BMJ Open Quality最新文献

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.

Background: In southwest Netherlands, hospitals collaborate to provide high-quality care for inflammatory bowel disease (IBD). To achieve this, a care pathway (CP) was implemented for treating IBD with advanced therapies. This study assessed the adherence to the CP and identified implementation barriers and facilitators.

Methods: A mixed-methods study was conducted. Quantitative data collected from health records from December 2020 to March 2023 were used to evaluate adherence, and differences were analysed with generalised mixed models. Surveys and semistructured interviews with healthcare providers (HCPs) were used to identify barriers and facilitators, using the extended normalisation theory.

Results: The study included 299 patients. Documentation of repeated screening for infectious diseases when prior tests exceeded 1 year decreased (p<0.001). Adherence to ordering blood tests as advised increased (p<0.001). For patients experiencing a flare, a small but significant increase was observed in the use of validated questionnaires for scoring disease activity (p=0.004). Adherence improved in registering smoking status (p=0.003), side effects (p<0.001), medication adherence (p<0.001) and ordering advised blood tests as recommended (p<0.001). Weight registration decreased (p=0.002).From 85 surveys, 42 were completed, with 11 interviews conducted. Facilitators were improving collaboration and the potential to standardise care. Barriers were the complexity of the implementation in health records, the difficulty for providers to change routines and IBD heterogeneity.

Conclusions: Adherence to the CP appears to be challenging, due to the difficulty HCPs experience in changing routines. Discrepancies between performed and documented tasks may affect adherence rates. The gradual improvement suggests increased familiarity with the CP may enhance adoption.

Trial registration: MEC-2020-075.

Background: Since 2006, the Australian government has expanded access to primary mental healthcare for youth aged 12-25 years through the headspace platform. However, structural barriers exist in the integration of headspace centres with local state-funded specialised mental health services. The aim of this study was to translate an emerging service integration framework (Youth Integration Project (YIP)) into a tool to determine levels of integration between headspace and local specialist services/programme and identify areas for improving service integration.

Method: The Rating of Integrated Health Services (RIHS) survey was developed based on the YIP framework to assess levels of youth mental health service integration in New South Wales (NSW) local health districts (LHDs). Managers of specialist services/programmes across 18 LHDs in NSW were invited to complete the RIHS survey. Responses were coded into indicators of levels of integrated care and aggregated into an overall assessment of service integration.

Results: Validity of the RIHS scales was indicated by positive correlations with independent items of service integration. In relation to integration levels, 41/56 services/programmes had minimal-to-basic levels of integration with headspace centres. The results were consistent across programmes and regions. Three structural areas of interagency collaboration were identified for improving service integration: (i) information systems, communication, products and technology; (ii) financing; and (iii) leadership, governance, policy and values.

Conclusions: The results provide evidence of the significantly fragmented youth mental healthcare system in Australia. There is a need to address structural aspects of service integration to improve integration between headspace and LHD services for young people.

Background: Therapeutic inertia (TI), the failure to intensify or de-intensify treatment when appropriate, is a contributor to poor guideline adherence in diabetes treatment, including the suboptimal use of sodium-glucose cotransporter 2 inhibitors (SGLT-2is) and glucagon-like peptide-1 receptor agonists (GLP-1RAs).

Methods: We developed a multifaceted improvement initiative targeting TI at four academic primary care practices, aiming to increase rates of SGLT-2i and GLP-1RA use for patients with type 2 diabetes (T2DM). Prescribing trends for GLP-1RAs, SGLT-2is, sulfonylureas and insulin were compiled quarterly over a 12-month baseline period and 12-month intervention period and analysed using interrupted time series analyses. Providers completed a brief questionnaire assessing project feasibility and acceptability.

Results: GLP-1RA prescribing showed an upward trend during both the baseline and intervention periods (+0.70% vs +0.87% per quarter; p=0.14 for difference) and increased significantly in the first intervention quarter (+1.73%; p=0.003). SGLT-2i prescribing was static during the baseline period, showed an upward trend during the intervention (0.0% vs +0.43% per quarter; p=0.05 for difference) and increased significantly in the first intervention quarter (+1.0%; p=0.03). In those prescribed a GLP-1RA or an SGLT-2i, sulfonylurea prescribing dropped significantly after intervention (-2.0% per quarter; p=0.02). Insulin prescribing rates did not change throughout the study period. There was no significant change in haemoglobin A1c among patients newly prescribed a GLP-1RA and/or an SGLT-2i during the intervention period (7.3% ±1.5% baseline vs 7.2% ±1.4% intervention period, p=0.23). Most providers indicated that they had prescribed (90%) and were more likely to prescribe (81%) GLP-1RAs and/or SGLT-2is in the future because of their participation.

Conclusions: A quality improvement initiative targeting drivers of TI was associated with increased rates of guideline-based medication prescribing for primary care patients with diabetes and may be applied to other conditions in which TI limits care optimisation or guideline adherence.

Background: Orphan and vulnerable children (OVC) are at a heightened risk of poor health outcomes, particularly in areas with a high prevalence of HIV/AIDS. Viral load (VL) testing is a vital component of HIV care that enables early detection of treatment failure and improves health outcomes. During the first half of the US Agency for International Development Family Focused HIV Prevention, Care and Treatment activity implementation (October 2023-March 2024), OVC VL testing coverage in Jinka town was 89%. This shortfall affects the timely diagnosis and treatment adjustments for OVC, posing a challenge in achieving the third 95% HIV target. This quality improvement (QI) project aims to improve VL testing coverage among OVC in Jinka town.

Method: A multidisciplinary QI team used the fishbone diagram to identify the root causes of low VL testing coverage. The nationally adopted model for improvement was employed using the plan-do-study-act (PDSA) cycles. Baseline data were taken from January to March 2024. The QI project was implemented from 1 April to 30 September 2024, for 6 months. A run chart was used to track the progress of the QI project and enforce evidence-based decision-making.

Interventions: The QI team tailored five well-worked interventions tested in three PDSA cycles, including appointment date reminders for OVC caregivers, on-the-job capacity building and targeted supportive supervision for staff, conducting caregiver awareness sessions, weekly VL result tracking and feedback mechanism and enhancing community-facility linkages.

Results: The run chart demonstrated a 7% increment in OVC VL testing coverage, evidenced by six consecutive data points above the median line, indicating a statistically significant association between the identified QI gap and the implemented interventions.

Conclusion: The QI project effectively improved the OVC VL testing coverage in Jinka town. This collaboration not only improves the VL testing coverage but also provides a comprehensive supportive environment for caregivers and families affected by HIV in the area.

Transthoracic echocardiograms (TTEs) have limited value in guiding management of normotensive patients with acute pulmonary embolism (PE). Nevertheless, TTEs are frequently ordered inappropriately. This quality improvement project aimed to decrease inappropriate TTE orders by 30% over 6 months in patients with PE admitted to general internal medicine at a community hospital. Two interventions were implemented using successive plan-do-study-act (PDSA) cycles: educational sessions for physicians and the distribution of TTE-ordering algorithms for triaging of TTE appropriateness. Four audits on TTE orders for inpatients with PE were conducted throughout the project: a pre-intervention audit (pre-audit; March to August 2020), a post-intervention 1 audit (post-I1; August to September 2022), a post-intervention 2 audit (post-I2; December 2022 to February 2023) and a post-intervention audit (post-audit; March to August 2023). The primary outcome measure was the proportion of inappropriate to appropriate TTE orders during the pre-intervention and post-intervention periods. During the pre-audit, post-I1, post-I2 and post-audit periods, 89, 23, 20 and 158 patients, respectively, were admitted with PEs. 37, 10, 3 and 14 patients in each of these periods, respectively, received a TTE for PE-related reasons and were therefore included in the audits. 42%, 43%, 15% and 24% of patients, respectively, received a TTE for PE-related reasons. 89%, 50%, 67% and 79% of those TTEs, respectively, were inappropriate. There was a transient decrease in inappropriate to appropriate TTE orders ratio after the first intervention (p<0.005). Inappropriate investigations lead to additional healthcare costs and delays in patient care. This quality improvement project highlights an ongoing need to increase awareness surrounding TTE indications to improve appropriate utilisation. Next steps include further PDSA cycles with additional interventions to continue to try and decrease inappropriate TTE orders in the community hospital setting.

Background: Completing the red reflex examination (RRE) of the eyes to screen for ophthalmologic abnormalities is an essential component of the newborn physical examination. An abnormal RRE should prompt consultation with an ophthalmologist to perform a formal ocular examination.

Local problem: Chart review at a level IV neonatal intensive care unit (NICU 1) noted a low rate of documentation that the RRE was completed prior to discharge for eligible patients and suboptimal rates at three other NICUs of varying acuities and operational structures (NICUs 2, 3, 4). This prompted the initiation of a quality improvement initiative to improve RRE completion before discharge.

Methods and interventions: A driver diagram was generated to guide testing and implementation of interventions including ophthalmoscope placement, clinician education and electronic health record (EHR) reminders over eight plan-do-study-act cycles at NICU 1. Using the knowledge gained from NICU 1, two impactful tests of change were utilised to perform a 2 ^∧ 2 factorial planned experiment (PE) at NICUs 2, 3 and 4.

Results: This initiative led to sustained improvement in completion of the RRE from baseline 66.8% (13-month period) to 100% (22-month intervention period with special cause noted) at NICU 1 with two abnormal RREs detected. The PE using established factors from NICU 1 at NICUs 2, 3 and 4 demonstrated that the combination of ophthalmoscope placement optimisation plus EHR RRE trigger led to 100% RRE compliance at all sites.

Conclusion: This initiative led to a sustained improvement in RRE completion at NICU 1. PE at three other NICUs of varying types and staffing structures identified a synergistic set of change factors, which may yield the greatest improvement across the spectrum of NICUs.

Background: Patients presenting emergently with chest pain often experience delays in obtaining an ECG. Studies have found variability in care for patients with acute coronary syndrome, with many patients facing delays to receiving timely ECGs. Delays in acquisition are associated with increased morbidity and mortality.

Local problem: Prior to our intervention, median time to ECG in the emergency department (ED) was 16.7 min, with peak times reaching 20.7 min in January 2024, exceeding American College of Cardiology/American Heart Association guidelines recommending an ECG within 10 min of arrival. Contributing factors included workflow inefficiencies, inadequate staffing and process inconsistency.

Methods: A quality improvement initiative was implemented from February 2024 to February 2025 aimed at reducing time to ECG and time to ECG interpretation. Key interventions included nursing education, process standardisation, stamps to standardise documentation, ECG responsibility reallocation (triage ECGs done by nurses, floor ECGs done by techs) and the creation of a designated ECG space in triage.

Results: There were 3510 eligible ECGs conducted across the 12-month intervention period with 1522 ECGs (43.4%) meeting the <10 min goal. The initiative led to a reduction in time to ECG by 4.68 min (95% CI -7.74 to -1.62), a 10.8% reduction in median door-to-ECG time from 1 year prior to the intervention (12.9 min to 11.4 min), and a 32% reduction in median door-to-ECG time (16.7 min to 11.4 min) from 6 months prior to the intervention. There was a 74% reduction in median ECG interpretation time (101 min to 26.5 min) over 12 months.

Conclusions: Process standardisation, role delegation and education effectively reduced ECG times in the ED. Changes in staff who complete ECGs and standardisation of documentation may aid in improving performance metrics in ED settings.