Journal for Healthcare Quality最新文献

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.

Abstract: Drug hypersensitivity reactions (DHRs) are potentially life-threatening, immune-mediated responses resulting from use of a medicinal product often requiring emergency department (ED) triage. For patient safety, DHR documentation in the electronic health record (EHR) is imperative-ensuring the health care team is alerted to patient risks with the offending drug. A Veterans Affairs Health Care System medication safety team uncovered that only 25.6% of patients treated for a DHR in their local ED had appropriate documentation of the DHR. To address this critical issue, a Quality Improvement (QI) project was designed with the aim of using a clinical surveillance tool to increase the DHR documentation rate in a single VA ED from 25.6% to ≥ 50% over 6 months. The DHR documentation rate was measured monthly and calculated by dividing the number of patients with appropriate DHR documentation after an ED visit for treatment of the DHR by the total number of patients visiting the ED for DHR treatment. Six months of postintervention data revealed an increase in appropriate DHR to 65.4%, through Exponentially Weighted Moving Averages Statistical Process Control analyses. This pharmacist-led QI project uses software already available at many institutions and illustrates one low-cost solution to address underreported DHRs.

Introduction: Hospitals have found difficulties performing routine procedures in a cost-effective and timely manner. We created a multidisciplinary "In-patient Procedural Team" (IPT) with the intent to meet the demand of nonvascular, nonenteral access procedures.

Methods: A team was assembled comprising advanced practice providers and sonographers with oversight by a surgeon. The IPT scope of practice includes thoracentesis, paracentesis, and lumbar punctures, performed at the bedside under ultrasound guidance.

Results: During 11 months, 2,453 procedures were performed. Of those, 1,196 were paracentesis, 1,099 thoracentesis (with 70 pigtail chest tubes placed), and 88 lumbar punctures. An 80.9% decrease in average consult completion time (9.75 hours vs. 1.86 hours, p < .01) and an 80.9% decrease in case creation-to-procedure start time (13.92 hours vs. 2.66 hours, p < .01) were found. When compared with pre-IPT data, procedures were now completed a mean of 19.2 hours earlier than historic controls. An estimate of 710 off-floor nursing hours were saved. In total, 3,500 patient transports around the hospital were eliminated.

Conclusions: The creation of an IPT intended to tackle complex in-patient procedures is a safe way to reduce time-to-procedure and off-floor nursing time while maintaining high-quality standards.

Introduction: Catheter-associated urinary tract infections (CAUTIs) are common complications in patients with traumatic brain injury (TBI) who require indwelling bladder catheters (IBCs). This study examined the impact of an Acute Urinary Retention Algorithm (AURA) nursing protocol that incorporates intermittent catheterization (IC) on CAUTI incidence.

Methods: A retrospective analysis was conducted on TBI patients with IBCs placed between 2018 and 2022 at a Level I trauma center in Southern California. Catheter-associated urinary tract infection incidence and catheter-associated complications were compared between patients treated with and without the AURA protocol.

Results: Among 73,005 patients with IBC, 255 had TBI and were admitted to the intensive care unit. Only 27 (10.6%) patients had catheters removed through the AURA protocol and had longer dwell times than the nonprotocol patients (2.59 vs. 2.44 days, p < .001). Catheter-associated urinary tract infection incidence was statistically similar between the protocol (7.4%) and nonprotocol groups (3.5%) ( p = .327). However, patients who developed CAUTI were more likely to have undergone more than one IC.

Conclusions: Timely removal of IBCs is crucial to minimizing the risk of CAUTI. This study highlights the underutilization of nurse-driven protocols such as AURA and suggests a careful application of IC in such protocols because of its potential association with increased CAUTI risk.

Background: Hypertension (HTN) is common in the inpatient setting, with many patients receiving as-needed (PRN) antihypertensive medications (anti-HTN) despite lack of benefit and risk of adverse events. We aimed to decrease PRN anti-HTN use in medical patients without hypertensive emergency without increasing adverse events associated with untreated HTN.

Methods: Our multimodal quality improvement (QI) intervention, which included multidisciplinary education and changes to the admission order set in the electronic medical record, was implemented from October 2021 through December 2021. We included adult medical patients with elevated blood pressure (BP) (systolic ≥130 mm Hg or diastolic ≥80 mm Hg) for evaluation of PRN anti-HTN use in pre- and postintervention periods. We excluded patients with admission diagnoses of hypertensive emergency and those requiring conservative BP management.

Results: Postintervention, the proportion of admissions with PRN anti-HTN use decreased by 53% for orders and 29% for administrations. Adverse events due to PRN anti-HTN use were more common than those due to untreated HTN (4% vs. 0.3%), and complications related to untreated HTN did not increase postintervention.

Conclusions: Our multimodal, multidisciplinary QI initiative was associated with decreased use of PRN anti-HTN in hospitalized medical patients and did not increase adverse events attributable to untreated HTN.

Introduction: Workplace violence (WPV) is a significant concern in healthcare settings and indicates the need for accurate reporting to plan and implement effective interventions. This article presents the results of a quality improvement (QI) initiative implemented at a large academic health sciences center to improve the reporting of WPV events.

Methods: The Plan-Do-Study-Act (PDSA) model was adopted to optimize the electronic reporting process, reduce inaccuracies of WPV reporting, and ensure appropriate follow-up from leadership and the Workplace Health, Safety, and Wellness (WHSW) team. Over two PDSA cycles, modifications of an electronic incident reporting form were made.

Results: The proportion of inaccurate reporting was significantly lower (χ 2 (1, N = 1,219) = 111.86, p = .001), after the QI initiative. In addition, the revisions increased staff follow-up and support from WHSW.

Conclusions: Our QI initiative demonstrated that simple adjustments to our WPV reporting, with the revision of an electronic reporting form, had a significant improvement on incident data accuracy and staff follow-up. These findings will contribute to our organization's staff and patient safety.

Abstract: Smoking is a preventable cause of death and morbidity. A department-wide quality improvement initiative was implemented to increase smoking cessation counseling and referral rates as part of a composite metric, which was tied to a faculty incentive. Eligible individuals were current smokers seen in any of 52 internal medicine clinics for a 12-month period. An infographic, a quality improvement newsletter, and outreach to leadership were used to increase awareness about the metric to stakeholders and to provide example workflows. To satisfy the metric, clinic staff offered a nicotine cessation clinic referral to tobacco users at the time of rooming in. If patients agreed, a referral order was pended for the provider to sign. If patients did not agree, literature on smoking cessation was appended to a patient's after-visit summary. Smoking cessation counseling was then documented in the electronic medical record. Rates were serially monitored at the individual clinic and health system level on a centralized, cloud-based dashboard. For a 12-month period, the composite of smoking cessation counseling and referral rates rose from a baseline of 8.6% to 25.6%. Referrals to nicotine cessation clinics increased during the first half of the period but did not during the second half.

Objective: In 2022, our pediatric and women's medical center observed a 166.67% increase in central line bloodstream infections (CLABSIs) in the pediatric population. A quality-focused group was initiated to implement changes to reduce CLABSIs.

Methods: Hand hygiene compliance, creating resource tools, implementing CLABSI prevention competencies, and CLABSI bundle audits were used as interventions.

Results: Our institution's CLABSI rate decreased 71% from 1.59 CLABSIs per 1,000 central line days in 2022 to 0.46 CLABSIs per 1,000 central line days in 2023.

Conclusions: A multifaceted approach with unit focus allowed our institution to decrease the number of CLABSIs in the pediatric and neonatal units.

Introduction: Minimally invasive innovations enhance procedural technology. However, healthcare quality demands addressing mental and physical workloads. This study analyzes flow disruptions uncovering specialty-specific patterns and systemic weaknesses, to enhance quality, processes, and patient safety.

Methods: Twenty-five cardiovascular, 40 orthopedic, 65 trauma care, and 30 neurosurgical cases were examined. The data were categorized using human factor taxonomy, and descriptive statistics were applied.

Results: Comparing the four specialties using RIPCORD TWA taxonomy, cardiovascular and trauma care were translated into one disruption every 2.2 minutes, followed by neurosurgery with one disruption every 2.7 minutes and orthopedics with one disruption every 3.7 minutes. Interruptions were the highest percentage for cardiovascular and orthopedics, with 54% and 46% of flow disruptions. Trauma care was heavily affected by communication flow disruption with 33%. Layout and coordination issues accumulate 26% of flow disruptions in neurosurgery.

Conclusions: Cardiovascular, orthopedics, trauma care, and neurosurgery each feature distinct workflows, risks, and teamwork dynamics, demanding tailored process improvements. By analyzing flow disruptions and systemic weaknesses, this study highlights patterns unique to each specialty, advocating for tailored interventions to enhance communication, coordination, layout optimization, and equipment usability for improved surgical safety and quality.

Abstract: High-quality documentation is vital for efficient patient care. This study aimed to enhance documentation clarity in the acute medical unit (AMU) at our local institution and to improve job completion rates and reduce missed jobs per patient per day (JPD). From January 26 to April 10, 2024, we collected data on 606 patients and 2,298 jobs. Four collaborators documented patient plans using either Standard Documentation or a novel Role-Specific Documentation. Standard Documentation used a single "Plan" heading, while Role-Specific Documentation used specific headings for "Doctors," "Nurses," and "MDT" (Multidisciplinary Team). Data were analyzed using Student t-test (p < .05). Standard Documentation group documented 1,291 jobs for 345 patients; Role-Specific Documentation group documented 1,007 jobs for 261 patients. Role-Specific Documentation had fewer missed jobs (147 vs. 294, p = .0002) and a higher percentage of completed jobs (85.74% vs. 77.99%, p = .0003). Although total job completion showed no significant difference, Role-Specific Documentation had more completed JPD (3.47 vs. 2.94, p = .0052). The Role-Specific Documentation system improved job completion and reduced missed JPD. Despite fewer patients, the new system proved more efficient, suggesting potential for wider adoption. Future studies should explore the documentation methods' impact on clinical outcomes and operational metrics.