, MSD (is Pediatric Dentist, Texas Children's Hospital, and Assistant Professor, Department of Pediatrics, Baylor College of Medicine.), Judith R. Campbell MD (is Attending Physician, Texas Children's Hospital, and Professor, Department of Pediatrics, Baylor College of Medicine.), Andrea L. Davis MPH, CIC (is Infection Control Preventionist, Texas Children's Hospital.), Anil George MD (is Pediatric Hematologist/Oncologist, Texas Children's Hospital, and Assistant Professor, Department of Pediatrics, Baylor College of Medicine.), David Steffin MD (is Associate Chief, Cell Therapy and Bone Marrow Transplant Program, Texas Children's Hospital, and Assistant Professor, Department of Pediatrics, Baylor College of Medicine.), Gabriella Llaurador MD (is Pediatric Stem Cell and Transplant Therapy Physician, Texas Children's Hospital, and Assistant Professor, Department of Pediatrics, Baylor College of Medicine.), Alexandra M. Stevens MD, PhD (is Pediatric Hematologist/Oncologist, Texas Children's Hospital, and Assistant Professor, Department of Pediatrics, Baylor College of Medicine. Please address correspondence to Zachary Prudowsky)","doi":"10.1016/j.jcjq.2024.07.005","DOIUrl":"10.1016/j.jcjq.2024.07.005","url":null,"abstract":"<div><h3>Background</h3><div>Mucosal barrier injury central line–associated bloodstream infections (MBI-CLABSIs) remain a challenge among the pediatric cancer population. These infections commonly occur by oral or gastrointestinal (GI) bacteria translocating through impaired gut or oral mucosa. Although strategies to prevent gut MBI-CLABSIs are well characterized, oral pathogen prevention strategies are lacking.</div></div><div><h3>Methods</h3><div>The authors’ oncodental collaboration quality improvement project, which included two Plan-Do-Study-Act (PDSA) cycles, aimed to improve MBI-CLABSI rates and oral care adherence on a pediatric hematopoietic stem cell transplant (HSCT) unit. PDSA cycle 1 integrated dental residents into existing rounds every third week to screen for dental, gum, and mucosal disease and provide targeted education to patients and families. PDSA cycle 2 implemented a novel oral health educator (OHE) role in which a trained dental hygienist rounded four days per week. Monthly MBI-CLABSI rates and oral care adherence were followed from December 2020 to May 2021 (baseline), June 2021 to March 2022 (PDSA cycle 1), and April 2022 to December 2022 (PDSA cycle 2). Qualitative surveys captured patient and family perception, and a cost savings analysis was completed.</div></div><div><h3>Results</h3><div>A 58.8% reduction in MBI-CLABSI rate (events per 1,000 central venous line days) was detected (baseline: 5.1; PDSA cycle 2: 2.1), oral care adherence improved 41.7% (baseline: 60.9%; PDSA cycle 2: 86.3%), 100% of patients found it beneficial to receive oral care demonstrations, and an annual cost savings of $541,000 was estimated.</div></div><div><h3>Conclusion</h3><div>Direct patient outcomes have measurably improved. This project suggests the implementation of an OHE in pediatric HSCT inpatient units may be valuable to patients and families and may be a cost-effective way to reduce MBI-CLABSIs resulting from oral pathogens.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"50 11","pages":"Pages 784-790"},"PeriodicalIF":2.3,"publicationDate":"2024-07-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141843644","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-07-23DOI: 10.1016/j.jcjq.2024.07.008
Jennifer L. Sullivan PhD (is Associate Director, Center of Innovation in Long Term Services and Supports (LTSS COIN), VA [US Department of Veterans Affairs] Providence Healthcare System, Providence, Rhode Island, and Associate Professor, Department of Health Services, Policy and Practice, School of Public Health, Brown University.), Marlena H. Shin JD, MPH (is Research Health Scientist. Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System.), Allison Ranusch MA (is Research Health Scientist, Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, Ann Arbor Michigan.), David C. Mohr PhD (is Investigator, Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, and Adjunct Research Assistant Professor, Department of Health Policy and Management, Boston University School of Public Health.), Charity Chen MS (is Data Analyst/Statistician, Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System.), Laura J. Damschroder (is Research Scientist, VA Center for Clinical Management Research (CCMR) VA Ann Arbor Healthcare System. Please address correspondence to Jennifer L. Sullivan)
Background
Patient safety culture (PSC) fosters an environment of trust where people are encouraged to share information to promote psychological safety. To measure PSC, the Veteran's Health Administration (VHA) developed a PSC survey consisting of 20 items administered to all VHA employees. The survey comprises four scales: (1) risk identification and Just Culture, (2) error transparency and mitigation, (3) supervisor communication and trust, and (4) team cohesion and engagement. Our objective was to compare the PSC survey data to qualitative data regarding high reliability organization (HRO) implementation from four purposively selected VHA hospitals to assess how it manifests and converges.
Methods
Qualitative data focused on understanding HRO implementation efforts were collected from key informants between 2019 and 2020 at 4 of the 18 VHA HRO implementation hospitals. To explore the extent and manifestation of each of the PSC scales among the 4 sites, we combined the qualitative data with the PSC survey data from each hospital using a joint display.
Results
Survey responses were significantly different between the 4 hospitals for all 4 PSC scales. Of the 20 PSC survey items, 12 (60.0%) significantly differed across the 4 hospitals. For example, we saw cross-hospital differences in the following survey items: “We are given feedback about changes put into place based on event reports” and “We take the time to identify and assess risks to patient safety.” Qualitative data supported manifestations for 80.0% (16/20) of PSC individual survey items among hospitals.
Conclusion
The authors found that the qualitative data manifestations were well aligned with the VHA PSC scales, but relationships were not always consistent between data sources. Further research is necessary to elucidate these relationships.
{"title":"A Mixed Methods Study Exploring Patient Safety Culture at Four VHA Hospitals","authors":"Jennifer L. Sullivan PhD (is Associate Director, Center of Innovation in Long Term Services and Supports (LTSS COIN), VA [US Department of Veterans Affairs] Providence Healthcare System, Providence, Rhode Island, and Associate Professor, Department of Health Services, Policy and Practice, School of Public Health, Brown University.), Marlena H. Shin JD, MPH (is Research Health Scientist. Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System.), Allison Ranusch MA (is Research Health Scientist, Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, Ann Arbor Michigan.), David C. Mohr PhD (is Investigator, Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, and Adjunct Research Assistant Professor, Department of Health Policy and Management, Boston University School of Public Health.), Charity Chen MS (is Data Analyst/Statistician, Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System.), Laura J. Damschroder (is Research Scientist, VA Center for Clinical Management Research (CCMR) VA Ann Arbor Healthcare System. Please address correspondence to Jennifer L. Sullivan)","doi":"10.1016/j.jcjq.2024.07.008","DOIUrl":"10.1016/j.jcjq.2024.07.008","url":null,"abstract":"<div><h3>Background</h3><div>Patient safety culture (PSC) fosters an environment of trust where people are encouraged to share information to promote psychological safety. To measure PSC, the Veteran's Health Administration (VHA) developed a PSC survey consisting of 20 items administered to all VHA employees. The survey comprises four scales: (1) risk identification and Just Culture, (2) error transparency and mitigation, (3) supervisor communication and trust, and (4) team cohesion and engagement. Our objective was to compare the PSC survey data to qualitative data regarding high reliability organization (HRO) implementation from four purposively selected VHA hospitals to assess how it manifests and converges.</div></div><div><h3>Methods</h3><div>Qualitative data focused on understanding HRO implementation efforts were collected from key informants between 2019 and 2020 at 4 of the 18 VHA HRO implementation hospitals. To explore the extent and manifestation of each of the PSC scales among the 4 sites, we combined the qualitative data with the PSC survey data from each hospital using a joint display.</div></div><div><h3>Results</h3><div>Survey responses were significantly different between the 4 hospitals for all 4 PSC scales. Of the 20 PSC survey items, 12 (60.0%) significantly differed across the 4 hospitals. For example, we saw cross-hospital differences in the following survey items: “We are given feedback about changes put into place based on event reports” and “We take the time to identify and assess risks to patient safety.” Qualitative data supported manifestations for 80.0% (16/20) of PSC individual survey items among hospitals.</div></div><div><h3>Conclusion</h3><div>The authors found that the qualitative data manifestations were well aligned with the VHA PSC scales, but relationships were not always consistent between data sources. Further research is necessary to elucidate these relationships.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"50 11","pages":"Pages 791-800"},"PeriodicalIF":2.3,"publicationDate":"2024-07-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141845224","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-07-18DOI: 10.1016/j.jcjq.2024.07.002
Ian R. Slade MD (is Associate Professor, Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine.), Aspen D. Avery MPH (is Research Coordinator, Harborview Injury Prevention and Research Center, Harborview Medical Center, University of Washington.), Carmen Gonzalez PhD, MA (is Associate Professor, Department of Communication, University of Washington.), Christine Chung MD (is Assistant Professor Division of Cardiology, Department of Medicine, University of Washington School of Medicine.), Qian Qiu MBA (is Research Consultant, Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine.), Yvonne M. Simpson MA (is Senior Director, Language Access and Cultural Advocacy, Department of Interpreter Services, Harborview Medical Center, University of Washington.), Christine Ector MPH (is Continuing Education Coordinator, Northwest Center for Public Health Practice, University of Washington.), Monica S. Vavilala MD (is Professor, Department of Anesthesiology and Pain Medicine, Professor, Pediatrics, and Adjunct Professor, Health Systems and Population Health, University of Washington School of Medicine. Please send correspondence to Ian R. Slade)
Introduction
Culturally and linguistically diverse (CALD) patients should but do not routinely receive professional interpretation. The authors examined provider perceptions of barriers and solutions to interpreter services (IS) in a safety-net hospital to inform quality improvement (QI).
Methods
A 13-item survey was distributed to 750 clinicians representing 10 services across professional roles, including social workers. Closed- and open-ended questions addressed accessing IS, IS value, and care for CALD patients. Respondents ranked eight barriers to routine IS use and provided ideas for improvement. Descriptive statistics characterized survey results in aggregate and by professional role and care team. Quantitative and qualitative results were triangulated for agreement between survey domains and coded free-text response themes.
Results
A total of 221 responses were analyzed (29.5% response rate). Cost was the lowest-ranked barrier across roles. Leading barriers were efficiency pressures and cumbersome access. Free-text responses agreed with these findings. CALD patients were perceived to have higher complication risk by 87.5% of social workers but by 56.8% of other roles. Recommendations to increase IS varied by team: streamlined access process (46.2% emergency, 37.8% inpatient respondents), expanded in-person interpretation (55.6% inpatient, 45.8% perioperative respondents), and better equipment (44.4% outpatient, 35.9% emergency, 25.0% perioperative respondents).
Conclusion
Provider experiences vary by care team and interpretation modality. Interpretation services are cumbersome to access and compete with efficiency pressures, leading to shortcuts that fail to provide adequate language access. Three initial QI efforts resulted: increased video interpretation equipment, a new language access committee, and a new language access leadership role.
{"title":"Effective Use of Interpreter Services for Diverse Patients in a Safety-Net Hospital: Provider Perceptions of Barriers and Solutions","authors":"Ian R. Slade MD (is Associate Professor, Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine.), Aspen D. Avery MPH (is Research Coordinator, Harborview Injury Prevention and Research Center, Harborview Medical Center, University of Washington.), Carmen Gonzalez PhD, MA (is Associate Professor, Department of Communication, University of Washington.), Christine Chung MD (is Assistant Professor Division of Cardiology, Department of Medicine, University of Washington School of Medicine.), Qian Qiu MBA (is Research Consultant, Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine.), Yvonne M. Simpson MA (is Senior Director, Language Access and Cultural Advocacy, Department of Interpreter Services, Harborview Medical Center, University of Washington.), Christine Ector MPH (is Continuing Education Coordinator, Northwest Center for Public Health Practice, University of Washington.), Monica S. Vavilala MD (is Professor, Department of Anesthesiology and Pain Medicine, Professor, Pediatrics, and Adjunct Professor, Health Systems and Population Health, University of Washington School of Medicine. Please send correspondence to Ian R. Slade)","doi":"10.1016/j.jcjq.2024.07.002","DOIUrl":"10.1016/j.jcjq.2024.07.002","url":null,"abstract":"<div><h3>Introduction</h3><div>Culturally and linguistically diverse (CALD) patients should but do not routinely receive professional interpretation. The authors examined provider perceptions of barriers and solutions to interpreter services (IS) in a safety-net hospital to inform quality improvement (QI).</div></div><div><h3>Methods</h3><div>A 13-item survey was distributed to 750 clinicians representing 10 services across professional roles, including social workers. Closed- and open-ended questions addressed accessing IS, IS value, and care for CALD patients. Respondents ranked eight barriers to routine IS use and provided ideas for improvement. Descriptive statistics characterized survey results in aggregate and by professional role and care team. Quantitative and qualitative results were triangulated for agreement between survey domains and coded free-text response themes.</div></div><div><h3>Results</h3><div>A total of 221 responses were analyzed (29.5% response rate). Cost was the lowest-ranked barrier across roles. Leading barriers were efficiency pressures and cumbersome access. Free-text responses agreed with these findings. CALD patients were perceived to have higher complication risk by 87.5% of social workers but by 56.8% of other roles. Recommendations to increase IS varied by team: streamlined access process (46.2% emergency, 37.8% inpatient respondents), expanded in-person interpretation (55.6% inpatient, 45.8% perioperative respondents), and better equipment (44.4% outpatient, 35.9% emergency, 25.0% perioperative respondents).</div></div><div><h3>Conclusion</h3><div>Provider experiences vary by care team and interpretation modality. Interpretation services are cumbersome to access and compete with efficiency pressures, leading to shortcuts that fail to provide adequate language access. Three initial QI efforts resulted: increased video interpretation equipment, a new language access committee, and a new language access leadership role.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"50 10","pages":"Pages 700-710"},"PeriodicalIF":2.3,"publicationDate":"2024-07-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141851781","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-07-16DOI: 10.1016/j.jcjq.2024.07.003
Stephen Biederman MD (is Assistant Professor, Division of Hospital Medicine, Virginia Commonwealth University (VCU).), Aashish Batheja MPH (is Medical Student, VCU.), Sharon Bednar MSN, RN, CEN, CPHQ, CLSS (is Process Engineer/Project Manager, Senior, VCU Health, Richmond, Virginia.), Chris Orange (is IT Professional, VCU Health.), Amy Hicks (is Training and Development Coordinator, VCU Health.), Stephen Miller DO (is Assistant Professor, Department of Emergency Medicine, VCU.), Patrice Forsen MS, RN, CEN (is Registered Nurse, VCU Health.), Amanda Stark MSN, RN (is Registered Nurse, VCU Health.), Gonzalo Bearman MD, MPH, FACP, FSHEA, FIDSA (is Professor, Department of Internal Medicine, VCU. Please address correspondence to Stephen Biederman)
Background
Sepsis is a life-threatening emergency, and early recognition and treatment in the emergency department (ED) is critical to improving outcomes.
Methods
The authors implemented an interdisciplinary quality improvement (QI) project to standardize sepsis screening workflow across an academic health system consisting of a large tertiary care urban hospital, one freestanding ED, and two small rural affiliate hospitals (RA-1 and RA-2). The research team used the Institute for Healthcare Improvement Model for Improvement framework, consisting of iterative Plan-Do-Study-Act (PDSA) cycles. The primary outcome was rates of screening for sepsis at each site. Secondary outcomes included sepsis mortality and Centers for Medicare & Medicaid Services (CMS) sepsis bundle (SEP-1) compliance at our main medical center. Primary outcome was assessed using electronic dashboards extracting the ratio of ED encounters with electronic health record (EHR)–documented sepsis screening per total ED encounters. The SEP-1 bundle was assessed as percent compliance, and mortality was calculated as average observed to expected (O:E). Averages were compared from preintervention to after initiating improvements using two-tailed t-tests.
Results
This QI project took place from December 2022 to December 2023 across four EDs that experience around 138,000 visits annually. A standardized workflow was established at ED triage with an EHR–based question and an associated nurse and physician defined response. Preintervention (October 2022 to November 2022) triage rates for sepsis were 1.7% (163/9,560), 25.3% (523/2,068), 11.0% (360/3,272), and 36.5% (915/2,506) at our main hospital, freestanding ED, RA-1, and RA-2, respectively. After four PDSA cycles, triage rates rose to 91.9% (4,927/5,360), 97.5% (1,032/1,059), 99.0% (1,845/1,863), and 97.4% (1,328/1,363), respectively (p < 0.005). Sepsis triage rates rose most slowly at the large academic medical center, where progressive PDSA cycles were needed to achieve > 90% screening for sepsis. Mean O:E mortality was 0.99 for the 9 months of available data preintervention and 0.83 in the 17 months postintervention (p = 0.07). CMS sepsis bundle compliance was 28.4% for the 15 months preintervention and 40.5% in the 17 months postintervention, (p = 0.14).
Conclusion
An interdisciplinary QI project leveraged EHR optimization to integrate with human workflows over four PDSA cycles to achieve standardized and improved screening for sepsis in the ED. This resulted in lower sepsis mortality and increased sepsis bundle compliance, though results were not statistically significant.
{"title":"Toward Standardization and High Reliability: Improved Sepsis Screening in Emergency Department Triage Across an Academic Health System","authors":"Stephen Biederman MD (is Assistant Professor, Division of Hospital Medicine, Virginia Commonwealth University (VCU).), Aashish Batheja MPH (is Medical Student, VCU.), Sharon Bednar MSN, RN, CEN, CPHQ, CLSS (is Process Engineer/Project Manager, Senior, VCU Health, Richmond, Virginia.), Chris Orange (is IT Professional, VCU Health.), Amy Hicks (is Training and Development Coordinator, VCU Health.), Stephen Miller DO (is Assistant Professor, Department of Emergency Medicine, VCU.), Patrice Forsen MS, RN, CEN (is Registered Nurse, VCU Health.), Amanda Stark MSN, RN (is Registered Nurse, VCU Health.), Gonzalo Bearman MD, MPH, FACP, FSHEA, FIDSA (is Professor, Department of Internal Medicine, VCU. Please address correspondence to Stephen Biederman)","doi":"10.1016/j.jcjq.2024.07.003","DOIUrl":"10.1016/j.jcjq.2024.07.003","url":null,"abstract":"<div><h3>Background</h3><div>Sepsis is a life-threatening emergency, and early recognition and treatment in the emergency department (ED) is critical to improving outcomes.</div></div><div><h3>Methods</h3><div>The authors implemented an interdisciplinary quality improvement (QI) project to standardize sepsis screening workflow across an academic health system consisting of a large tertiary care urban hospital, one freestanding ED, and two small rural affiliate hospitals (RA-1 and RA-2). The research team used the Institute for Healthcare Improvement Model for Improvement framework, consisting of iterative Plan-Do-Study-Act (PDSA) cycles. The primary outcome was rates of screening for sepsis at each site. Secondary outcomes included sepsis mortality and Centers for Medicare & Medicaid Services (CMS) sepsis bundle (SEP-1) compliance at our main medical center. Primary outcome was assessed using electronic dashboards extracting the ratio of ED encounters with electronic health record (EHR)–documented sepsis screening per total ED encounters. The SEP-1 bundle was assessed as percent compliance, and mortality was calculated as average observed to expected (O:E). Averages were compared from preintervention to after initiating improvements using two-tailed <em>t</em>-tests.</div></div><div><h3>Results</h3><div>This QI project took place from December 2022 to December 2023 across four EDs that experience around 138,000 visits annually. A standardized workflow was established at ED triage with an EHR–based question and an associated nurse and physician defined response. Preintervention (October 2022 to November 2022) triage rates for sepsis were 1.7% (163/9,560), 25.3% (523/2,068), 11.0% (360/3,272), and 36.5% (915/2,506) at our main hospital, freestanding ED, RA-1, and RA-2, respectively. After four PDSA cycles, triage rates rose to 91.9% (4,927/5,360), 97.5% (1,032/1,059), 99.0% (1,845/1,863), and 97.4% (1,328/1,363), respectively (<em>p</em> < 0.005). Sepsis triage rates rose most slowly at the large academic medical center, where progressive PDSA cycles were needed to achieve > 90% screening for sepsis. Mean O:E mortality was 0.99 for the 9 months of available data preintervention and 0.83 in the 17 months postintervention (<em>p</em> = 0.07). CMS sepsis bundle compliance was 28.4% for the 15 months preintervention and 40.5% in the 17 months postintervention, (<em>p</em> = 0.14).</div></div><div><h3>Conclusion</h3><div>An interdisciplinary QI project leveraged EHR optimization to integrate with human workflows over four PDSA cycles to achieve standardized and improved screening for sepsis in the ED. This resulted in lower sepsis mortality and increased sepsis bundle compliance, though results were not statistically significant.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"50 11","pages":"Pages 809-816"},"PeriodicalIF":2.3,"publicationDate":"2024-07-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141842321","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-07-03DOI: 10.1016/j.jcjq.2024.07.001
Jonathan B. Perlin MD, PhD, MSHA, MACP, FACMI (is President and Chief Executive Officer, The Joint Commission, Oakbrook Terrace, Illinois.)
{"title":"A Half Century of Quality and Safety","authors":"Jonathan B. Perlin MD, PhD, MSHA, MACP, FACMI (is President and Chief Executive Officer, The Joint Commission, Oakbrook Terrace, Illinois.)","doi":"10.1016/j.jcjq.2024.07.001","DOIUrl":"10.1016/j.jcjq.2024.07.001","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"50 9","pages":"Page 617"},"PeriodicalIF":2.3,"publicationDate":"2024-07-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141716789","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-07-01DOI: 10.1016/j.jcjq.2024.02.009
Cori C. Grant PhD, MBA (is Assistant Professor, Department of Preventive Medicine, and Tennessee Population Health Consortium, University of Tennessee Health Science Center, Memphis.) , Fawaz Mzayek MD, PhD (is Associate Professor, Division of Epidemiology, Biostatistics, and Environmental Health, School of Public Health, University of Memphis, and Tennessee Population Health Consortium.) , Hadii M. Mamudu PhD, MPA (is Professor, Department of Health Services Management and Policy, and Center for Cardiovascular Risk Research, College of Public Health, East Tennessee State University.), Satya Surbhi PhD (is Assistant Professor, Center for Health System Improvement, Department of Medicine, and Tennessee Population Health Consortium, University of Tennessee Health Science Center, Memphis.), Umar Kabir PhD, MPH (is Research Leader, Center for Health System Improvement, and Director of Operations, Tennessee Population Health Consortium, University of Tennessee Health Science Center, Memphis.), James E. Bailey MD, MPH (is Professor, Department of Preventive Medicine, and Director, Center for Health Systems Improvement, University of Tennessee Health Science Center, Memphis. Please address correspondence to Cori C. Grant)
Driving Forces
Many states with high rates of cardiovascular disease (CVD) lack statewide quality improvement (QI) infrastructure (for example, resources, leadership, community) to address relevant health needs of the population. Academic health centers are well positioned to play a central role in addressing this deficiency. This article describes early experience and lessons learned in building statewide QI infrastructure through the Tennessee Heart Health Network (Network).
Approach
A statewide, multistakeholder network composed of primary care practices (PCPs), health systems, health plans, QI organizations, patients, and academic institutions was led by the University of Tennessee Health Science Center (UTHSC), an academic health center, to improve cardiovascular health by supporting dissemination and implementation of patient-centered outcomes research (PCOR) evidence-based interventions in primary care. PCPs were required to select and implement at least one of three interventions (health coaching, tailored health-related text messaging, and pharmacist-physician collaboration).
Outcomes and Key Insights
Thirty statewide organizational partners joined the Network in year one, including 18 health systems representing 77 PCPs (30.0% of 257 potentially eligible PCPs identified) with approximately 300,000 patients. The organizational partners share EHRs for the ongoing tracking and reporting of key health metrics, including hypertension control and delivery of tobacco cessation counseling. Of the 77 PCPs, 62 continue participation after year two (80.5% retention). Main barriers to participation and reasons for discontinuing participation included reluctance to share data and changes in leadership at the health system level. These 62 PCPs selected the following interventions to implement: health coaching (41.9%), tailored health-related text messages (48.4%), and pharmacist-physician collaboration (40.3%).
Conclusion and What's Next
Academic health centers have broad reach and high acceptability by diverse stakeholders. Tennessee's experience illustrates how academic health centers can serve as platforms for building a statewide infrastructure for disseminating, implementing, and sustaining QI interventions at the practice level. Assessment of Network impact is ongoing.
{"title":"Building Statewide Quality Improvement Capacity to Improve Cardiovascular Care and Health Equity: Lessons from the Tennessee Heart Health Network","authors":"Cori C. Grant PhD, MBA (is Assistant Professor, Department of Preventive Medicine, and Tennessee Population Health Consortium, University of Tennessee Health Science Center, Memphis.) , Fawaz Mzayek MD, PhD (is Associate Professor, Division of Epidemiology, Biostatistics, and Environmental Health, School of Public Health, University of Memphis, and Tennessee Population Health Consortium.) , Hadii M. Mamudu PhD, MPA (is Professor, Department of Health Services Management and Policy, and Center for Cardiovascular Risk Research, College of Public Health, East Tennessee State University.), Satya Surbhi PhD (is Assistant Professor, Center for Health System Improvement, Department of Medicine, and Tennessee Population Health Consortium, University of Tennessee Health Science Center, Memphis.), Umar Kabir PhD, MPH (is Research Leader, Center for Health System Improvement, and Director of Operations, Tennessee Population Health Consortium, University of Tennessee Health Science Center, Memphis.), James E. Bailey MD, MPH (is Professor, Department of Preventive Medicine, and Director, Center for Health Systems Improvement, University of Tennessee Health Science Center, Memphis. Please address correspondence to Cori C. Grant)","doi":"10.1016/j.jcjq.2024.02.009","DOIUrl":"10.1016/j.jcjq.2024.02.009","url":null,"abstract":"<div><h3>Driving Forces</h3><p>Many states with high rates of cardiovascular disease (CVD) lack statewide quality improvement (QI) infrastructure (for example, resources, leadership, community) to address relevant health needs of the population. Academic health centers are well positioned to play a central role in addressing this deficiency. This article describes early experience and lessons learned in building statewide QI infrastructure through the Tennessee Heart Health Network (Network).</p></div><div><h3>Approach</h3><p>A statewide, multistakeholder network composed of primary care practices (PCPs), health systems, health plans, QI organizations, patients, and academic institutions was led by the University of Tennessee Health Science Center (UTHSC), an academic health center, to improve cardiovascular health by supporting dissemination and implementation of patient-centered outcomes research (PCOR) evidence-based interventions in primary care. PCPs were required to select and implement at least one of three interventions (health coaching, tailored health-related text messaging, and pharmacist-physician collaboration).</p></div><div><h3>Outcomes and Key Insights</h3><p>Thirty statewide organizational partners joined the Network in year one, including 18 health systems representing 77 PCPs (30.0% of 257 potentially eligible PCPs identified) with approximately 300,000 patients. The organizational partners share EHRs for the ongoing tracking and reporting of key health metrics, including hypertension control and delivery of tobacco cessation counseling. Of the 77 PCPs, 62 continue participation after year two (80.5% retention). Main barriers to participation and reasons for discontinuing participation included reluctance to share data and changes in leadership at the health system level. These 62 PCPs selected the following interventions to implement: health coaching (41.9%), tailored health-related text messages (48.4%), and pharmacist-physician collaboration (40.3%).</p></div><div><h3>Conclusion and What's Next</h3><p>Academic health centers have broad reach and high acceptability by diverse stakeholders. Tennessee's experience illustrates how academic health centers can serve as platforms for building a statewide infrastructure for disseminating, implementing, and sustaining QI interventions at the practice level. Assessment of Network impact is ongoing.</p></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"50 7","pages":"Pages 533-541"},"PeriodicalIF":2.3,"publicationDate":"2024-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140329819","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-07-01DOI: 10.1016/j.jcjq.2023.12.002
Samantha L. Bernstein PhD, RN (is Registered Nurse–Postpartum Unit, Massachusetts General Hospital, Boston, and Assistant Professor, School of Nursing, MGH Institute of Health Professions, Boston.), Maya Picciolo BSN, RN (is Labor and Delivery Registered Nurse, Massachusetts General Hospital.), Elisabeth Grills BSN, RN (is Postpartum Registered Nurse, Massachusetts General Hospital.), Kenneth Catchpole PhD (is Professor, Clinical Practice and Human Factors, College of Medicine, Medical University of South Carolina. Please address correspondence to Samantha L. Bernstein)
Background
Maternal morbidity and mortality is rising in the United States. Previous studies focus on patient attributes, and most of the national data are based on research performed at urban tertiary care centers. Although it is well understood that nurses affect patient outcomes, there is scant evidence to understand the nurse work system, and no studies have specifically studied rural nurses. The authors sought to understand the systems-level factors affecting rural obstetric nurses when their patients experience clinical deterioration.
Methods
The research team used a qualitative descriptive approach, including a modified critical incident technique, in interviews with bedside nurses (n = 7) and physicians (n = 4) to understand what happens when patients experience clinical deterioration. Physicians were included to better understand the systems in which nurses work. Clinicians were interviewed at three rural hospitals in New England, with a mean births per year of 190.
Findings
Six systems-level factors/themes were identified: (1) shortages of resources; (2) need for teamwork; (3) physicians’ multiple conflicting and simultaneous responsibilities, such as seeing patients in the office while women labor on the hospital floor; (4) need for all team members to be at the top of their game; (5) process issues during high-acuity patient transfer, including difficulty finding available beds at tertiary care centers; and (6) insufficient policies that take low-resource contexts into account, such as requiring two registered nurses to remove emergency medications from the medication cabinet.
Conclusion
Rural nurses need policies and protocols that are written with their hospital context in mind. Hospitals may need outside support for content expertise, but policies should be co-created with clinicians with rural practice experience.
{"title":"A Qualitative Study of Systems-Level Factors That Affect Rural Obstetric Nurses’ Work During Clinical Emergencies","authors":"Samantha L. Bernstein PhD, RN (is Registered Nurse–Postpartum Unit, Massachusetts General Hospital, Boston, and Assistant Professor, School of Nursing, MGH Institute of Health Professions, Boston.), Maya Picciolo BSN, RN (is Labor and Delivery Registered Nurse, Massachusetts General Hospital.), Elisabeth Grills BSN, RN (is Postpartum Registered Nurse, Massachusetts General Hospital.), Kenneth Catchpole PhD (is Professor, Clinical Practice and Human Factors, College of Medicine, Medical University of South Carolina. Please address correspondence to Samantha L. Bernstein)","doi":"10.1016/j.jcjq.2023.12.002","DOIUrl":"10.1016/j.jcjq.2023.12.002","url":null,"abstract":"<div><h3>Background</h3><p>Maternal morbidity and mortality is rising in the United States. Previous studies focus on patient attributes, and most of the national data are based on research performed at urban tertiary care centers. Although it is well understood that nurses affect patient outcomes, there is scant evidence to understand the nurse work system, and no studies have specifically studied rural nurses. The authors sought to understand the systems-level factors affecting rural obstetric nurses when their patients experience clinical deterioration.</p></div><div><h3>Methods</h3><p>The research team used a qualitative descriptive approach, including a modified critical incident technique, in interviews with bedside nurses (<em>n</em> = 7) and physicians (<em>n</em> = 4) to understand what happens when patients experience clinical deterioration. Physicians were included to better understand the systems in which nurses work. Clinicians were interviewed at three rural hospitals in New England, with a mean births per year of 190.</p></div><div><h3>Findings</h3><p>Six systems-level factors/themes were identified: (1) shortages of resources; (2) need for teamwork; (3) physicians’ multiple conflicting and simultaneous responsibilities, such as seeing patients in the office while women labor on the hospital floor; (4) need for all team members to be at the top of their game; (5) process issues during high-acuity patient transfer, including difficulty finding available beds at tertiary care centers; and (6) insufficient policies that take low-resource contexts into account, such as requiring two registered nurses to remove emergency medications from the medication cabinet.</p></div><div><h3>Conclusion</h3><p>Rural nurses need policies and protocols that are written with their hospital context in mind. Hospitals may need outside support for content expertise, but policies should be co-created with clinicians with rural practice experience.</p></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"50 7","pages":"Pages 507-515"},"PeriodicalIF":2.3,"publicationDate":"2024-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S1553725023002982/pdfft?md5=444411057d9b39cba80a78536ecc72fa&pid=1-s2.0-S1553725023002982-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139193611","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-07-01DOI: 10.1016/j.jcjq.2024.03.005
Karen Trang MD (is General Surgery Resident and Resident Research Fellow, Department of Surgery, University of California, San Francisco (UCSF).), Logan Pierce MD (is Assistant Clinical Professor, Department of Medicine, UCSF.), Elizabeth C. Wick MD (is Professor, and Vice Chair of Quality and Safety, Department of Surgery, UCSF. Please address correspondence to Karen Trang)
Background
Although access to a professional medical interpreter is federally mandated, surgeons report underutilization during informed consent. Improvement requires understanding the extent of the lapses. Adoption of electronic consent (eConsent) has been associated with improvements in documentation and identification of practice improvement opportunities. The authors evaluated the impact of the transition from paper to eConsent on language-concordant surgical consent delivery for patients with limited English proficiency (LEP).
Methods
The study period (February 8, 2023, to June 14, 2023) corresponds to the period immediately following the institutional adoption of eConsents. Inclusion criteria included age > 18 years, documented preferred language other than English, and self-signed eConsent form. The authors assessed documentation of language-concordant interpreter-mediated verbal consent discussion and delivery of the written surgical consent form in a language-concordant template. Performance was compared to a preimplementation baseline derived from monthly random audits of paper consents between January and December 2022.
Results
A total of 1,016 eConsent encounters for patients with LEP were included, with patients speaking 49 different languages, most commonly Spanish (46.5%), Chinese (22.1%), and Russian (6.8%). After the implementation of eConsent, overall documentation of language-concordant interpreter-mediated consents increased from 56.9% to 83.9% (p < 0.001), although there was variation between surgical services and between languages, suggesting that there is still likely room for improvement. Most patients (94.1%) whose preferred language had an associated translated written consent template (Spanish, Chinese, Russian, Arabic), received a language-concordant written consent.
Conclusion
The transition to eConsent was associated with improved documentation of language-concordant informed consent in surgery, both in terms of providing written materials in the patient's preferred language and in the documentation of interpreter use, and allowed for the identification of areas to target for practice improvement with interpreter use.
{"title":"The Impact of Using Electronic Consents on Documentation of Language-Concordant Surgical Consent for Patients with Limited English Proficiency","authors":"Karen Trang MD (is General Surgery Resident and Resident Research Fellow, Department of Surgery, University of California, San Francisco (UCSF).), Logan Pierce MD (is Assistant Clinical Professor, Department of Medicine, UCSF.), Elizabeth C. Wick MD (is Professor, and Vice Chair of Quality and Safety, Department of Surgery, UCSF. Please address correspondence to Karen Trang)","doi":"10.1016/j.jcjq.2024.03.005","DOIUrl":"10.1016/j.jcjq.2024.03.005","url":null,"abstract":"<div><h3>Background</h3><p>Although access to a professional medical interpreter is federally mandated, surgeons report underutilization during informed consent. Improvement requires understanding the extent of the lapses. Adoption of electronic consent (eConsent) has been associated with improvements in documentation and identification of practice improvement opportunities. The authors evaluated the impact of the transition from paper to eConsent on language-concordant surgical consent delivery for patients with limited English proficiency (LEP).</p></div><div><h3>Methods</h3><p>The study period (February 8, 2023, to June 14, 2023) corresponds to the period immediately following the institutional adoption of eConsents. Inclusion criteria included age > 18 years, documented preferred language other than English, and self-signed eConsent form. The authors assessed documentation of language-concordant interpreter-mediated verbal consent discussion and delivery of the written surgical consent form in a language-concordant template. Performance was compared to a preimplementation baseline derived from monthly random audits of paper consents between January and December 2022.</p></div><div><h3>Results</h3><p>A total of 1,016 eConsent encounters for patients with LEP were included, with patients speaking 49 different languages, most commonly Spanish (46.5%), Chinese (22.1%), and Russian (6.8%). After the implementation of eConsent, overall documentation of language-concordant interpreter-mediated consents increased from 56.9% to 83.9% (<em>p</em> < 0.001), although there was variation between surgical services and between languages, suggesting that there is still likely room for improvement. Most patients (94.1%) whose preferred language had an associated translated written consent template (Spanish, Chinese, Russian, Arabic), received a language-concordant written consent.</p></div><div><h3>Conclusion</h3><p>The transition to eConsent was associated with improved documentation of language-concordant informed consent in surgery, both in terms of providing written materials in the patient's preferred language and in the documentation of interpreter use, and allowed for the identification of areas to target for practice improvement with interpreter use.</p></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"50 7","pages":"Pages 528-532"},"PeriodicalIF":2.3,"publicationDate":"2024-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S1553725024000758/pdfft?md5=e14af92ed2c52547db1aae81073fd1ba&pid=1-s2.0-S1553725024000758-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140268335","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-07-01DOI: 10.1016/j.jcjq.2024.03.010
Zoe Grabinski MD (is Assistant Professor, Ronald O. Perelman Department of Emergency Medicine and Department of Pediatrics, New York University Grossman School of Medicine.), Kar-mun Woo MD (is Clinical Associate Professor, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Olumide Akindutire MD (is Clinical Associate Professor, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Cassidy Dahn MD (is Clinical Associate Professor, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Lauren Nash PA (is Senior Physician Assistant, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Inna Leybell MD (is Clinical Assistant Professor, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Yelan Wang MS (is Senior Data Analyst, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Danielle Bayer MS (is Senior Data Analyst, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Jordan Swartz MD (is Clinical Associate Professor, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Catherine Jamin MD (is Clinical Associate Professor, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Silas W. Smith MD (is Clinical Associate Professor, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine and Institute for Innovations in Medical Education, New York University Grossman School of Medicine. Please address correspondence to Zoe Grabinski)
Background
Review of emergency department (ED) revisits with admission allows the identification of improvement opportunities. Applying a health equity lens to revisits may highlight potential disparities in care transitions. Universal definitions or practicable frameworks for these assessments are lacking. The authors aimed to develop a structured methodology for this quality assurance (QA) process, with a layered equity analysis.
Methods
The authors developed a classification instrument to identify potentially preventable 72-hour returns with admission (PPRA-72), accounting for directed, unrelated, unanticipated, or disease progression returns. A second review team assessed the instrument reliability. A self-reported race/ethnicity (R/E) and language algorithm was developed to minimize uncategorizable data. Disposition distribution, return rates, and PPRA-72 classifications were analyzed for disparities using Pearson chi-square and Fisher's exact tests.
Results
The PPRA-72 rate was 4.8% for 2022 ED return visits requiring admission. Review teams achieved 93% agreement (κ = 0.51) for the binary determination of PPRA-72 vs. nonpreventable returns. There were significant differences between R/E and language in ED dispositions (p < 0.001), with more frequent admissions for the R/E White at the index visit and Other at the 72-hour return visit. Rates of return visits within 72 hours differed significantly by R/E (p < 0.001) but not by language (p = 0.156), with the R/E Black most frequent to have a 72-hour return. There were no differences between R/E (p = 0.446) or language (p = 0.248) in PPRA-72 rates. The initiative led to system improvements through informatics optimizations, triage protocols, provider feedback, and education.
Conclusion
The authors developed a review methodology for identifying improvement opportunities across ED 72-hour returns. This QA process enabled the identification of areas of disparity, with the continuous aim to develop next steps in ensuring health equity in care transitions.
{"title":"Evaluation of a Structured Review Process for Emergency Department Return Visits with Admission","authors":"Zoe Grabinski MD (is Assistant Professor, Ronald O. Perelman Department of Emergency Medicine and Department of Pediatrics, New York University Grossman School of Medicine.), Kar-mun Woo MD (is Clinical Associate Professor, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Olumide Akindutire MD (is Clinical Associate Professor, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Cassidy Dahn MD (is Clinical Associate Professor, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Lauren Nash PA (is Senior Physician Assistant, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Inna Leybell MD (is Clinical Assistant Professor, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Yelan Wang MS (is Senior Data Analyst, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Danielle Bayer MS (is Senior Data Analyst, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Jordan Swartz MD (is Clinical Associate Professor, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Catherine Jamin MD (is Clinical Associate Professor, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine.), Silas W. Smith MD (is Clinical Associate Professor, Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine and Institute for Innovations in Medical Education, New York University Grossman School of Medicine. Please address correspondence to Zoe Grabinski)","doi":"10.1016/j.jcjq.2024.03.010","DOIUrl":"10.1016/j.jcjq.2024.03.010","url":null,"abstract":"<div><h3>Background</h3><p>Review of emergency department (ED) revisits with admission allows the identification of improvement opportunities. Applying a health equity lens to revisits may highlight potential disparities in care transitions. Universal definitions or practicable frameworks for these assessments are lacking. The authors aimed to develop a structured methodology for this quality assurance (QA) process, with a layered equity analysis.</p></div><div><h3>Methods</h3><p>The authors developed a classification instrument to identify potentially preventable 72-hour returns with admission (PPRA-72), accounting for directed, unrelated, unanticipated, or disease progression returns. A second review team assessed the instrument reliability. A self-reported race/ethnicity (R/E) and language algorithm was developed to minimize uncategorizable data. Disposition distribution, return rates, and PPRA-72 classifications were analyzed for disparities using Pearson chi-square and Fisher's exact tests.</p></div><div><h3>Results</h3><p>The PPRA-72 rate was 4.8% for 2022 ED return visits requiring admission. Review teams achieved 93% agreement (κ = 0.51) for the binary determination of PPRA-72 vs. nonpreventable returns. There were significant differences between R/E and language in ED dispositions (<em>p</em> < 0.001), with more frequent admissions for the R/E White at the index visit and Other at the 72-hour return visit. Rates of return visits within 72 hours differed significantly by R/E (<em>p</em> < 0.001) but not by language (<em>p</em> = 0.156), with the R/E Black most frequent to have a 72-hour return. There were no differences between R/E (<em>p</em> = 0.446) or language (<em>p</em> = 0.248) in PPRA-72 rates. The initiative led to system improvements through informatics optimizations, triage protocols, provider feedback, and education.</p></div><div><h3>Conclusion</h3><p>The authors developed a review methodology for identifying improvement opportunities across ED 72-hour returns. This QA process enabled the identification of areas of disparity, with the continuous aim to develop next steps in ensuring health equity in care transitions.</p></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"50 7","pages":"Pages 516-527"},"PeriodicalIF":2.3,"publicationDate":"2024-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140276367","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}