Quality Management in Health Care最新文献

Background and objective: Cesarean section (C-section) is a widely used surgical procedure in obstetrics and is currently the only method of safe delivery for pregnant women with serious complications, comorbidities, or difficult labor. This study aims to evaluate the impact of clinical educational interventions on medication use during lactation and its effects on postpartum women following a C-section.

Methods: Health care professionals received training on evidence-based medication use during lactation. This historical control study enrolled 136 women in the control group (2020) and 154 in the intervention group (2021), with a focus on cesarean deliveries, rooming-in, and the willingness to breastfeed. Women received routine breastfeeding guidance with added decision-making support on breastfeeding and medication use. Evaluation used tools like the Iowa Infant Feeding Attitude Scale (IIFAS) and the Latching, Sucking, Nipple Type, Position, Holding (LATCH) score. Breastfeeding attitudes, colostrum onset time, and exclusive breastfeeding rates were compared using chi-square test, t test, and Mann-Whitney U test.

Results: After forming a cross-disciplinary breastfeeding decision-making team and conducting training on medication use during lactation for medical staff, there was a significant change in the medical staff's attitudes toward medication use during lactation before and after the training (P < .05). The proportion of women in the intervention group who held a positive attitude toward breastfeeding was higher than that in the control group, and the difference was statistically significant (P < .05). The proportion of women in the intervention group whose colostrum started between 24 and 36 hours and 36 and 48 hours was higher than that in the control group, while the proportion whose colostrum started between 48 and 72 hours and >72 hours was lower than that in the control group. The exclusive breastfeeding rate at different periods before discharge was statistically significant (P < .05). The exclusive breastfeeding rate at 7 days, 42 days, 3 months, and 6 months in the intervention group was higher than that in the control group, and the difference was statistically significant (P < .05).

Conclusions: The intervention improved exclusive breastfeeding rates and health care professionals' attitudes toward lactation and medication use. Educating postpartum women on breastfeeding decisions and medication use after cesarean delivery positively influenced maternal attitudes, potentially promoting better breastfeeding practices and higher exclusive breastfeeding rates for infants aged 0 to 6 months.

Background and objectives: The Hospital at Home (HaH) model of care is used worldwide to introduce a patient centered style of care outside of the traditional hospital setting. HaH has been shown to improve the health care experience of patients, family caregivers (FCGs) and health care providers (HCPs). Island Health's HaH surpassed the milestone of enrolling 2600 patients in September 2024. We previously published the preliminary results of patient and FCG experiences with HaH and the processes and timelines in the development of experience surveys.15 The AT-HOME research team has continued to work towards improving the HaH model of care by collaborating with participants and implementing feedback.

Methods: In this paper, we discuss the results of implementing a prospective survey over 18 months (October 2021-April 2023) using a convenience sample method to assess patient and FCG experiences with the Island Health HaH program and give an overview of HCP experience. Patient and FCG experience are reported among many themes, such as admission, care quality, medication management, technology, intravenous treatment/infection prevention, discharge, FCG roles and responsibilities, and overall experience.

Results: This paper reports that 100% of patients (n = 266) and 98% of FCG (n = 142) would recommend HaH to their friends and family, and 98% of patients (n = 262) and 97% of FCG (n = 144) would choose to be admitted to HaH if they were in the same position again. Similarly, 100% of HCP (n = 40) would recommend HaH to friends/family who require care and meet the criteria. Overall, patients, FCG and HCP continued to report having a positive experience with the HaH program and provided vital feedback for further improvement.

Conclusion: The HaH model of care is newly implemented in hospitals in Victoria, BC, Canada, and has been shown to positively impact the experience of patients, FCGs, and HCPs.

Background and objectives: Workplace violence (WPV) committed against frontline health care workers is a worldwide concern but relatively little is known about relative rates of reported WPV events as identified through patient safety event (PSE) reports before and during the COVID-19 pandemic. This study sought to understand how the COVID-19 pandemic changed the rates and characteristics of reported WPV events committed by patients against health care workers, as captured in the PSE report system for a Mid-Atlantic health care system.

Methods: This retrospective cohort study analyzed voluntary self-reported PSE reports from March 1, 2018 to February 28, 2022. We analyzed reports in 2 equal periods-pre-pandemic (March 2018-February 2020) and during the pandemic (March 2020-February 2022) -focusing on WPV incidents. Data included event types, reporting locations, staff roles, and resolution strategies, comparing pre- and during-pandemic trends.

Results: We identified differences in WPV PSE reports pre-pandemic versus during the pandemic. During the pandemic, there were more reports involving disorderly individuals and fewer incidents of physical and verbal abuse compared to the pre-pandemic period. Resolutions during the pandemic often involved medication, patient restraint, de-escalation, and security intervention, with fewer reports from providers and nurses but more from other health care staff like security officers.

Conclusion: PSE reports contain valuable information pertaining to the identification of system hazards such as WPV events. Analyzing such data provides important insights into how the COVID-19 pandemic affected WPV incidents recorded in PSE system and may also provide a helpful orientation for ongoing monitoring of such events within other health care systems nationwide.

Background and objectives: Management by Objectives (MBO) is effective in reducing the incidence of nursing safety adverse events. This study assessed the effectiveness of applying MBO in the standardized management of orthopedic nursing adverse events and whether it improved the performance of nurses in the areas of specialty theory, technical practice, and educational communication.

Methods: A prospective study was conducted in the orthopedic department of our hospital from May 2021 to April 2023. Fracture patients were divided into a control group (n = 176) receiving standard care and an intervention group (n = 208) where nurses applied MBO principles. We compared nursing performance, the occurrence of adverse events, and patient satisfaction between the 2 groups.

Results: Nurses in the intervention group demonstrated superior performance in specialty theories, technical operations, and education and communication compared to the control group (all P < .05). The occurrence rate of adverse events in the intervention group was 4.81%, significantly lower than the 11.93% observed in the control group. Patient satisfaction scores for nursing processes, environment management, and health education were higher in the intervention group.

Conclusion: These findings suggest that applying MBO to orthopedic nursing can promote standardization of care, effectively reduce nursing adverse events, improve overall safety management, and enhance patient satisfaction. The study provides evidence for the potential benefits of implementing MBO in orthopedic nursing settings to improve care quality and patient outcomes.

Background and objective: Emergency departments (ED) receive significant scrutiny regarding their function and processes, as the ED is typically the initial hospital entry point for patients. Process improvement initiatives have been shown to improve ED performance metrics. However, these initiatives are often carried out as individual projects rather than comprehensive program redesigns. Therefore, this study aimed to determine if a novel model created with the principles of design-thinking improved patient experience and flow metrics in several EDs within a hospital system.

Methods: A multi-faceted approach was developed focusing on both culture and performance within 7 EDs. The PEOPLE+ model was developed, which comprises 5 key areas of focus: philosophy, economics, operational architecture, providers, and leadership. The PEOPLE+ model served as the framework that prioritized all providers, supported staff, optimized patient care, and embraced adaptability and continuous improvement. Left without being seen (LWBS), left against medical advice, emergency medical services volume, diversion hours, visit volume, patient experience, admit volume, length of stay (LOS) discharged, LOS admitted, median door-to-provider time, patient door to provider time <30 minutes, total transfers, total boarders, and total boarder hours were compared 22 months before to 24 months post-implementation.

Results: Following the partnership, there were statistically significant improvements in LWBS (-80.0%; P < .001), leaving against medical advice (-17.6%; P < .001), diversion hours (-95.6%; P < .001), patient experience (+250.7%; P < .001), LOS discharged (-24.2%; P < .001), LOS admitted (-16.9%; P < .001), median door-to-provider time (-55.2%; P < .001), and patient door to provider <30 minutes (+51.5%; P < .001). LWBS (-47.4%; P < .001), diversion hours (≤-84.6%; P ≤ .025), and median door-to-provider time (≤ -31.3%; P < .001) during the second, third, and fourth post-6-month time frames were significantly lower compared to the first 6 months following the partnership, whereas leaving against medical advice (≤-27.8%; P ≤ .013) and LOS discharged (≤ -12.8%; P ≤ .042) during the third and fourth 6-month time frames were significantly lower compared to the first 6 months following the partnership. Conversely, patient experience (≥ +36.5%; P ≤ .040) and patient door-to-provider <30 minutes (≥ +18.1%; P < .001) during the second, third, and fourth 6-month time frames were significantly greater compared to the first 6 months following the partnership.

Conclusions: Changes to philosophic, economic, operational, leadership, and staffing models highlighted by provider ownership and direct provider involvement in developing and executing changes allowed ED performance metrics to significantly improve.

The Purified Protein Derivative (PPD) skin test is a commonly utilized screening method for tuberculosis. For many health care workers, the test is required annually. There is a paucity of data on the cost effectiveness of the test.

Objectives: Evaluate the estimated time loss and financial burden that are associated with PPD testing.

Methods: A survey was developed and distributed to health care workers at a hospital employee health clinic. Data on each respondent's profession as well as time spent at the PPD reading site and travel time were collected. Hospital system-wide time and productivity losses were calculated. Nationwide time and productivity losses were estimated.

Results: Time and productivity losses related to PPD testing from 288 respondents (1.87% of all employees within the health system) amounted to 165 hours, 27 minutes and $4631.71, equating to system-wide time and productivity losses of 9004 hours, 23 minutes (63% of which was spent on travel to and from the clinic) and productivity losses of $252 074.38 (more than 11% of the hospital system's annual operating expenses), respectively, across all 15 674 employees. This represents just 0.087% of the estimated 18 million health workers nationwide, who incur estimated time and productivity losses of 10 340 621 hours and 30 minutes and $289 481 873.20, respectively.

Conclusions: In necessitating a follow-up visit, PPD testing incurs substantial time losses. Since 63% of these time losses occur during paid working hours, the PPD test also incurs significant productivity losses for employers. These losses call for the evaluation of a more cost-effective system of tuberculosis testing. This study was approved by Lifespan - The Miriam Hospital IRB (approval #925592-12). All participants provided written informed consent prior to participating.

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.