BMJ Open Quality最新文献

Background: Having initially done our critical appraisal of various studies, we found that geriatric wards have a higher prevalence of delirium and dementia. Among this older population, sensory aids were found to be important in orientating delirious patients, and deficits in vision/hearing were associated with an increased risk of delirium. Delirium and dementia are associated with increased morbidity and mortality. This quality improvement project aimed to increase staff awareness of patient sensory aid needs and thus improve patient care as a result.

Methods: We started off with a driver diagram to identify what the primary and secondary drivers are for improving the quality of care for patients with sensory impairment. Of the drivers discussed, we believed that we could have a meaningful impact on improving sensory impairment awareness among the multidisciplinary team (MDT) on the ward. We then went through our Plan, Do, Study, Act (PDSA) cycles, which were as follows: PDSA cycle 1, where I and my two colleagues educated the MDT on how to use the electronic patient records property form checklist, which was being underused. This form tracks whether patients require sensory aids. We did three teaching sessions during board rounds and audited the use of this form over time. PDSA cycle 2 used a laminated bedside checklist that is filled in by the MDT and is used as a visual reminder of the patient's sensory impairment status.

Results: The EPR form completion rate increased by 14% over a period of 4 weeks, although this was not statistically significant. 18% of the bedside checklists were filled in, which was statistically significant. Both interventions in combination led to a statistically significant increase in sensory impairment awareness, with a 32% decrease in sensory aid unknown rates, a 40% decrease in dementia unknown rates and a 56% decrease in both sensory and dementia unknown rates. Delirium status was not formally assessed in this QIP due to documentation inconsistencies; however, its relevance remains acknowledged.

Drowning is the leading cause of death in children 1-4 years old in the USA. Paediatricians play an important role in giving anticipatory guidance on drowning prevention. This quality improvement initiative aimed to increase the rate of drowning prevention counselling with provision of educational materials to caregivers of children aged 0-10 years during clinical encounters in an outpatient setting.We refined a previously published Texas state educational programme that included evidence-based counselling strategies across three Plan Do Study Act (PDSA) cycles, with the addition of preintervention baseline counselling phase during expansion of the programme nationally to 17 and 21 states in 2022 and 2023, respectively. All participating paediatricians in office-based, urgent care and emergency settings completed demographic, preintervention and postintervention and programme evaluation surveys. Paediatricians in office-based settings (majority of participants) tracked counselling rate across baseline and three PDSA cycles. Caregivers completed postintervention surveys on knowledge and anticipated behaviour change. Drowning prevention education was supplemented by materials provided to caregivers including brochures and wearable water watcher tags to promote adult supervision.During the first 2 years of national expansion, 120 physicians and 7886 caregivers participated in the programme. Provision of drowning prevention educational materials to caregivers significantly closed an existing gap. Less than 25% of caregivers reported receipt of brochure/checklist and only 6% water watcher tag at baseline; compared with 98% and over 90%, respectively, after PDSA 3 in both years. 69.3% of physicians were able to efficiently counsel on drowning prevention within 2 mins in 2022 versus 82.1% in 2023 (p value<0.001). Most caregivers found the counselling helpful and planned to use the water safety strategies. We demonstrated a significant increase in mean counselling rate from preintervention phase (26.8%) through end of PDSA 3 (64.9%) in this national programme.

Increasing MRI capacity is of primary importance to both NHS England and individual radiology departments. Consequently, central funding was provided to allow trusts to instal artificial intelligence-enabled image reconstruction (AI-IR) on their MRI scanners, with the stated aim of increasing capacity by two patients scanned per day within a year of installation on a given scanner. This work demonstrates how a two-phase quality improvement (QI) initiative can be followed to increase capacity using AI-IR in a community diagnostic centre (CDC) at Mile End Hospital and an acute trauma centre, the Royal London Hospital, in East London with comprehensive stakeholders' engagement.The Model for Improvement framework was used. Our pilot study focused on 3 Plan-Do-Study-Act (PDSA) cycles for three anatomies in musculoskeletal (MSK) imaging at our CDC. A second, substantive study at our major trauma centre was followed, which was a 20-month project encompassing all MSK anatomies of interest.In our initial pilot study at the CDC, we were able to reduce booking times by 10 min for Knee, Ankle and Spine protocols. In our wide-ranging MSK programme at our trauma centre, we saved on average of 07:26 min per scan and while an increased throughput was not achieved, an increase in complex patients being scanned, from 7% to 15% was achieved, reducing healthcare inequities.Our two-centre study suggests that engaging with stakeholders in a structured QI programme can significantly reduce scanning times, improve patient experience and allow for longer precare and postcare time. Additionally, significant throughput increase at the CDC for low-risk ambulatory patients suggests efforts to increase capacity using this technology should be focused at such centres and other scanners focused on ambulatory outpatients, while for scanners focused on inpatients, paediatrics and A&E at trauma centres, the time saved can be used to increase the capacity for complex patients, reducing waiting times for these patients.

Background: Hospitals often face complex and life-threatening situations that heighten the risk of medical errors. Improving patient safety culture is important to reduce these errors. This study aims to identify trends in patient safety culture within a paediatric intensive care unit (PICU) and to explore strategies for improvement.

Methods: The study had a mixed-methods design, combining quantitative and qualitative methods, and was done at the PICU of Sophia Children's Hospital (Rotterdam, The Netherlands). The Safety Attitudes Questionnaire (SAQ) was used to measure patient safety culture, with surveys administered in 2009, 2012, 2014, 2017, 2019 and 2023. Trends in patient safety culture over time were analysed. Additionally, staff members provided recommendations to improve patient safety, which were subsequently categorised into overarching themes. An expert panel was convened and interviews with staff members were conducted to further evaluate the most frequently mentioned recommendations and assess their relevance and feasibility for implementation.

Results: From 2009 to 2023, patient safety culture demonstrated overall improvement. However, specific domains, including stress recognition, perceptions of management and working conditions, still show room for further improvement. Most recommendations identified through the SAQ fell within the themes of interprofessional communication, medical equipment and hospital working environment, and staffing. Concrete suggestions included appointing a dedicated contact person to improve communication with parents and establishing clear agreements to strengthen communication and teamwork within the PICU.

Conclusions: The patient safety culture at the PICU of Sophia Children's Hospital improved over the years, although areas for improvement remain. Sustained improvements in patient safety culture require continuous investment in interprofessional communication, workplace conditions and staffing. This study not only highlights long-term trends but also presents actionable strategies proposed by staff to address persistent challenges. Effective implementation and ongoing evaluation of these interventions are essential to strengthen safety culture, enhance staff well-being and ultimately improve patient outcomes.

Background: Inappropriate packed red blood cell (pRBC) transfusions increase patient risk and healthcare costs. Initial audits at Niagara Health (Ontario, Canada) revealed only 85% and 54% compliance with Choosing Wisely Canada guidelines for pre-transfusion hemoglobin (≤80 g/L) and single-unit transfusion, respectively.

Methods: We conducted a nonrandomized, interrupted time-series Quality Improvement Project (QIP) using the Model for Improvement. Interventions included technologist-led prospective screening of pRBC orders, policy updates, and educational campaigns. Outcome measures were rates of inappropriate transfusions based on hemoglobin and single-unit criteria; balancing measures included transfusion-related adverse events. Sustainability was assessed using Statistical Process Control charts. Cost analysis estimated savings using an activity-based cost of $C1500 per pRBC unit.

Results: Initial implementation improved compliance to 90% (pre-transfusion hemoglobin) and 71% (single-unit) within three months. Extended analysis (2021-2024) demonstrated sustained rates of 90% and 77%, respectively. At the St. Catharines Site, monthly median transfusions decreased from 273 to 173 units, yielding a 56% reduction in RBC utilization and 44% cost savings amounting to $C5052000.

Conclusions: Technologist-led screening achieved sustained improvements in transfusion appropriateness, leading to substantial cost savings. Variability across sites underscores the need for further research on contextual factors influencing future QIP success.

Introduction: In paediatric patients with concern for septic arthritis, arthrocentesis may be performed under anaesthesia with intraoperative cell count determining need for surgical intervention. Shorter turnaround time (TAT) between collection and result minimises anaesthesia exposure for the patient and surgical time for the treatment team. This study evaluated a quality improvement (QI) initiative to decrease TAT to <1 hour by improving interdisciplinary communication and placing visual reminders ('stat card') to indicate priority handling.

Methods: 206 consecutive paediatric patients who underwent arthrocentesis for the diagnosis of septic arthritis were identified. Midway through the collection period, the QI intervention (stat card) was implemented. We collected the date and time of arthrocentesis and sample verification (TAT) and calculated the proportion of TAT <1 hour preintervention and postintervention. We collected variables related to the affected joint and whether the stat card was used. Operative time was calculated for those samples collected in the Operating Room (OR).

Results: The final study population included 109 patients preintervention and 88 patients postintervention. Postintervention, the stat card was used in only 44% (20/45) of eligible cases. Compliance was highest in aspirations of the hip (75%). After adjusting for the affected joint, the odds of TAT <1 hour were higher in the postintervention stat card group compared with the postintervention no stat card group (odds ratio 7.10, p=0.0147) and to the preintervention group (odds ratio 3.63, p=0.0810). There was no difference between the postintervention no stat card versus the preintervention groups (odds ratio 0.51, p=0.2524). TAT was significantly decreased when the stat card was used (42 min) compared with when it was not used (84 min) (mean difference -39.5%, p=0.0178). After adjusting for the affected joint, there was no difference in operative time across the three groups (p=0.2531).

Conclusion: A multidisciplinary QI initiative for the intraoperative diagnosis of septic arthritis was effective in reducing cell count TAT but demonstrated poor compliance and failed to reduce operative time.

Globally, wildfire smoke and extreme heat events are increasing in frequency and intensity. Western Canada, including the Province of British Columbia (BC), is impacted annually by these events, resulting in the accelerated development of public health messaging and emergency preparedness. It is particularly important to reach, educate and empower individuals who are highly susceptible to climate events, such as those with respiratory diseases, through targeted communication strategies delivered by trusted sources. We aimed to develop an evidence-informed action plan (AP) tool and pilot integration into clinical encounters with patients living with asthma and chronic obstructive pulmonary disease (COPD).The project team developed a draft tool-a BC Wildfire Smoke and Extreme Heat AP document inspired by the concept of an Asthma AP-along with a guide to support healthcare providers in addressing questions during patient counselling sessions. Iterative feedback from trained patient partners, clinicians and knowledge translation specialists was incorporated to refine messaging and delivery. Use of the tool was piloted in clinical encounters between certified respiratory educators (CREs) and patients living with asthma and COPD in two regional health authorities. Additional process and content feedback was gathered via questionnaires and focus groups.Patients (project participants) reported that AP tool use increased their understanding and preparedness for wildfire smoke and extreme heat events. While the plan was positively received by providers in a CRE role, time constraints and staffing capacity were highlighted as barriers to implementation. Suggested improvements included strengthened public awareness, preseason deployment and enhancement of content and delivery. Additional quality improvement cycles are needed to increase readability, accessibility and actionability.

Background: Delayed or inconsistent administration of N-acetylcysteine (NAC) for paracetamol overdose in the emergency department (ED) poses a risk to patient safety, with current Royal College of Emergency Medicine (RCEM) standards often not being met. The traditional 21-hour NAC regimen is associated with adverse drug reactions, medication errors and prolonged admissions. The Scottish and Newcastle Acetylcysteine Protocol (SNAP) was introduced as a simpler alternative with comparable efficacy. This quality improvement project (QIP) aimed to improve compliance with RCEM standards by implementing targeted interventions while also reducing the length of inpatient stay and maintaining patient safety.

Method: This QIP was conducted at Royal Derby Hospital using a multidisciplinary, systematic approach based on Plan-Do-Study-Act cycles. Baseline data were collected from 100 randomly selected patients (November 2021-May 2022) and compared with outcomes during a 52-week intervention period (September 2023-August 2024). Interventions included educational sessions, quick reference materials and enhanced prescribing tools. Data were analysed for compliance with RCEM standards, adverse events (liver function derangement and anaphylactoid reactions) and system-level measures, such as length of inpatient stay and timing of paracetamol plasma levels.

Results: A total of 214 patients were included. Compliance with RCEM standard 1 improved from 36% to 43%. No change was noted for standards 2 and 3. Median inpatient stay decreased from 35 hours to 30.5 hours. No significant differences were found in adverse events. Special cause variation was identified in paracetamol plasma level timing, attributed to early sampling in some cases.

Conclusion: This QIP addressed problems of delayed or inconsistent NAC administration in the ED by improving compliance with RCEM standard 1 and reducing inpatient stay while maintaining patient safety. Although standards 2 and 3 did not improve, the interventions proved cost-effective, feasible and scalable. Future work should focus on sustaining improvements and exploring patient-centred outcomes across diverse healthcare settings.

Introduction: The COVID-19 pandemic flooded intensive care units with patients needing supportive care. In Scandinavia, the greater Stockholm area was among the most affected. This study aimed to capture healthcare workers' conditions and challenges during this prolonged crisis, including perspectives from the intensive care team.

Methods: The data consist of 22 semistructured individual interviews with regular and temporary healthcare workers involved in the intensive care of COVID-19 patients, including nurse assistants, registered nurses, critical care nurses and consultant and junior physicians. Thematic analysis was used to analyse the data.

Results: The overarching theme that emerged was trying to create order in chaos.The theme encompassed four categories: adaptation with consequences, learning and growing while sacrificing my health, supporting and balancing staff resources without having enough, and challenging ICU values and standards. Each category comprised multiple subcategories.

Conclusion: Our study demonstrates challenges and identifies workarounds, support strategies and personnel learning experienced by COVID-19 intensive care teams in delivering patient care, ensuring patient safety and managing staff resilience. The findings can be used to better prepare for future crises.

Introduction: Sepsis causes over 20% of deaths annually, with early recognition and management being key strategies to preventing patient deterioration. Despite being the largest group of hospital-based clinicians, the role of registered nurses (RNs) in sepsis remains poorly defined.

Objective: To describe the roles and responsibilities of RNs in early recognition and management of sepsis in acute hospital settings, applying the Action, Actor, Context, Target and Time (AACTT) Implementation Science Framework to specify nursing behaviours across domains, and identify evidence gaps to inform future research and practice.

Methods: The review was conducted using the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) checklist. We searched Medline, EMBASE, CINAHL and PubMed for studies discussing the contribution of RNs in acute hospital-based sepsis care. Data were extracted and mapped to the AACTT framework domains.

Results: 27 (90%) of 30 included studies described RNs as the actor responsible for the action of sepsis screening. 26 studies (87%) described RN actions relating to timely care escalation and sepsis management. A broader range of actions was identified in resource-restricted contexts, with three (10%) studies reporting RN-initiated blood tests, chest X-rays, intravenous fluids and antimicrobials.Across 16 studies (53%), eight roles with dedicated focus on sepsis identification and management were identified; only one study outlined formal training requirements. Nurse practitioners were excluded here given their credentialed role and scope.

Conclusion: Nurses perform essential actions in early sepsis recognition and management, with several RN roles focused on sepsis care identified. A broader scope of nurse-initiated actions was identified in resource-restricted contexts to meet clinical demand. There is potential for a greater scope of nursing actions in sepsis care for the benefit of patients and health services, but to achieve this, standardised training requirements need to be developed, and scope of practice defined.