BMJ Quality & Safety最新文献

Background: Improving small and sick newborn care (SSNC) is crucial in resource-limited settings. Newborn Essential Solutions and Technologies (NEST360), a multicountry alliance, aims to reduce newborn mortality through evidence-based interventions. NEST360 developed a multipronged approach to improving quality. We use implementation research (IR) to describe this approach and report emerging implementation outcomes.

Methods: The implementation research logic model (IRLM) was applied to link contextual factors, implementation strategies, mechanisms and implementation outcomes, capturing successes and challenges of the improving quality approach. Data sources included programme data, peer-reviewed publications and team input. Contextual factors were organised by the NEST360-UNICEF SSNC implementation toolkit. Strategies were grouped by the Expert Recommendations for Implementation Change list, and implementation outcomes were measured using Proctor's implementation outcomes.

Results: We developed an IRLM to describe the implementation of NEST360's improving quality model. This IRLM included 33 contextual factors; 42% were barriers, 42% were facilitators, and 15% were both a barrier and facilitator. Additionally, we identified 10 implementation strategies that NEST360 used. The logic model also describes the connections between the contextual factors, the strategies that address them, and the preliminary implementation outcomes. Examples of the outcomes measured include Reach with 100% of units logging into the NEST360-Implementation Tracker (NEST-IT) at least once (October 2023 to March 2024), Adoption with 100% of units conducting a quality improvement (QI) project (April 2024 to June 2024), and Feasibility with 93% of units reporting NEST-IT data in their QI project documentation (April 2024 to June 2024). Finally, this study identified sustainability strategies as a critical need.

Conclusions: Integrating IR and QI enhances SSNC in resource-limited settings. Addressing barriers, leveraging facilitators and using structured IR frameworks advanced QI efforts, thereby improving intervention reach, adoption and feasibility while building scalable systems for high-quality healthcare.

Background: The Child Opportunity Index (COI) is a multidimensional measure of US neighbourhood-level conditions needed for healthy development. COI is associated with healthcare delivery and outcomes. Formal quality improvement (QI) may influence the relationship between COI, quality of care and outcomes in children.

Objective: To assess the association between COI and paediatric sepsis care delivery and outcomes and determine if baseline disparities in care change over time among hospitals in the Improving Pediatric Sepsis Outcomes (IPSO) collaborative.

Methods: Retrospective cohort study of IPSO patients probabilistically linked to the Pediatric Health Information System database from 2017 to 2021. Primary exposure was COI. We estimated differences in the proportions of patients in each COI quintile identified via standardised sepsis recognition protocols (screening tool, huddle documentation and/or order set use) and who received a bundle of recommended care (standardised sepsis recognition, plus bolus <1 hour and antibiotic <3 hours). We further assessed the timeliness of each bundle component and mortality. We evaluated changes in standardised sepsis recognition over time using generalised linear models.

Results: 31 260 sepsis cases from 24 hospitals were included. Cross-sectional analysis over the entire study period found patients in the Very High COI quintile were most likely to be identified via standardised recognition protocols and receive IPSO's recommended care bundle (67.7% and 46%, respectively). Over time, standardised sepsis recognition improved for all; the greatest improvements were among inpatients in the Very Low COI quintile.

Conclusion: Disparities exist in paediatric sepsis care delivery by COI. Over the course of the IPSO collaborative, care improved most for children in the lowest COI quintile. QI collaboratives focused on standardisation and shared learning may reduce disparities.

Background: Since 2015, the National Institute for Health and Care Excellence (NICE) guidelines have recommended antenatal magnesium sulfate (MgSO₄) for mothers in preterm labour (<30 weeks' gestation) to reduce the risk of cerebral palsy (CP) in the preterm baby. However, the implementation of this guideline in clinical practice was slow, and MgSO₄ use varied between maternity units. In 2018, the PRrevention of Cerebral palsy in PreTerm labour (PReCePT) programme, an evidence-based quality improvement (QI) intervention to improve use of MgSO₄, was rolled out across England. Earlier evaluation found this programme to be effective and cost-effective over the first 12 months. We extended the original evaluation to determine the programme's longer-term impact over 4 years, its impact in later preterm births, the impact of the COVID-19 pandemic, and to compare MgSO₄ use in England (where PReCePT was implemented) to Scotland and Wales (where it was not).

Methods: Quasi-experimental longitudinal study using data from the National Neonatal Research Database on babies born <30 weeks' gestation and admitted to a National Health Service neonatal unit. Primary outcome was the percentage of eligible mothers receiving MgSO₄, aggregated to the national level. Impact of PReCePT on MgSO₄ use was estimated using multivariable linear regression. The net monetary benefit (NMB) of the programme was estimated.

Results: MgSO₄ administration rose from 65.8% in 2017 to 85.5% in 2022 in England. PReCePT was associated with a 5.8 percentage points improvement in uptake (95% CI 2.69 to 8.86, p<0.001). Improvement was greater when including older preterm births (<34 weeks' gestation, 8.67 percentage points, 95% CI 6.38 to 10.96, p<0.001). Most gains occurred in the first 2 years following implementation. PReCePT had a NMB of £597 000 with 89% probability of being cost-effective. Following implementation, English uptake appeared to accelerate compared with Scotland and Wales. There was some decline in use coinciding with the onset of the pandemic.

Conclusions: The PReCePT QI programme cost-effectively improved use of antenatal MgSO₄, with anticipated benefits to the babies who have been protected from CP.

Background: This study addresses the need for a comprehensive, evidence-informed conceptually based quality framework for structures and processes of perioperative care.

Methods: We combined a rapid review of international academic literature and UK grey literature with a participatory consultation. The review included primary studies, guidelines and grey literature identified through searches of PsycINFO, MEDLINE, CINAHL and institutional websites. Findings were synthesised across studies using an inductive process, with key concepts identified, mapped, refined and organised into a preliminary framework. We consulted with UK-based multidisciplinary professionals and patient/carer representatives (public contributors), who together formed a 14-person Expert Collaborative Group using a participatory exercise hosted on the Thiscovery online platform. Descriptive analysis was used for quantitative responses and content analysis was used for free text analysis.

Results: We were able to develop a 10-domain framework that encapsulates structural and process-related features important to high-quality perioperative care, using the rapid review to generate a preliminary framework and consultation with professionals and public contributors to refine it. The final framework, termed 'Perioperative Framework'(P-Frame), comprises domains covering environment and facilities, leadership and governance, organisational culture, shared decision-making, multidisciplinary working, patient optimisation, clinical protocols, post-operative support, staff education and workforce planning. Importantly, the framework integrates the perspectives of patients and carers and seeks to ensure relevance across clinical, operational and experiential dimensions of care.

Conclusions: P-Frame, based on the available evidence and the views of UK clinicians and patients, offers a potentially valuable tool for monitoring and improving perioperative care quality as well as supporting research efforts. It will benefit from further evaluation and testing of use in practice in different contexts and countries.