Journal for Healthcare Quality最新文献

Introduction: Laboratory test utilization initiatives are well-studied in academic centers but less so in rural and community hospitals. We applied the EPIDEM model ( e xploration, p romotion, i mplementation, d ocumentation, e valuation, m odification) across a nine-hospital, predominantly rural health system to reduce unnecessary daily laboratory tests.

Methods: At the medical center, we began engaging key partners in October 2020 through targeted in-person meetings. Electronic health record (EHR) interventions (removing daily ×3 ordering, Choosing Wisely reminders, interval-based ordering restrictions) started system-wide in April 2021. Regional hospitals received EHR interventions and educational materials only.

Results: After clinical leadership approval in December 2020, our initiative's popularity accelerated, as groups requested inclusion. Across the health system, there was a 6%-20% reduction in tests per inpatient day. At the medical center, ordering decreased in December 2020 and dropped further with each EHR intervention. Unlike the sustained improvement observed at the medical center, ordering initially increased in the regional hospitals, decreased with each EHR intervention, but ultimately returned near baseline levels.

Conclusions: Social and behavioral strategies are essential for sustaining daily laboratory test reduction efforts. Lasting cultural change may require local champions at each hospital. The EPIDEM model prioritizes relational and contextual factors, enabling quality improvement even in resource-limited settings.

Introduction: Early identification and management of sepsis improves patient outcomes, yet hospitals struggle to consistently screen patients on arrival and during hospitalization. The Centers for Disease Control published Hospital Sepsis Program Core Elements to guide hospital sepsis management and outcomes improvement efforts and will measure the sepsis core elements with the National Healthcare Safety Network Annual Hospital Survey.

Methods: To further sepsis care management, our community-owned, nonprofit hospital implemented an emergency department quality improvement project, introducing rule-based artificial intelligence (AI) for sepsis identification with a workflow. Objectives were to measure rule-based AI sensitivity, sepsis management compliance, length of stay (LOS), and mortality rate.

Results: A total of 895 cases were included in the final dataset, 370 preimplementation and 525 postimplementation. Postimplementation rule-based AI alerts identified 93.9% (493 of 525) cases for sepsis management interventions. After rule and workflow implementation, combined 3-hour compliance for antibiotic given, blood culture drawn, and lactate measured was 89.5%. Average LOS decreased by 2.3 days ( p < .001), and mortality per 100 cases decreased by 22.3% ( p = .0998).

Conclusions: Implementing rule-based AI software to identify severe sepsis in conjunction with a sepsis workflow decreased LOS for patients diagnosed with either severe sepsis or septic shock.

Abstract: Although pneumococcal vaccination decreases the rate of pneumonia-associated hospitalization and mortality, rates of pneumococcal vaccination among adults aged 65 years and older remained relatively unchanged during the period of 2019-2022. To improve the rate of pneumococcal vaccine coverage among patients aged 65 years and older in our academic internal medicine clinic, we conducted a quality improvement project centered on previsit planning as the intervention. Previsit planning was implemented in a phased approach, divided into three intervention periods, each involving an increasing number of medical teams. The previsit planning intervention was performed by medical assistants who reviewed vaccination status of patients scheduled for the following day and pended vaccination orders when indicated. When compared with baseline vaccination rates, rates increased in each of the three interventions (7.5%-33.3% [ p < .05], 8.9%-39.6% [ p < .05], 27.8%-38.9% [ p < .05], respectively). Previsit planning can improve pneumococcal vaccination uptake in the ambulatory setting by distributing responsibilities for addressing care gaps across multiple team members, with potential benefits also including reduced provider burnout, improved clinic flow, and improvement of team members' preparation for patient visits.

Background: Percutaneous ultrasound-guided core needle biopsies (CNB) and fine needle aspirations (FNA) provide high yield and minimal risk for neck pathology diagnosis. Organizational shifts led to the planned closing of a long-standing pathology FNA clinic and a potential doubling in biopsy volume for our neuroradiology neck biopsy service.

Purpose: We formulated a quality improvement (QI) initiative with three goals for our service: (1) maintain or decrease mean days to biopsy, (2) maintain or decrease variation in days to biopsy, and (3) maintain diagnostic yield.

Methods: We added physician assistants to the biopsy team and opened a community hospital biopsy clinic. Weekly neuroradiology neck CNB and FNA were tracked from September 4, 2023, to June 23, 2024.

Results: As anticipated, biopsy volume nearly doubled (6.1 ± 2.4 to 12.1 ± 1.2 per week between the first and last 8 weeks, p = .006). Statistical process control methods showed special cause shorter mean times-to-biopsy (8.6 days from 9.6 days) and special cause reduced week-to-week variation (0.8 days from 2.0 days) attributable to our process changes without special cause change in diagnostic rate (90.1% across the project period).

Conclusions: These results highlight the successful application of QI methodology to modify and monitor volume-driven adaptations in a medical procedure clinic.

Abstract: Effective management of patient care delivery within the Veterans Affairs (VA) and Department of Defense (DOD) healthcare systems requires innovative strategies to implement clinical practice guidelines (CPGs). The authors explore the expansion of these strategies by leveraging the Strategic Analytics for Improvement and Learning data, the Electronic Quality Measures dashboard, and Patient Aligned Care Teams across the Veterans Health Administration enterprise. A multidisciplinary, national, virtual Community of Practice (CoP) using subject matter expert presentations that utilize the VA/DOD CPGs and strategic methods for implementation to enhance patient outcomes was developed and implemented. This work aims to detail the development and implementation of a virtual CoP that integrates multidisciplinary expertise and data analytics to enhance CPG adoption and implementation. The implications of CPG CoP discussed reflect the ongoing success and growth of the program's CPG CoP.

Background: Six cancer centers conducted a pragmatic type-II hybrid effectiveness-implementation study of eSyM, an electronic patient-reported outcomes (ePRO)-based symptom management program. Centers collected key performance indicators and recorded implementation strategies. To inform efforts to deploy ePROs as part of routine care, we sought to identify strategies associated with periods of special cause variation in weekly ePRO submission rates.

Methods: ePRO utilization rates and implementation strategies were collected from August 2019 to April 2022. Statistical process control (SPC) methodology was used to identify periods of non-random variation, known as special cause variation, for all six centers. Investigators identified implementation strategies that were temporally associated with periods of special cause variation across centers.

Results: For 714 weeks of ePRO reporting, the mean weekly response rate was 22.3% with wide variability by site. SPC charts detected multiple special cause variations at all sites. Direct patient outreach strategies to educate about and encourage use of ePROs were most associated with positive special cause variation.

Conclusions: These findings highlight the positive effect of direct patient outreach on ePRO responsiveness and identify opportunities for improving symptom management. Quality improvement techniques, such as SPC charting, could help facilitate implementation of complex interventions and tailor them to the needs of specific populations and health systems.

Introduction: Hospitals need objective data about the time allocated to nursing tasks, particularly for older inpatients who often need assistance with activities of daily living (ADLs), such as toileting and mobility.

Methods: This descriptive time-motion study objectively measured the time registered nurses (RNs) and nursing assistants (NAs) spent on clinical and ADL care and made comparisons by staff type. Research staff completed 277 standardized observation hours on three hospital units caring for older patients.

Results: Registered nurses and NAs spent 38% and 34% of their time, respectively, on indirect care tasks, with medical record documentation being most common. Both staff types spent an additional 34% of their time on direct care tasks. Medication pass consumed the most RN direct care time, and ADL care consumed the most NA direct care time. Activities of daily living care was observed in fewer than 25% of patient encounters, despite 73%-89% of patients across the three units requiring ADL care assistance. Overall, staff spent less than 10% of their time idle.

Conclusions: Objective data related to the time allocated to nursing tasks are necessary to inform skill mix adjustments or other staffing strategies to meet older inpatients' care needs.

Introduction: Brain herniation is a life-threatening condition due to increased intracranial pressure. Timely intervention is essential to improving outcomes. Brain herniation code alerts (BHCA) were instated at our institution to streamline management. We launched a quality initiative to increase protocol utilization and reduce intervention time.

Methods: Educational sessions were held for house staff (e.g., surgery, medicine, neurology residents, advanced practice providers) with pre-educational and post-educational surveys. BHCA were reviewed retrospectively: 38 pre-education and 15 post-education. We measured time to head computed tomography (CTH), hyperosmolar therapy, Glasgow Coma Scale (GCS), and in-hospital mortality.

Results: House staff assessments improved after educational sessions ( p < .001). They correctly activated BHCA in 100% of post-education cases (vs. 18.4% pre-education). Time to CTH was similar (pre: 35.7 ± 6.42 minutes; post: 41.9 ± 6.36 minutes). Time to hyperosmolar therapy trended toward faster administration (pre: 20.5 ± 2.5 minutes; post: 13.67 ± 2.03 minutes, p = .05). No significant differences were found in GCS or mortality ( p > .05).

Conclusions: Providers had better understanding of BHCA due to education sessions, increasing BHCAs called and improving time to medication administration.

Implications for practice: Brain herniation syndromes are rare but have high mortality if not treated immediately. A streamlined process is critical for rapid diagnosis, resource mobilization, and timely intervention. Ongoing system improvements and staff education can reduce errors and improve outcomes.

Background: Emergency department (ED) utilization among Medicare Advantage patients has been a growing concern. Many patients opt for ED visits, which can lead to overcrowding and increased healthcare costs. Understanding the underlying reasons for this preference is crucial for developing strategies to optimize healthcare delivery and reduce unnecessary ED visits.

Purpose: The current project aimed to understand the reasons Medicare Advantage patients choose to seek care in the ED setting.

Methods: Patients completed interviews to understand drivers behind their choice to seek care in the ED. The responses were analyzed using generative AI to identify themes shaping patient decisions.

Results: Results showed that most ED visits occurred during hours when clinics were open, with injury and trauma-related visits being the most common reasons. The decision to visit the ED was often self-initiated, influenced by friends and family, or guided by healthcare professionals. Many patients used healthcare-related technology, but indicated challenges related to navigating technology. Patients preferred to seek care from their primary care provider (PCP) and specified that their PCP was their first point of contact for nonemergency issues. Patients' decisions on where and when to seek healthcare services were influenced by factors such as preference for a specific health system, insurance coverage, location and accessibility, and experiences with certain facilities or services.

Conclusions: The project provides insights into the reasons for avoidable ED visits and could be useful in developing strategies to reduce avoidable ED visits and improve patient care.

Abstract: Patients with lower extremity orthopedic trauma are at increased risk of venous thromboembolism (VTE). American College of Surgeons data revealed that a New York Level 2 Trauma Center administered unfractionated heparin (UFH) four times more often, and low molecular weight heparin (LMWH) two-and-a-half times less often, than national averages, despite institutional and national guidelines supporting use of LMWH over UFH. We retrospectively reviewed VTE prophylaxis practices in adult patients with lower extremity orthopedic trauma at the institution to identify trends and/or aberrant administration. Pearson chi-square tests of independence were utilized to determine significance. Approximately 57.3% received no preoperative VTE prophylaxis, whereas 32.8% received UFH and 9.1% received LMWH. Unfractionated heparin was administered at greater or equal frequency than LMWH within each age, sex, and diagnosis group. Patients admitted to general surgical units received UFH more frequently than those admitted to orthopedics. A multimodal intervention can be used to change current practices and improve care quality.