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Implementing an Oral Health Educator Contributes to Reduced MBI-CLABSI Rates for Pediatric Hematopoietic Stem Cell Transplant Patients 实施口腔健康教育有助于降低小儿造血干细胞移植患者的 MBI-CLABSI 感染率
IF 2.3 Q2 HEALTH CARE SCIENCES & SERVICES Pub Date : 2024-07-23 DOI: 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.
背景粘膜屏障损伤中心静脉相关性血流感染(MBI-CLABSIs)仍然是儿科癌症患者面临的一项挑战。这些感染通常是由口腔或胃肠道(GI)细菌通过受损的肠道或口腔黏膜转运引起的。作者的肿瘤牙科合作质量改进项目包括两个 "计划-实施-研究-行动"(PDSA)周期,旨在提高儿科造血干细胞移植(HSCT)病房的MBI-CLABSI感染率和口腔护理依从性。PDSA 循环 1 将牙科住院医师纳入现有的每三周一次的查房中,以筛查牙齿、牙龈和粘膜疾病,并为患者和家属提供有针对性的教育。PDSA 周期 2 实施了新颖的口腔健康教育者(OHE)角色,由一名训练有素的牙科卫生学家每周查房四天。在 2020 年 12 月至 2021 年 5 月(基线)、2021 年 6 月至 2022 年 3 月(PDSA 周期 1)和 2022 年 4 月至 2022 年 12 月(PDSA 周期 2)期间,对每月的 MBI-CLABSI 感染率和口腔护理依从性进行了跟踪调查。结果发现 MBI-CLABSI 感染率(每 1,000 个中心静脉输液天数中的感染率)降低了 58.8%(基线:5.1;PDSA 周期 2:2.1),口腔护理依从性降低了 20.8%(每 1,000 个中心静脉输液天数中的感染率)。1),口腔护理依从性提高了 41.7%(基线:60.9%;PDSA 循环 2:86.3%),100% 的患者认为接受口腔护理演示是有益的,估计每年可节约成本 54.1 万美元。该项目表明,在儿科造血干细胞移植住院病房实施口腔护理示范项目对患者和家属都很有价值,也是减少口腔病原体导致的 MBI-CLABSIs 的一种经济有效的方法。
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Zobeck MD, MPH (is Pediatric Hematologist/Oncologist, Texas Children's Hospital, and Assistant Professor, Department of Pediatrics, Baylor College of Medicine.),&nbsp;Jenell Robins BSDH, RDH (is Oral Health Educator/Registered Dental Hygienist, Texas Children's Hospital.),&nbsp;Sharon Staton MS-SSEM, BSN, RN (is Clinical Specialist, Texas Children's Hospital.),&nbsp;Janet DeJean MSN, RN (is Clinical Specialist, Texas Children's Hospital.),&nbsp;Esther Yang DDS (is Chief of Service, Department of Dentistry, Texas Children's Hospital, and Assistant Professor, Department of Pediatrics, Baylor College of Medicine.),&nbsp;Claudia X. Harriehausen DDS, MSD (is Pediatric Dentist, Texas Children's Hospital, and Assistant Professor, Department of Pediatrics, Baylor College of Medicine.),&nbsp;Judith R. Campbell MD (is Attending Physician, Texas Children's Hospital, and Professor, Department of Pediatrics, Baylor College of Medicine.),&nbsp;Andrea L. Davis MPH, CIC (is Infection Control Preventionist, Texas Children's Hospital.),&nbsp;Anil George MD (is Pediatric Hematologist/Oncologist, Texas Children's Hospital, and Assistant Professor, Department of Pediatrics, Baylor College of Medicine.),&nbsp;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.),&nbsp;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.),&nbsp;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}
引用次数: 0
A Mixed Methods Study Exploring Patient Safety Culture at Four VHA Hospitals 探索 4 家退伍军人事务部医院患者安全文化的混合方法研究
IF 2.3 Q2 HEALTH CARE SCIENCES & SERVICES Pub Date : 2024-07-23 DOI: 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.
背景患者安全文化(Patient Safety Culture,PSC)营造了一种信任的环境,鼓励人们分享信息以促进心理安全。为了衡量患者安全文化,退伍军人健康管理局(VHA)制定了一项患者安全文化调查,其中包括 20 个项目,调查对象为退伍军人健康管理局的所有员工。该调查包括四个量表:(1)风险识别和公正文化;(2)错误透明度和缓解;(3)主管沟通和信任;以及(4)团队凝聚力和参与度。我们的目标是将 PSC 调查数据与有目的选择的四家 VHA 医院有关高可靠性组织 (HRO) 实施的定性数据进行比较,以评估高可靠性组织 (HRO) 的表现和趋同情况。方法在 2019 年至 2020 年期间,我们从 18 家 VHA HRO 实施医院中的 4 家医院的关键信息提供者处收集了侧重于了解 HRO 实施工作的定性数据。为了探索这 4 家医院的 PSC 量表的程度和表现,我们使用联合显示屏将定性数据与每家医院的 PSC 调查数据结合起来。在 20 个 PSC 调查项目中,有 12 个项目(60.0%)在 4 家医院之间存在显著差异。例如,我们在以下调查项目中发现了医院间的差异:"我们会根据事件报告对已实施的变更进行反馈 "和 "我们会花时间识别和评估患者安全风险"。定性数据支持医院间 80.0% (16/20)的 PSC 单个调查项目的表现形式。结论作者发现,定性数据表现形式与 VHA PSC 量表非常吻合,但数据源之间的关系并不总是一致的。有必要开展进一步研究来阐明这些关系。
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引用次数: 0
Effective Use of Interpreter Services for Diverse Patients in a Safety-Net Hospital: Provider Perceptions of Barriers and Solutions 在一家安全网医院中为不同患者有效使用口译服务:医疗服务提供者眼中的障碍与解决方案
IF 2.3 Q2 HEALTH CARE SCIENCES & SERVICES Pub Date : 2024-07-18 DOI: 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.
导言:文化和语言多样性(CALD)患者应该得到专业的口译服务,但并不是经常得到这种服务。作者研究了一家安全网医院的医疗服务提供者对口译服务(IS)障碍和解决方案的看法,以便为质量改进(QI)提供信息。方法:向 750 名临床医生发放了一份包含 13 个项目的调查问卷,这些医生代表了 10 个服务部门的不同专业角色,其中包括社会工作者。封闭式和开放式问题涉及获取 IS、IS 价值以及对 CALD 患者的护理。受访者列出了常规使用 IS 的八大障碍,并提出了改进意见。描述性统计对调查结果进行了汇总,并按专业角色和护理团队进行了分类。对定量和定性结果进行了三角测量,以确定调查领域和编码后的自由文本回复主题之间是否一致。结果共分析了 221 份回复(回复率为 29.5%)。成本是所有角色中排名最低的障碍。主要障碍是效率压力和繁琐的访问。自由文本回复与这些结果一致。87.5%的社工认为 CALD 患者有较高的并发症风险,但 56.8% 的其他角色认为 CALD 患者有较高的并发症风险。不同团队对增加 IS 的建议各不相同:简化访问流程(46.2% 的急诊患者和 37.8% 的住院患者回答)、扩大当面口译(55.6% 的住院患者和 45.8% 的围手术期患者回答)以及改善设备(44.4% 的门诊患者、35.9% 的急诊患者和 25.0% 的围手术期患者回答)。获得口译服务非常繁琐,而且效率压力大,导致人们走捷径,无法提供充分的语言服务。三项最初的 QI 工作取得了成果:增加了视频口译设备,成立了新的语言使用委员会,并设立了新的语言使用领导职位。
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引用次数: 0
Toward Standardization and High Reliability: Improved Sepsis Screening in Emergency Department Triage Across an Academic Health System 实现标准化和高可靠性:改进学术医疗系统急诊科分诊中的败血症筛查
IF 2.3 Q2 HEALTH CARE SCIENCES & SERVICES Pub Date : 2024-07-16 DOI: 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.
背景败血症是一种危及生命的急症,急诊科(ED)的早期识别和治疗对改善预后至关重要。方法作者实施了一个跨学科质量改进(QI)项目,以规范一个学术医疗系统的败血症筛查工作流程,该系统由一家大型三级医疗城市医院、一家独立的急诊科和两家小型农村附属医院(RA-1 和 RA-2)组成。研究小组采用了美国医疗保健改进研究所的改进模式框架,包括 "计划-实施-研究-行动"(PDSA)迭代循环。主要结果是各医疗机构的败血症筛查率。次要结果包括脓毒症死亡率和我们主要医疗中心的医疗保险和医疗补助服务中心(CMS)脓毒症捆绑治疗(SEP-1)达标率。主要结果是通过电子仪表盘提取有电子健康记录(EHR)记录的脓毒症筛查的急诊室就诊人次与急诊室就诊总人次的比率来评估的。SEP-1 套件的合规性以百分比进行评估,死亡率则以平均观察值与预期值 (O:E) 进行计算。结果该 QI 项目于 2022 年 12 月至 2023 年 12 月在四家急诊室开展,这四家急诊室每年的就诊量约为 138,000 人次。在急诊室分流时建立了标准化工作流程,其中包括一个基于电子病历的问题以及相关护士和医生定义的回复。干预前(2022 年 10 月至 2022 年 11 月),主医院、独立急诊室、RA-1 和 RA-2 的败血症分诊率分别为 1.7%(163/9,560)、25.3%(523/2,068)、11.0%(360/3,272)和 36.5%(915/2,506)。经过四个 PDSA 循环后,分流率分别上升到 91.9%(4,927/5,360)、97.5%(1,032/1,059)、99.0%(1,845/1,863)和 97.4%(1,328/1,363)(p <0.005)。大型学术医疗中心的败血症分流率上升最慢,该中心需要逐步推进 PDSA 循环,以达到 90% 的败血症筛查率。干预前 9 个月的平均 O:E 死亡率为 0.99,干预后 17 个月的平均 O:E 死亡率为 0.83(p = 0.07)。在干预前的 15 个月和干预后的 17 个月中,CMS 败血症捆绑包合规率分别为 28.4% 和 40.5%(p = 0.14)。结论一个跨学科 QI 项目利用 EHR 优化与人类工作流程的整合,通过四个 PDSA 循环,实现了 ED 败血症筛查的标准化和改进。这降低了脓毒症死亡率,提高了脓毒症捆绑治疗的依从性,但结果并无统计学意义。
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引用次数: 0
A Half Century of Quality and Safety 半个世纪的质量与安全
IF 2.3 Q2 HEALTH CARE SCIENCES & SERVICES Pub Date : 2024-07-03 DOI: 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.)
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引用次数: 0
Building Statewide Quality Improvement Capacity to Improve Cardiovascular Care and Health Equity: Lessons from the Tennessee Heart Health Network 建设全州质量改进能力,改善心血管护理和健康公平:田纳西心脏健康网络的经验。
IF 2.3 Q2 HEALTH CARE SCIENCES & SERVICES Pub Date : 2024-07-01 DOI: 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.

推动力:许多心血管疾病(CVD)高发州缺乏全州范围的质量改进(QI)基础设施(如资源、领导力、社区),无法满足人口的相关健康需求。学术健康中心完全有能力在解决这一不足方面发挥核心作用。本文介绍了通过田纳西州心脏健康网络(网络)在全州范围内建立 QI 基础设施的早期经验和教训:方法:田纳西大学健康科学中心(UTHSC)作为一个学术健康中心,领导了一个全州范围的多方利益相关者网络,该网络由初级保健实践(PCP)、医疗系统、医疗计划、QI 组织、患者和学术机构组成,旨在通过支持在初级保健中传播和实施以患者为中心的结果研究(PCOR)循证干预措施来改善心血管健康。要求初级保健医生从三种干预措施(健康指导、量身定制的健康相关短信以及药剂师与医生合作)中选择并实施至少一种:全州范围内有 30 个组织合作伙伴在第一年加入了该网络,其中包括 18 个医疗系统,代表 77 名初级保健医生(占已确定的 257 名潜在合格初级保健医生的 30.0%),约有 30 万名患者。这些组织合作伙伴共享电子病历,以持续跟踪和报告关键健康指标,包括高血压控制和戒烟咨询。在 77 家初级保健医生中,62 家在第二年后继续参与(80.5% 的保留率)。参与的主要障碍和停止参与的原因包括不愿意共享数据和医疗系统领导层的变动。这 62 名初级保健医生选择实施以下干预措施:健康指导(41.9%)、定制健康相关短信(48.4%)和药剂师与医生合作(40.3%):学术健康中心具有广泛的影响力,并能为不同的利益相关者所接受。田纳西州的经验说明,学术健康中心可以作为一个平台,为在实践层面传播、实施和维持 QI 干预措施建立一个全州范围的基础设施。对网络影响的评估正在进行中。
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引用次数: 0
A Qualitative Study of Systems-Level Factors That Affect Rural Obstetric Nurses’ Work During Clinical Emergencies 影响农村产科护士临床急救工作的系统因素定性研究
IF 2.3 Q2 HEALTH CARE SCIENCES & SERVICES Pub Date : 2024-07-01 DOI: 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.

背景美国的孕产妇发病率和死亡率呈上升趋势。以往的研究主要集中在患者的属性上,而大多数国家的数据都是基于在城市三级护理中心进行的研究。虽然人们都知道护士会影响患者的治疗效果,但了解护士工作系统的证据却很少,也没有专门研究农村护士的研究。作者试图了解农村产科护士在病人临床病情恶化时受系统层面因素影响的情况。研究小组采用定性描述法,包括修改后的关键事件技术,对床边护士(7 人)和医生(4 人)进行访谈,以了解病人临床病情恶化时发生的情况。采访医生是为了更好地了解护士工作的系统。临床医生在新英格兰地区的三家乡村医院接受了访谈,这些医院的年平均分娩量为 190 例。研究结果确定了六个系统层面的因素/主题:(1) 资源短缺;(2) 团队合作的需要;(3) 医生同时承担多种相互冲突的责任,如在办公室为病人看病,而产妇却在医院分娩;(4) 团队所有成员都需要处于最佳状态;(5) 高危病人转院过程中的流程问题,包括在三级护理中心难以找到可用床位;(6) 未充分考虑低资源环境的政策,如要求两名注册护士从药箱中取出急救药物。结论农村护士需要根据医院的实际情况制定政策和协议。医院可能需要外部专业内容支持,但政策应与具有农村实践经验的临床医生共同制定。
{"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.),&nbsp;Maya Picciolo BSN, RN (is Labor and Delivery Registered Nurse, Massachusetts General Hospital.),&nbsp;Elisabeth Grills BSN, RN (is Postpartum Registered Nurse, Massachusetts General Hospital.),&nbsp;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}
引用次数: 0
The Impact of Using Electronic Consents on Documentation of Language-Concordant Surgical Consent for Patients with Limited English Proficiency 使用电子同意书对英语水平有限的患者签署语言一致的手术同意书的影响
IF 2.3 Q2 HEALTH CARE SCIENCES & SERVICES Pub Date : 2024-07-01 DOI: 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.

背景虽然获得专业医疗口译服务是联邦政府的规定,但外科医生报告称在知情同意过程中使用率不足。要改善这种情况,就必须了解失误的程度。电子同意书(eConsent)的采用与文件记录的改进和实践改进机会的识别有关。作者评估了从纸质同意书到电子同意书的过渡对英语水平有限(LEP)的患者提供语言一致的手术同意书的影响。方法研究期间(2023 年 2 月 8 日至 2023 年 6 月 14 日)与机构采用电子同意书之后的时间段相对应。纳入标准包括年龄在 18 周岁以上,有文件证明其首选语言为英语以外的语言,以及自行签署的电子同意书。作者评估了语言一致的口译员中介口头同意讨论记录,以及以语言一致模板提供的书面手术同意书。结果共纳入了 1,016 次针对 LEP 患者的电子同意书会诊,患者使用 49 种不同的语言,其中最常见的是西班牙语(46.5%)、中文(22.1%)和俄语(6.8%)。实施电子同意书后,语言一致的口译员中介同意书的总体记录率从 56.9% 提高到 83.9%(p <0.001),但不同手术服务和不同语言之间存在差异,表明仍有改进的余地。大多数患者(94.1%)的首选语言都有相关的书面同意书翻译模板(西班牙语、中文、俄语、阿拉伯语),他们都收到了语言一致的书面同意书。结论向电子同意书的过渡与手术中语言一致的知情同意书记录的改善有关,无论是在提供患者首选语言的书面材料方面,还是在口译员使用的记录方面,都是如此,而且还可以确定口译员使用方面需要改进的地方。
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引用次数: 0
The Joint Commission Journal on Quality and Patient Safety 50th Anniversary Article Collections: Maternal and Perinatal Care 联合委员会《质量与患者安全杂志》50周年文章集:孕产妇和围产期护理
IF 2.3 Q2 HEALTH CARE SCIENCES & SERVICES Pub Date : 2024-07-01 DOI: 10.1016/j.jcjq.2024.05.013
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引用次数: 0
Evaluation of a Structured Review Process for Emergency Department Return Visits with Admission 评估急诊科入院回访的结构化审查流程
IF 2.3 Q2 HEALTH CARE SCIENCES & SERVICES Pub Date : 2024-07-01 DOI: 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.

背景回顾急诊科(ED)入院后的再次就诊情况可以发现改进的机会。将健康公平视角应用于复诊,可以突出护理过渡中的潜在差异。目前还缺乏对这些评估的通用定义或切实可行的框架。作者旨在为这一质量保证(QA)流程开发一种结构化方法,并进行分层公平分析。方法作者开发了一种分类工具,用于识别潜在可预防的入院 72 小时复诊(PPRA-72),包括定向、无关、非预期或疾病进展的复诊。第二个评审小组对该工具的可靠性进行了评估。为了尽量减少无法归类的数据,还开发了一种自我报告种族/民族(R/E)和语言算法。使用皮尔逊卡方检验(Pearson chi-square)和费雪精确检验(Fisher's exact tests)对处置分布、回访率和 PPRA-72 分类进行了差异分析。审查小组在二元判定 PPRA-72 与非可预防性回访方面的一致性达到 93% (κ = 0.51)。在急诊室处置方面,R/E 和语言之间存在明显差异(p < 0.001),R/E 白人在指标就诊时入院的频率更高,而其他白人在 72 小时回访时入院的频率更高。不同种族/族裔的 72 小时内复诊率存在显著差异(p < 0.001),但不同语言的 72 小时内复诊率没有显著差异(p = 0.156),其中黑人 72 小时内复诊率最高。在 PPRA-72 比率方面,R/E(p = 0.446)和语言(p = 0.248)之间没有差异。该倡议通过信息学优化、分诊协议、医疗服务提供者反馈和教育来改进系统。这一质量保证流程能够识别出存在差异的领域,从而不断制定下一步措施,确保护理过渡中的健康公平。
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引用次数: 0
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