BMJ Open Quality最新文献

Background: Central line-associated bloodstream infection (CLABSI) is a major contributor to morbidity and mortality among neonates admitted to the neonatal intensive care unit (NICU). Point-of-care quality improvement (POCQI) methods can reduce the rate of CLABSI by improving compliance with the care bundle.

Methods: A quality improvement study comprising three phases was planned in the NICU of a tertiary care hospital in western India to assess the impact of the central line care bundle. Baseline data were collected for 8 weeks to find the incidence of CLABSI. An aim statement was made and a team formed. A root cause analysis was conducted to identify the factors contributing to the high rate of CLABSI. Various changed ideas were tested in plan-do-study-act cycles and monitored with process indicators. Ideas were adopted or adapted based on their impact. Compliance with insertion and maintenance bundles was used as a process indicator, while the CLABSI rate served as an outcome indicator.

Results: CLABSI rate reduced from 66/1000 catheter days (May 2023) to 18/1000 catheter days (95% CI 0.14 to 0.79; p value 0.012) during the study. Insertion bundle compliance increased to 85% during the intervention phase and 70% during the sustainability phase. Maintenance bundle compliance was 45% and 35% during the intervention and sustainability phases, respectively.

Conclusion: POCQI methods can help increase bundle care compliance in the NICU and reduce CLABSI rates in low- and middle-income country settings.

Due to growing awareness of risks associated with benzodiazepine (BZD) use, these medications are now considered potentially inappropriate for older adults. Despite this, older adults are more likely to receive these medications than younger adults, with those in long-term care (LTC) being particularly vulnerable, emphasising the importance of reducing BZD prescriptions. Other studies have shown success in reducing BZD prescriptions using a patient-focused multicomponent intervention: however, this approach has not been well studied in LTC.During a seventeen-month quality improvement (QI) initiative conducted in an Edmonton LTC facility, a patient-focused multicomponent intervention (pharmacist-led medication review, counselling, patient and staff education, and new patient information resources) was implemented to reduce BZD prescriptions by 50%. Outcome measures included changes in BZD prescriptions and patients' usage of BZDs, including dose and dosing frequency. Process measures included intervention component delivery, while balancing measures included financial cost, number of falls and additional medication usage.Numerous unforeseen complications arose, related to the facility and participant recruitment, which required several study adaptations. Ultimately, our goal sample size was not reached. All 10 recruited participants underwent the intervention, resulting in several individuals having their BZDs deprescribed. Although all participants received printed patient information material, few were formally educated. However, two staff education sessions were conducted, which were well attended and received. No complications ensued, and financial costs were minimal.While our QI initiative reduced BZD usage, implementation challenges and a smaller than predicted sample size likely impacted the results obtained. Staff education was well received, suggesting further education is needed. The challenges encountered require subsequent cycles to fully assess the intervention's effectiveness and sustainability, including a more comprehensive assessment of the context, enablers and barriers. By sharing our experience, we hope to optimise the success of future research initiatives, as these challenges are common within research.

Background: Anticoagulation for stroke prevention is often recommended for patients with non-valvular atrial fibrillation (AF), yet many eligible patients do not receive guideline-concordant anticoagulation. Prior quality improvement (QI) initiatives to improve anticoagulation in AF have had mixed results.

Methods: Preventing Preventable Strokes: Scalability used a triad of interventions to increase the number of eligible patients with AF receiving guideline-concordant anticoagulation, including (1) a best practice alert integrated with the electronic health record, (2) clinician education and (3) patient communication about the anticoagulation therapy that encouraged shared decision-making with clinicians. These interventions were conducted in primary care and cardiology outpatient clinics at (University of Florida Health). Patient-level data were collected during a 6-month intervention period and compared with a 6-month historical control period. Generalised estimating equations with a logistic link were used to estimate the odds of anticoagulant use, adjusting for demographic and clinical characteristics.

Results: A total of 3274 individuals were included during the intervention period and 3200 during the preintervention period. The average anticoagulation rate increased from 75.7% to 79.2% across the two periods. In the fully adjusted model, patients in the intervention period had significantly higher odds of anticoagulant use compared with the preintervention period (adjusted OR (aOR) 1.13, 95% CI 1.05 to 1.21, p=0.0007). MyChart activation (aOR 1.38, 95% CI 1.19 to 1.61, p<0.0001) was also associated with increased anticoagulant use. Older age and higher CHA₂DS₂-VASc scores were associated with greater odds of anticoagulant use, while higher HAS-BLED scores and care in primary care (rather than cardiology) were associated with lower odds.

Conclusions: A triad of QI interventions at the practice, clinician and patient levels increased guideline-concordant anticoagulation use among patients with AF in half of the primary care and cardiology clinics in the University of Florida Health system.

Referrals are a fundamental part of working life for a resident doctor, where an efficient system is needed when liaising with different specialties. Within a secondary care district general hospital, a lack of standardised protocols was recognised, which can lead to delays in patient care. The aim of this project was to improve knowledge and confidence among resident doctors when referring to specialties. A baseline study highlighted a lack of confidence among resident doctors, often relying on other colleagues when referring to each specialty. Our team created a comprehensive referrals sheet, through a series of plan-do-study-act (PDSA) cycles across a 5-year period, from 2019 to 2024. This referrals sheet described routine, urgent and out-of-hours referrals pathways for each specialty and was uploaded to the hospital's intranet for centralised access. This was then re-evaluated to assess the short-term and long-term impact of this intervention. This project resulted in a widespread improvement of doctors' knowledge of referrals within the hospital, with an average confidence of inpatient referral from 49.0% to 74.4%, and outpatient referral from 28.0% to 57.0%. This study not only solidifies the referrals sheet as a useful and sustainable resource, but highlights the importance of PDSA cycles and direct improvements in clinical workflow. Future directions could aim at referrals being integrated with hospital software, as some specialties have begun to do.

Background: The appropriate use criteria (AUC) developed by the American Academy of Orthopaedic Surgeons (AAOS) provide evidence-based guidance for managing paediatric supracondylar humerus fractures (SCHFs), yet adherence varies widely in clinical practice. This quality improvement project aimed to improve the rate of 'appropriate' management for paediatric SCHF at a tertiary referral centre in Egypt by systematically implementing the AAOS AUC through a structured, multicycle intervention.

Methods: We conducted a three-cycle plan-do-study-act quality improvement project at Mansoura University Emergency Hospital between January 2021 and May 2023, including all children under 18 years with acute SCHFs. Cycle 1 (n=58) established baseline adherence. Cycle 2 (n=62) implemented educational workshops and a departmental protocol. Cycle 3 (n=58) introduced reinforcement training, regular case discussions, visual reminders and individualised audit feedback. The primary outcome was the proportion of cases managed 'appropriately' according to the AUC.

Results: Among 178 patients, appropriate management increased from 62.1% at baseline to 75.8% after initial education and 87.9% after reinforcement interventions, representing a 25.8% absolute improvement. Rarely appropriate management decreased from 19.0% to 3.4%. The greatest improvements occurred in Gartland type II fractures. Key baseline barriers included the lack of AUC awareness (78% of surgeons unfamiliar), absence of standardised protocols and variable surgeon preferences. Following sustained educational interventions and audit feedback, AUC tool utilisation increased from 45% to 95%.

Conclusions: A phased quality improvement initiative combining education, protocolisation, reinforcement training and audit feedback significantly improved adherence to evidence-based guidelines for paediatric SCHFs. Sustained educational interventions with regular case-based discussions and individualised feedback are essential for long-term practice change. Organisational factors, particularly lack of awareness and inconsistent application of guidelines, represent the primary modifiable barriers to adherence.

Digital consent systems provide a modern alternative to traditional paper-based methods, improving legibility, documentation accuracy, compliance with National Health Service (NHS) medicolegal standards and patient understanding. This quality improvement project evaluated the implementation of a digital consent system in the Trauma and Orthopaedics department at Sandwell and West Birmingham NHS Trust, comparing paper-based consent with the digital system. Baseline data were collected retrospectively from July to August 2024 and compared with prospective data following implementation from August to October 2024, using quantitative measures of documentation quality and qualitative feedback from healthcare professionals (n=24) and patient (n=619) surveys. An iterative Plan-Do-Study-Act cycle approach was used to refine the process.Following implementation, legibility improved from 42-48% to 100% across all digital consents, and documentation of alternative treatment options increased substantially from 5% to 95% in trauma cases and from 0% to 98% in elective cases. Risks and benefits were documented in 100% of digital consents. Patient and clinician surveys demonstrated high satisfaction, with a mean System Usability Score of 77.5, comparable to high-performing consumer technology platforms. Identified barriers included accessibility issues for less digitally literate patients and technical challenges such as digital signing on smaller devices. The transition to digital consent resulted in a cumulative cost saving of £2552.90 over the first 7 months.The introduction of digital consent significantly improved documentation quality, patient and clinician satisfaction and generated measurable cost savings. Ongoing challenges relating to accessibility and technical usability require targeted interventions. This project demonstrates the potential for digital consent systems to support efficient, sustainable and patient-centred care, with opportunities for broader adoption across NHS specialties.

Background: Human and planetary health are deeply interconnected and endangered by the triple planetary crisis: climate change, biodiversity loss and pollution. Despite proactive measures being pursued to reduce healthcare's overall environmental footprint, relatively few of these are directed at primary care, notwithstanding that it accounts for up to 25% of healthcare's ecological impact. Within Ireland's primary healthcare sector, despite a growing recognition of the importance of environmentally sustainable healthcare, little is known about the perspectives of those healthcare professionals (HCPs) working in the sector to delivering more environmentally sustainable primary care services.

Methods: This qualitative descriptive study explored the knowledge and attitudes of community pharmacists, dentists, general practitioners and practice nurses working in primary care in Ireland, toward planetary health and sustainable healthcare. Semistructured interviews were conducted between May and September 2024 and analysed using inductive qualitative content analysis.

Results: Analysis of interviews (n=20) produced a broad range of insights which were consolidated into three higher order categories. Findings revealed that while HCPs recognised the importance of climate action, many felt unable to translate concern into practical change in primary care due to barriers such as a lack of knowledge, limited guidance and inadequate system-level supports. HCPs emphasised the need for targeted training, access to practical tools and clear leadership from the relevant stakeholders.

Conclusion: This study highlights the urgent need to shift from reliance on individual motivation to practice sustainably, to a coordinated public health response in Ireland. Achieving this requires educational and systemic changes, including supportive policy, incentivisation and practical sustainable interventions, to embed environmental sustainability into routine care.

Background: Obstetrical haemorrhage is a common complication of childbirth, and all patients are at risk for haemorrhage. Mortality attributable to haemorrhage has been decreasing in the USA, but the incidence of haemorrhage has continued to increase. In Ohio, one-third (31%) of all pregnancy-related deaths in 2020 were due to causes other than infection, mental health or embolisms, with 3% of those attributed to haemorrhage. Haemorrhage was the third leading cause of pregnancy-related death in the state from 2008 to 2016.

Methods: Sponsored by the Ohio Department of Children and Youth, the Hemorrhage Quality Improvement Project (QIP) applies the Institute for Healthcare Improvement's methodology to implement structured quality improvement (QI) activities to improve key measures and implement the Alliance for Innovation on Maternal Health's Obstetric Hemorrhage Patient Safety Bundle. Hospitals provided patient data and completed surveys. Data from participating hospitals were used to calculate and monitor improvement in primary process measures (quantitative blood loss and haemorrhage risk assessment).

Results: Across Ohio, 22 delivery hospitals spanning 13 health systems participated in the Hemorrhage QIP pilot. Participating hospitals achieved a statistically significant improvement in all process measures, including quantitative blood loss documentation (both overall and when limited to vaginal deliveries) and in the completion of haemorrhage risk assessment between admission and delivery.

Conclusions: The Hemorrhage QIP demonstrates feasibility of a statewide QI initiative to improve care for women who experience obstetrical haemorrhage. Delivery hospitals have clinical expertise to improve outcomes related to postpartum haemorrhage care. Providing opportunity for peer-to-peer learning, evidence-based resources and QI coaching within a replicable QI project creates an opportunity to reduce preventable morbidity and mortality caused by an obstetric haemorrhage.

Background and objectives: Medication administration errors (MAEs) are frequent and preventable. While the five rights (5R) rule and the double-check are standard practices for safe drug administration, incidents still occur. MAEs involving high-risk drugs such as opioids are a major concern, especially in older patients. To address this, a practical, error-driven training was developed through an opioid Room of Horrors (RoH) to reinforce the 5R rule and the double-check procedure and map risks within the opioid medication-use process, thereby improving the safety of opioid administration. The secondary objective was to evaluate participant satisfaction with the training.

Method: The opioid RoH integrates four errors and four hazards hidden in the opioid medication-use process. Participants, working in pairs, were asked to prepare and administer an opioid to a fictitious patient. Two assessors recorded the number of errors detected and hazards avoided. During the debriefing, assessors reviewed and explained these items to the pair of trainees combined with a refresh on the 5R rule and the double-check process. Detection and avoidance rates were analysed using descriptive statistics. Participants assessed the training through a satisfaction questionnaire.

Results: A total of 86 sessions were conducted, involving 172 participants including nurses, nurse assistants and physicians from a geriatric department. Participants detected errors such as wrong patient (60%), expired drugs (63%), incorrect strength or galenic form (55%) and documented allergy (55%), while most hazards were avoided, except for the correct device, which was used in only 65% of cases. Double-check performance was inefficient mainly focusing on the dose check. Satisfaction was high (9.2/10), and 73% of participants reported a knowledge gain.

Conclusions: The opioid RoH is an effective training to refresh and emphasise the rigorous application of the 5R rules and the double-check procedure to reduce MAEs. Additionally, this simulation showed persistent gaps such as patient identification and double-check failures, highlighting the need to strengthen safety practices through continuous training and institutional-level system improvements in medication administration safety.

Medication reconciliation is the practice of making sure that medication lists are accurate through transitions of care. This is critical to reduce medication prescription medication errors, which can compromise patient safety. Evidence indicates that communication breakdowns account for a sizable portion of prescription errors, highlighting the importance of efficient medication reconciliation.Medication reconciliation has been recognised as an important patient safety measure by Sheikh Shakhbout Medical City (SSMC), a large tertiary hospital in the United Arab Emirates. Senior leadership at SSMC, in an effort to adopt safer practices, decided to increase the outpatient medication reconciliation compliance goal to 92%; however, meeting this new goal proved difficult. According to an analysis of the first two quarters of 2023 performance data, the department of medicine's average outpatient medication reconciliation compliance rate was persistently below the new goal of 92%, at 80%.Over the course of 14 months, from August 2023 to September 2024, 133 328 patient visits were evaluated at the department of medicine outpatient specialty clinics, a busy department serving about 9500 patients each month.This publication's goal is to highlight the quality improvement initiatives that were put in place to increase outpatient medication reconciliation compliance as well as the results of those initiatives. We were able to increase the department of medicine outpatient medication reconciliation compliance rate from an average of 80% in August 2023 to 97% in April through September 2024 by applying critical thinking, technology and human factor principles. This improvement was maintained.This study highlights the need for quality improvement teams using information technology to understand the clinical context and human elements at play. The department of medicine's outpatient medication reconciliation improvement initiative paved the way for possible replication in other departments and healthcare organisations by disseminating the lessons acquired from this quality improvement project throughout the hospital.