BMJ Open Quality最新文献

Indwelling urinary catheters are often inserted and retained without appropriate indications in the inpatient setting, leading to catheter-associated urinary tract infections (CAUTIs). Previous multidisciplinary toolkits have created modest reductions in inappropriate catheterisation, but these effects were not sustained. This study aimed to achieve a 50% reduction in catheter-days and CAUTIs per 100 patient-days in a general medicine ward at a Canadian tertiary care hospital.A preintervention evaluation of urinary catheterisation was completed by retrospective chart review from 2020 to 2022. A quality improvement initiative was then conducted using an interrupted time series design. Patients admitted during the study period to general internal medicine on the pilot ward with an indwelling urinary catheter were included.A physician-targeted intervention in the electronic medical record system triggered reminders for patients with catheters inserted for more than 24 hours. The second intervention implemented standardised discussion of catheterised patients in daily multidisciplinary rounds. Finally, a chronic catheter order was created for patients with chronic indwelling catheters.Our outcome measures were the number of catheter-days and CAUTIs per 100 patient-days. Process measures were the utilisation of electronic reminder features and implementation of catheter review during multidisciplinary rounds. The balancing measure was the frequency of urinary catheter reinsertion following a failed trial of void.Catheter-days per 100 patient-days decreased from 14.2 to 5.8 days postintervention. CAUTIs decreased from 0.47 to 0.31 CAUTI per 100 patient-days. On average, 80% of patients with catheters were reviewed monthly during multidisciplinary rounds. 24 patients required catheter reinsertion postintervention due to a failed trial of void.The implementation of a multifaceted approach on a general medicine ward consisting of physician reminders, standardised discussion of catheters in multidisciplinary rounds and chronic catheter orders was associated with a sustained reduction in catheter use and CAUTIs.

Background: Hospitalists frequently provide care to inpatients situated across numerous medical units, resulting in inefficiency, poor clinician experience and disjointed teamwork. We implemented geographical cohorting of clinician teams to improve team cohesion, efficiency and interprofessional team experience.

Methods: We conducted an interrupted time series study of medical inpatients at a single academic medical centre. Preintervention: July 2018-April 2019, intervention development: April 2019-May 2019 and the postintervention: June 2019-June 2020. The intervention included geographical cohorting of clinician teams onto dedicated inpatient medical wards, standardisation of unit-based interprofessional rounds and end-of-day unit-based huddles. The primary outcome was surveys of team experience and the secondary outcome was the number of pages to physicians (efficiency measure).

Results: A total of 6043 patients were included in the study: 2668 preintervention, 386 intervention development and 2989 postintervention. 3240 (53.6%) were female and two (<1.0%) were transgender. Postintervention versus preintervention team experience improved in: awareness of healthcare workers (HCWs) method to contact physicians (56.1% vs 19.0%, p<0.001), ease of contact of physician (82.5% vs 59.5%, p=0.001), timeliness of physician response (78.9% vs 61.9%, p=0.020), agreement of team on care plan (80.7% vs 73.8%, p=0.018) and care plan is communicated efficiently (71.9% postintervention vs 45.2% preintervention, p=0.005) and timely (68.4% postintervention vs 45.2% preintervention, p=0.003). Mean physician pages reduced by a postintervention estimate (factor) of -5.80 (95% CI: -6.30 to -5.29, p<0.001). Linear mixed-effects models of clinical patient outcomes demonstrated no significant changes.

Conclusions: Geographical cohorting of inpatient teams was associated with improved efficiency and team experience outcomes.

Telemedicine can improve care delivery through reducing clinic wait-time, improving accessibility to specialist care, minimising cross-infection risk at patient's convenience. Despite these benefits, telemedicine uptake remained low within our gastroenterology department, with only four teleconsultations conducted in 6 months prior to this project's conceptualisation. This quality improvement (QI) project aimed to improve telemedicine utilisation within our department by 20% over a 3-month period. Surveys conducted during the planning phase identified key barriers to telemedicine adoption, including high clinic load, concerns over medicolegal issues and unfamiliarity with data security protocols. To address these issues, a multistakeholder QI team introduced several key measures, including streamlining telemedicine workflow, providing clinician training and implementing patient educational posters. These interventions successfully increased the adoption of telemedicine (median 8 (IQR 2.5) vs 31 (IQR 13) teleconsultations per month, p<0.01) over the intervention period, with 84% of patients reporting positive experiences. Additionally, this project reduced carbon emissions, saving approximately 3446 kg of CO2, equivalent to 388 gallons of gasoline. This QI project highlights the potential for telemedicine to enhance healthcare delivery while promoting environmental sustainability. Key lessons include the importance of structured workflows and stakeholder engagement to overcome barriers. Future interventions should aim to refine telemedicine pricing models and expand the initiative to other departments within the hospital to ensure long-term sustainability.

Introduction: It is widely acknowledged that health disparities exist in minority populations, with ethnicity, gender, language, ability and culture emerging as critical determinants of health outcomes. At present, research is available demonstrating that patients with protected characteristics experience less favourable patient safety outcomes. However, there has been limited focus on reviewing how processes within the healthcare system contribute to this inequity of care received by minority populations. This study reviews the prevalence of incident reporting of medication errors for people with selected protected patient characteristics within an acute NHS Trust. The aim is to determine if there are unexplained variations.

Method: This cross-sectional study was conducted across an NHS Trust group of five hospitals, serving a diverse local population. Incidents reporting errors in medication use were obtained for the 7-month period between 1 January 2021 and 31 July 2021. The χ² test was used to assess if protected patient characteristics impacted the rate of medicine-related error reporting.

Result: Medication error reporting is not equitable between different gender, ethnic or age groups. The results of this study show that these characteristics were negatively related to the number of medication incidents reported.

Conclusion: This study demonstrates that further systematic support is required to reduce the variations in medicine error reporting for patients with key protected characteristics. Infrastructure to overcome known barriers to safe care in the mainstream such as language, culture, beliefs and lower levels of understanding needs further development.

Background: A set of interventions in a hand hygiene change package was developed in a pilot ward by the end of 2017. In 2018, Changi General Hospital embarked on scaling up the change package to other wards with the intention to eventually spread the hand hygiene change package hospital-wide.

Methods: Changi General Hospital conducted a quality improvement project on hand hygiene with the intention to effect organisation-wide improvement in hand hygiene. Spread methodologies such as the Institute for Healthcare Improvement's framework for Spread and various complementary spread concepts such as having an organisational strategy, which plans for spread as early as possible, and addressing social aspects of change were applied in order to scale up and spread a change package.

Setting: A general tertiary care hospital in Singapore.

Results: Overall hospital-wide hand hygiene compliance improved from a median of 66% during the pilot phase to 73% in the scale-up phase (p<0.05) to 82% during the spread phase (p<0.05).

Conclusions: A systematic approach to hand hygiene improvement based on spread literature successfully improved and sustained hospital-wide hand hygiene compliance. Success factors included the development of a change package that had clear guiding principles, with the intent to create proactive learning cycles within units which could be adapted to work in various contexts.

Background: Venous thromboembolism (VTE), which includes both pulmonary embolism and deep vein thrombosis, is a common yet significant postoperative complication. Patient Safety Indicator (PSI)-12 was introduced by Centers for Medicare & Medicaid Services and Agency for Healthcare Research and Quality to track this potentially preventable complication. We initiated a multifaceted process to reduce our postoperative VTE rates through a four-pillar initiative structure. Our objective was to assess the impact of a multifaceted process and quality improvement initiative on the rate of postoperative VTE at an academic medical centre.

Methods: Our study was conducted at Duke University Medical Center. Our intervention consisted of a four-pillar initiative structure: building a consensus on appropriate VTE prophylaxis through surgical specialty champions; incorporating VTE prophylaxis recommendations in the provider electronic health record workflow; using a measurement dashboard; and reviewing all individual postoperative VTE cases with clinical champions. We collected pre-intervention data on PSI-12 rates for 12 months ending in September 2019, initiated improvement strategies in September 2020 and reviewed results of our improvement strategies at the end of December 2021 for a 15-month timespan.

Results: In 2019, we identified 94 postoperative VTE events per 13 522 adult surgical discharges for a rate of 0.695%. In 2021, we identified 71 postoperative VTE events per 12 292 adult surgical discharges for a rate of 0.578%. This represents a gross reduction in postoperative VTE event rate by 23 when comparing our pre-intervention and post-intervention timeframes which was both a clinically and statistically significant difference (p<0.0001, 95% CI: 0.1050 to 0.1288).

Conclusions: The four-pillar initiative structure implemented was successful in reducing postoperative VTE rates, reducing costs and lowering hospital length of stay.

Background: There is a need for guidance to support human factors/ergonomics (HFE) practitioners to conceive and design HFE interventions that live up to the fundamental principles underpinning the discipline of HFE. The principles are that HFE has a systems focus, is design driven and focuses on both performance and well-being outcomes.

Objectives: The objectives of this scoping review are to: identify studies that meet these principles in order to discover how commonly HFE studies meet the principles for the practice of HFE; the scope and characteristics of studies that meet the principles; and the learning that can be gleaned from these studies.

Eligibility criteria: The principles were operationalised into four criteria that were used to select studies: (1) The intervention acts on more than one aspect or element of the system; (2) a context-relevant needs assessment or systems analysis phase is undertaken to design the intervention; (3) the intervention has an active element that is designed to enhance safety, quality, efficiency, effectiveness or well-being and (4) the intervention is evaluated.

Sources of evidence: The review considered all studies published in peer-reviewed journals between 2010 and July 2024 in which an HFE or related intervention is presented and evaluated. Electronic searches were conducted across five databases plus Google Scholar.

Charting methods: Data extraction was done by consensus using extraction forms and following two stages: (1) data extraction and (2) data interpretation.

Results: A total of 13 intervention studies met the inclusion criteria, suggesting that adherence to core HFE principles is rare. All included studies self-identified as HFE intervention studies. All interventions had a clearly defined scope and most targeted at least four system elements, that is, person, tools, technology, task, process, organisation, environment. The 'people' element was the one most commonly targeted. A wide range of organisational level and patient outcomes were measured, but no employee safety or well-being outcomes were measured in the included studies. In all cases, the intervention team included healthcare providers working with HFE/systems engineering/improvement experts, who often led the project.

Background: Staphylococcus aureus bacteraemia had a higher mortality rate than average at Kingston Health Sciences Centre (KHSC). Infectious diseases specialist consultation has been shown to improve outcomes for S. aureus bacteraemia by increasing adherence to evidence-based care practices. Yet, infectious disease specialists were not involved in many cases at KHSC.

Aim: To improve adherence to evidence-based care practices by increasing the proportion of patients with S. aureus bacteraemia who receive a formal infectious diseases consultation.

Interventions: A multimodal intervention consisting of (1) daily automated email of positive blood culture results to the infectious diseases team; (2) standardisation of prompts attached to positive blood culture results on the electronic medical record; (3) policy of mandatory infectious diseases consultation and (4) education of resident physicians.

Implementation and evaluation: The outcome measure was adherence to evidence-based care practices, defined as echocardiography, repeating blood cultures and treatment with a first-line antibiotic. A secondary outcome measure was 90-day mortality. The process measure was the proportion of patients receiving formal infectious diseases consultation. A balancing measure was hospital length of stay. All measures were monitored semimonthly using statistical process control charts for time periods before and after intervention.

Results: There were 171 and 186 patients with S. aureus bacteraemia in the preintervention and postintervention period, respectively. Between these two periods, the proportion of those who received evidence-based care practices increased from 73% to 82% (p=0.031) and demonstrated special cause variation. Mortality changed from 29% to 24% (p=0.400). The proportion of patients receiving an infectious diseases consultation increased from 47% to 90% (p<0.001) and demonstrated special cause variation. The median (IQR) length of stay was 18 (11-30) days and 17 (11-42) days in the preintervention and postintervention period, respectively (p=0.442).

Conclusions: A multimodal intervention that implemented mandatory infectious diseases consultation significantly improved evidence-based care practices for S. aureus bacteraemia.

Non-invasive ventilation (NIV) and continuous positive airway pressure (CPAP) use positive airway pressure delivered via a tight-fitting mask to treat respiratory failure. In the acute setting, the mask covers the nose and mouth with various interface options. National guidelines indicate that NIV use should be targeted for close to continuous use in the first 24 hours.Research has shown that some oro-nasal masks can generate pressures between 6.37 and 12.2 kPa on the nasal bridge when adjusted to minimise mask leak, essential in reducing patient-ventilator asynchrony. Research has also shown that tissue damage and necrosis can occur after just 2 hours of pressure-induced ischaemia at a pressure of 4.6 kPa, demonstrating this patient cohort's high risk of developing a medical device-related pressure injury (MDRPI).Baseline data from October 2021 onwards identified eight nasal bridge pressure ulcers reported via the Trust's incident reporting system. Five were classified as suspected deep tissue injury, and three were classified as category 2. No ulcers were scored at category 3 or worse.This project used the Plan Do Study Act (PDSA) approach to prevent any new nasal bridge pressure ulcer derived from using NIV or CPAP therapy for any patient admitted to our hospital site for 40 days from 1 November 2022. Using four PDSA cycles, there was a statistically significant reduction in the frequency of category 2 MDRPIs caused by NIV mask interfaces for 1466 'NIV days' across 19 calendar months.

Between April 2020 and March 2021, the number of fall-related emergency admissions in England for adults over 65 years was 1933 per 100 000 people. Adult patients in hospital may be at risk of falling for many reasons including a history of falls, being medically unwell, dementia or delirium, the effects of their treatment or medication, poor mobility, visual and other sensory impairments along with their general well-being. Research has shown that falls can be reduced by 20%-30% through multifactorial assessments and interventions. The aim of these assessments and interventions is to identify and treat underlying reasons for falls such as muscle weakness, cardiovascular problems, dementia, delirium, incontinence and medication. However, national audits have found low levels of implementation of these assessments and interventions in UK hospitals. As part of a new patient safety improvement initiative, a collaborative was developed to reduce the incidence of in-patient falls rate per 1000 bed days within five older adults' mental health wards in a health board in Wales. The falls collaborative project has resulted in substantial improvements in care, including an increase of patients receiving lying and standing blood pressure assessment, medication review and delirium assessments. While reported falls rates stayed the same for the five wards, when each ward individually was factored in, we saw a reduction in two wards and estimated that the increase in falls for the remaining of three wards was related to a previous state of under-reporting, considering the numbers stayed levelled throughout the collaborative. The small reduction we saw was achieved without any extra support or allocated resources, and the ongoing staffing challenges all five wards experienced throughout the collaborative, all these improvements were received as a great success. The team was shortlisted for the National Health Service Wales Awards in the Safe Care category, something they took great pride in.