Quality Management in Health Care最新文献

Background and objectives: Our goal was to reduce the days of mechanical ventilation by 25% from 173 to 130 h without adversely impacting the number of self-extubations.

Methods: Data for the "Define" phase of the DMAIC approach were obtained through meetings with stakeholders to identify potential gaps in care. The study included patients with acute respiratory distress syndrome (ARDS) mechanically ventilated in the medical ICU. We identified nursing knowledge of the Richmond Agitation-Sedation Scale (RASS) scoring and identification of appropriate times for ventilator titration as key factors for intervention. We implemented educational interventions including structured in-person and self-study materials, embedded educational posters, and follow-up assessments to assess learning outcomes. Post-intervention patient data were assessed after the interventions.

Results: Mechanical ventilation duration decreased from 173 to 126 h, resulting in a 27% nominal reduction and meeting our pre-specified target. There was no increase in the balancing measure of self-extubations.

Conclusion: Targeted interventions focusing on reducing excessive sedation in mechanically ventilated patients with ARDS may reduce duration of mechanical ventilation.

Background and objectives: Iron deficiency anemia (IDA) is common and often responds to oral iron replacement therapy. Intravenous (IV) iron is indicated in those unresponsive to or unable to take oral iron, but at a high cost. Institutions may implement formulary restrictions to minimize cost from inappropriate use. The objective of this study was to assess IV iron prescribing appropriateness measured as adherence to provincial inpatient order set criteria.

Methods: This retrospective chart review included adult inpatients prescribed IV iron 1 month pre- or post-order set implementation. Patients receiving hemodialysis, in their first trimester of pregnancy, admitted for stays longer than 365 days, and sites with less than 10 patients were excluded. IV iron order set eligibility criteria includes a hemoglobin less than 130 g/L, evidence of iron deficiency or blood loss, and justification for use of IV rather than oral iron. Alignment with the eligibility criteria was compared (1) pre- and post-implementation of the order set and (2) with use of an order set compared to handwritten orders. Iron administration costs and adverse reactions were captured as secondary outcomes. Statistical analysis included descriptive analysis and comparisons, using the 2-proportion z-test, with a significance level of 0.05, completed via Microsoft Excel and SPSS Statistics.

Results: Overall, 607 patients were included, 408 in the pre-implementation group and 199 post-implementation; most admitted for childbirth (26% and 24%), with the majority prescribed iron sucrose (99% and 66%). Two-thirds (64%) of patients met order set criteria (62% pre- and 67% post-order set implementation; P = .246). Use of an order set increased adherence compared to handwritten orders (71% vs 58%, P = .001). Reasons for non-adherence (n = 221) included iron studies unavailable (53%) and unclear indication for IV rather than oral iron (44%), costing $60,639.20 (35% of overall costs). Thirteen patients (2%) experienced an adverse reaction (all mild-moderate).

Conclusions: Implementation of an IV iron order set did not statistically increase adherence to the eligibility criteria during the study period. Those not meeting criteria may qualify for oral iron or lack an IDA diagnosis, increasing adverse event risk and health care costs. Mandatory order set use, supplemented with targeted education and health system supports (eg, computerized prescriber order entry), may increase alignment with criteria, improving resource stewardship and patient outcomes.

Background and objectives: Prolonged hospitalization (PH) increases the burden on patients and health care finances. In Japan, health policy initiatives have aimed to reduce the length of hospital stays (LOS). Previous studies have suggested that LOS is influenced by patient characteristics and the quality of hospital care. This retrospective observational study aimed to elucidate differences across hospitals in the extent to which prolonged hospitalization is controlled, through the calculation of a risk-adjusted indicator.

Methods: This study included inpatients 15 years of age and older diagnosed with pneumonia from 2014 to 2022. Hospitalization exceeding the average duration was defined as PH. We developed an RPH ratio indicator using Japanese administrative claim data in 2014-2022 and each period (2014-2016, 2017-2019, 2020-2022). The RPH ratio was calculated by the actual number of PH patients and the expected number of PH patients. The expected number of PH patients was determined using logistic regression analysis with risk-adjusted variables.

Results: A total of 36,417 patients with pneumonia from 39 hospitals were included. The mean LOS was 19.2 days. The PH rate was 41.7%. The mean (± standard deviation) RPH ratio was 100.5 ± 21.4, ranging from 47.9 to 153.3, indicating a 3.2-fold difference between the minimum and maximum ratios. We found a significant positive relationship between changes in the ratio for each consecutive period.

Conclusion: This study revealed significant variations among hospitals in the quality of LOS management and identified a notable trend in RPH ratios. Hospitals with high RPH ratios were likely to yield similar results in subsequent periods, emphasizing the importance of supporting hospitals.

Background and objectives: Retrospective studies examining errors within a surgical scheduling setting do not fully represent the effects of human error involved in transcribing critical patient health information (PHI). These errors can negatively impact patient care and reduce workplace efficiency due to insurance claim denials and potential sentinel events. Previous reports underscore the burden physicians face with prior authorizations which may lead to serious adverse events or the abandonment of treatment due to these delays. This study simulates the process of PHI transfer during surgical scheduling to examine the error rate of experienced schedulers when manually transferring PHI from surgical forms into electronic health records (EHR).

Methods: Participants (n = 50) manually input PHI from four surgical scheduling forms into a simulated EHR form. Eight critical data points were identified and defined as data that delay claim approvals and payments. Subjects were randomly assigned to either a control (18 minutes) or experimental (10 minutes) group. Transcription errors were flagged to measure the percentage of incorrectly inputted data fields. Two-tailed t-tests were used to determine statistical significance ( P < .05).

Results: 100% of subjects in both cohorts had at least one or more errors in every form. The 10-minute cohort had a higher average "critical errors" rate than the 18-minute cohort ( P = .03). Of the 200 forms completed, 171 forms contained 1 or more "critical errors," resulting in a potential 85.5% delay or denial in authorization or payments. The highest incidence of critical errors across all fields occurred with ICD-10 codes, CPT codes, authorization number, procedure, and insurance ID number. As critical errors fields of authorization number and insurance ID often lead to automatic denials, not only are they more susceptible to transcription error due to alphanumeric values but more indicative of delays in treatment.

Conclusions: These findings reveal a clear "pain point" in the routine scheduling process that leads to authorization and payment denials. With various touch points of manual data transfer in surgical scheduling, data degradation due to human error may compound at each step. Health care institutions should consider adopting digital solutions and investing in training programs to optimize clinical practice efficiency and reduce the possibility of inaccurate manual PHI transfer. Future case studies on denied payments will help further elucidate the economic impact on practices, as well as inform strategic decisions by those who directly handle health care management.

Background and objectives: Nurses' documentation of communication, including notification of critical laboratory results (CLR), is important to ensure safe, high-quality care. Evidence supports peer audit with feedback as a quality improvement (QI) intervention to improve documentation. Nursing compliance with CLR documentation requirements was below goal for several years in an intensive care unit. To address this problem, a peer audit and feedback intervention was implemented and evaluated.

Methods: Compliance with CLR documentation requirements was evaluated pre- and postintervention, for a total of 12 months. The evaluation also included data from the peer audits and a survey to assess nurses' perceptions. The 5-month intervention was a timely peer audit and feedback of CLR events.

Results: CLR documentation compliance improved from 6.4% to 9.6% (50% improvement), which was clinically meaningful but not statistically significant. Nurses had overall positive perceptions of the peer audit and feedback as a QI tool, perceiving it as nonpunitive and helpful for improving practice.

Conclusion: Results support continued examination of peer audit and feedback to improve nursing documentation. Future projects should address the limited time for nurses to engage in QI projects.

Background and objective: Central Line-Associated Bloodstream Infection (CLABSI) remains a leading cause of death among critically ill patients. Implementing preventive measures and adhering to best practices are crucial actions to proactively prevent its occurrence. This project aimed to reduce the overall CLABSI rate in adult medical/surgical Intensive Care Units (ICUs) of hospitals under the Ministry of Defense Health Services (MODHS) in Saudi Arabia. The baseline CLABSI rate was 2 cases per 1000 catheter days during the first quarter of 2020, while the target was to achieve a rate equal to or lower than 0.8 as reported by the American National Healthcare Safety Network (NHSN) in 2013.

Methods: The initiative was carried out across 15 hospitals under the purview of MODHS. Data on CLABSI incidents were collected from the ICUs dedicated to adult medical and surgical care. The project utilized the Institute for Healthcare Improvement collaborative model to achieve breakthrough improvement in a short-term learning system that facilitated the collaboration of participating hospitals in the pursuit of enhancements in CLABSI rates. The project involved 3 cycles, each consisting of a learning session followed by an action period.

Results: The data revealed a continuous improvement in the overall CLABSI rate within MODHS hospitals, progressing positively for 4 consecutive quarters and attaining a value of 0.3 during the third quarter of 2021. This signifies an impressive 85% reduction from the initial baseline of 2, and the rate remains below the project benchmark of 0.8.

Conclusion: The project successfully employed collaborative learning cycles, fostering effective knowledge-sharing among teams and promoting active engagement. This approach proved instrumental in achieving learning objectives, identifying gaps, and determining appropriate courses of action. Key factors for the project's success included standardizing the change package, conducting regular training sessions, encouraging open discussions, and sharing experiences.