BMJ Open Quality最新文献

Importance: Guidelines recommend avoiding unnecessary laboratory tests to minimise risks of anaemia in hospitalised patients as well as reduce costs, but there are costs to skipping routine labs including missing acute kidney injury.

Objective: Quantify the costs and benefits of routine labs in dollar costs as well as mortality.

Evidence review: This is a retrospective analysis of 48 204 admissions at University of Kentucky Hospitals and simulates different strategies for skipping labs.

Findings: In a simplified estimate of pure dollar costs, the costs of daily labs appear to outweigh the costs of missing acute kidney injury.

Conclusions and relevance: In both dollar costs and the number of patients with mortality effects, the benefits of randomly skipping labs appear to significantly outweigh the costs, but the costs are not insignificant.

Early discharge and follow-up for medical admissions could facilitate reduced length of stay and improve patient satisfaction. However, evidence to confirm this is lacking. Peterborough City Hospital (PCH) designed an early ward discharge clinic (EWDC) service embedded within its acute medicine department to provide clinicians with the opportunity for a prompt clinical review following a hospital admission.Across three cycles, several interventions aimed to improve the utilisation of clinic, appropriateness of referrals and reduce the number of missed attendances. Our work has demonstrated that a service such as the EWDC can provide ample opportunity for early review of patients which could reduce the rate of readmissions and improve services. Interventions to date have improved the utilisation of the clinic, reduced the number of patients not being aware of appointments and provided training opportunities for junior clinicians. Data has also suggested a high level of patient satisfaction from using the service.Further research is needed to confirm the use of such services in reducing readmissions and mortality, however, results from clinics at individual units such as PCH provide useful insight until such data is available.

Paediatric patients often present with symptoms of respiratory illnesses in the weeks leading up to surgery. Current or recent illness can increase the risk of experiencing perioperative respiratory complications. Ideally, children with recent illnesses should be identified before coming to the hospital to determine the safest course of action. We recognised that our system lacked a standardised process for documenting preoperative respiratory illness during the preoperative phone call. The global aim of this quality improvement initiative was to decrease paediatric perioperative respiratory adverse events. The SMART Aim (Specific, Measurable, Achievable, Relevant and Time-bound) was to increase the percentage of patients with standardised documentation of preoperative respiratory illness from 0% to 90% by 1 March 2023. Implementation of a standardised preoperative illness questionnaire increased standardised illness documentation from 0% to 95%. Nurses quickly adopted this intervention and easily integrated it into their routine workflow. Clinical leaders elected to implement the intervention electronically across all three operating room (OR) locations (main OR, satellite location and procedure centre). Future implementation of additional standardised preoperative processes will be needed to improve the global aim of decreasing perioperative respiratory complications.

Background: Inappropriate prescribing may have detrimental consequences for the patient and increase healthcare utilisation and costs. Academic detailing (AD) is an interactive outreach method to deliver non-commercial evidence-based medical information to healthcare professionals, aiming to improve patient care. Performing AD virtually has recently become more relevant, especially with the COVID-19 pandemic.

Objectives: The aim of this study was to explore general practitioners' (GP's) experiences and perceptions of virtually delivered AD.

Methods: We invited practicing GPs that had received virtual AD in Norway during autumn 2020. Semistructured individual interviews were audio and video recorded during February-May 2021. Interviews were transcribed and analysed applying thematic analysis according to Braun and Clarke.

Results: From interviews with nine GPs, we identified five themes concerning (1) informants' satisfaction with virtual AD and their opinions about the detailers and their characteristics, (2) factors that are important for participation in AD, with the campaign topic being the most important, (3) a paradox between the informants' desire for more time for discussion and the time constraint they are facing, (4) the many benefits of virtual AD compared with in-person AD and (5) the informants' perceived learning outcomes are unaffected by mode of AD delivery.

Conclusion: Virtual AD worked very well in terms of scheduling the visit, using technology to facilitate the visit and achieving the same learning outcomes. Virtual AD should be offered to GPs as an alternative to the traditional in-person AD, especially in remote geographical areas or in circumstances when physical outreach is challenging.

Advanced care planning (ACP) is a series of ongoing voluntary discussions between patients, families and healthcare professionals to plan for their future healthcare needs. Despite patients with rheumatic diseases having high symptom burden and disease complications, the ACP completion rates in patients with rheumatic diseases remain low. In this quality improvement project, we aimed to increase the number of completed ACP in a tertiary referral rheumatology centre in Singapore from 0 to 1 per month. We showed a statistically significant increase in ACP completion across 1 year with two Plan-Do-Study-Act cycles. Further studies are needed to explore further interventions for ACP completion in patients with rheumatic diseases.

Major lower limb amputation (MLLA) is a lifesaving but life-altering surgical procedure. Psychological distress is common and typically heightened in the acute postoperative period. Despite the negative impact that poor psychological functioning can have on the health outcomes of this population, there is a lack of high-quality guidance outlining how to best support the psychological needs of individuals post-MLLA. The aim of this project was to develop practical and feasible interventions for improving the provision of emotional support for all patients on the vascular surgical ward post-MLLA. Adapted from the Holistic Needs Assessment Adversity-Restoration-Compatibility framework used within oncology services to provide holistic care to patients, the project included two key interventions. The primary intervention involved developing a model for an 'emotionally supportive conversation' (ESC), which was delivered by a member of the vascular surgical team under supervision of a Clinical Psychologist. During the 6-month implementation phase, 27 patients received an ESC, an average of 8 days post-MLLA. The secondary intervention involved training for vascular surgical ward staff, led by a Clinical Psychologist. This focused on raising awareness of common signs of distress, building skills and confidence in responding to distress and providing information on where to signpost patients for further support. Prior to the primary and secondary interventions, 43% of patients reported receiving sufficient information from hospital staff on how they would feel postoperatively and 57% stated they had received sufficient support from staff during their stay. Post-implementation, these figures increased to 86% and 71%, respectively. This project represents a novel, creative and cost-effective way for psychological services to add value to the quality of care provided to vascular surgical patients during the inpatient phase post-MLLA.

Background: The University of Florida (UF) Equal Access Clinic Network (EACN) is the largest student-run free healthcare clinic network in Florida. The UF EACN serves those who are underinsured or uninsured in Alachua County and its surrounding area. Nationally, average total clinic time per medical visit has been established to be 84 min.

Problem: Before this project, average patient cycle time at the UF EACN was 125.3 min, and there was no established quality improvement (QI) team to implement changes to address inefficiencies.

Methods: This was a prospective QI study that recorded patient cycle times for patients who received healthcare at any of the four primary care free clinics across the UF EACN from 5 July 2022 to 6 April 2023.

Interventions: Eighteen Plan-Do-Study-Act cycles were tailored to each of the four primary care clinic's needs with a focus on reducing patient cycle time by addressing the following identified problems: prolonged intake process, translation services, limited numbers of volunteers, and other inefficiencies and bottlenecks in workflow.

Results: The median patient cycle time at the EACN shifted from 125.3 min to 112.7 min over a nine month period. This drop of 12.6 min meant patients saw a 10.1% reduction in patient cycle time across the EACN.

Conclusion: Underserved patients at EACN are experiencing increased value by having shorter patient cycle times.

Background: Older people living in care homes are often frail and clinically complex. The Enhanced Health in Care Homes (EHCH) framework supports organisational and clinical strategies to deliver good care, promoting proactive person-centred care by whole system collaboration. We evaluate the impact of a new role, the Extensivist, in the delivery of EHCH for older people living in care homes.

Aims: To evaluate implementation processes and the clinical utility of the Extensivist in older people care homes in the London borough of Southwark.

Methods: The Extensivist (Band 8a Advanced Nurse Specialist skilled in frail older people) was embedded within the care home general practitioners (GP) service for a 2-year pilot (2019-2021). Implementation processes were evaluated. Impact of the Extensivist role was evaluated by the number of Comprehensive Geriatric Assessment (CGA) completed, interventions and other clinical activity performed as well as qualitative case studies and semistructured feedback from care home workers and professionals.

Results: The Extensivist feasibly delivered CGA and implemented intervention plans. The role iteratively developed to support wider aspects of care including advance care planning (ACP) and training. Challenges included building trust, the time-consuming nature of CGA, ACP and coordinated communication. Case studies and semistructured feedback indicated the role was considered valuable in the delivery of clinical care, supporting residents, families, care homes and GPs and as a resource for education for care home workers.

Conclusions: The Extensivist is a valuable resource and a linchpin in the delivery of EHCH framework in care homes for older adults in Southwark. Further evaluations to assess reproducibility in other areas of the UK are warranted.

Background: Hospitals should adopt multiple methods to monitor incidents for a comprehensive review of the types of incidents that occur. Contrary to traditional incident reporting systems, the Green Cross (GC) method is a simple visual method to recognise incidents based on teamwork and safety briefings. Its longitudinal effect on patient safety culture has not been previously assessed. This study aimed to explore whether the implementation of the GC method in a postanaesthesia care unit changed nurses' perceptions of different factors associated with patient safety culture over 4 years.

Methods: A longitudinal quasi-experimental pre-post intervention design with a comparison group was used. The intervention unit and the comparison group, which consisted of nurses, were recruited from the surgical department of a Norwegian university hospital. The intervention unit implemented the GC method in February 2019. Both groups responded to the staff survey before and then annually between 2019 and 2022 on the factors 'work engagement', 'teamwork climate' and 'safety climate'. The data were analysed using logistic regression models.

Results: Within the intervention unit, relative to the changes in the comparison group, the results indicated significant large positive changes in all factor scores in 2019, no changes in 2020, significant large positive changes in 'work engagement' and 'safety climate' scores in 2021 and a significant medium positive change in 'work engagement' in 2022. At baseline, the comparison group had a significantly lower score in 'safety climate' than the intervention unit, but no significant baseline differences were found between the groups regarding 'work engagement' and 'teamwork climate'.

Conclusion: The results suggest that the GC method had a positive effect on the nurses' perception of factors associated with patient safety culture over a period of 4 years. The positive effect was completely sustained in 'work engagement' but was somewhat less persistent in 'teamwork climate' and 'safety climate'.

Introduction: In any healthcare setting, cardiopulmonary resuscitations (CPRs) stand out as demanding and chaotic resuscitation endeavours. Emergency departments (EDs) witness a significant volume of CPRs. Given the critical nature of CPR, content knowledge and procedural skills alone fall short in delivering optimal care. Effective teamwork, complemented by a well-coordinated response, is imperative for achieving favourable patient outcomes. A survey conducted in our ED highlighted that while the majority of staff acknowledged the significance of teamwork in CPR and were aware of the whiteboard for assigning team roles, only 19% were familiar with their individual roles during CPR.

Methods: To address this gap, our project aimed to increasing the role delegation for CPR from 19% to 80% within 2 months. We formed an interprofessional team and implemented strategies through four plan-do-study-act cycles. Interventions encompassed increasing sensitisation, creating a simplified format for assigning team roles and entrusting the nursing team leader of each shift with the responsibility of role assignment for accountability. The sharing of progress charts for acknowledgment served as a motivating factor, leading to sustained adherence to the project goals without necessitating reminders in the final two weeks.

Results: This project proved to be highly successful as our process indicator steadily increased and remained above the target for 4 consecutive weeks.

Conclusion: Our results underscore the importance of patience and teamwork in achieving project objectives. It serves as a good example of the efficiency of simple and cost-effective interventions, one that can be replicated and implemented in other EDs.