Highlights • A new ventilator-associated pneumonia prevention bundle using a systematic approach to elicit clinician perceptions on potential interventions for ventilator-associated pneumonia was ...developed. • There were 65 potential interventions identified through an extensive literature review. • A 2-step Delphi method was implemented to gain consensus on the final list of interventions. • There were 155 clinicians with expertise and interest in ventilator-associated pneumonia treatment and prevention who participated in the process of consensus development. • There were 5 process and 14 structural or policy-driven interventions identified.
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Background Surgical site infections (SSI) are a common and costly problem, prolonging hospitalization and increasing readmission. Adherence to well-known infection control process measures has not ...been associated with substantial reductions in SSI. To date, the global burden of preventable SSI continues to result in patient harm and increased health care costs on a broad scale. Study Design We designed a study to evaluate the association between implementation of a surgery-based comprehensive unit-based safety program (CUSP) and postoperative SSI rates. One year of pre- and post-CUSP intervention SSI rates were collected using the high-risk pilot module of the American College of Surgeons National Surgical Quality Improvement Program (July 2009 to July 2011). The CUSP group met monthly and consisted of a multidisciplinary team of front-line providers (eg, surgeons, nurses, operating room technicians, and anesthesiologists) who were directly involved in the care of colorectal surgery patients. Surgical Care Improvement Project process measure compliance was monitored using standard methods from the Centers for Medicare and Medicaid Services. Results In the 12 months before implementation of the CUSP and interventions, the mean SSI rate was 27.3% (76 of 278 patients). After commencement of interventions, the rate was 18.2% (59 of 324 patients) for the subsequent 12 months—a 33.3% decrease (95% CI, 9–58%; p < 0.05). The interventions included standardization of skin preparation; administration of preoperative chlorhexidine showers; selective elimination of mechanical bowel preparation; warming of patients in the preanesthesia area; adoption of enhanced sterile techniques for skin and fascial closure; addressing previously unrecognized lapses in antibiotic prophylaxis. There was no difference in surgical process measure compliance as measured by the Surgical Care Improvement Project during the same time period. Conclusions Formation of small groups of front-line providers to address patient harm using local wisdom and existing evidence can improve patient safety. We demonstrate a surgery-based CUSP intervention that might have markedly decreased SSI in a high-risk population.
Background The goals of quality improvement are to partner with patients and loved ones to end preventable harm, continuously improve patient outcomes and experience, and eliminate waste, yet few ...programs have successfully worked on of all these in concert. Study Design We evaluated implementation of a pathway designed to improve patient outcomes, value, and experience in colorectal surgery. The pathway expanded on pre-existing comprehensive unit-based safety program infrastructure and used trust-based accountability models at each level, from senior leaders (chief financial officer and senior vice president for patient safety and quality) to frontline staff. It included preoperative education, mechanical bowel preparation with oral antibiotics, chlorhexidine bathing, multimodal analgesia with thoracic epidurals or transversus abdominus plane blocks, a restricted intravenous fluids protocol, early mobilization, and resumption of oral intake. Eleven months of pre- and post-pathway outcomes, including length of stay (LOS), National Surgical Quality Improvement Program surgical site infection (SSI), venous thromboembolism, and urinary tract infection rates, patient experience, and variable direct costs were compared. Results Three hundred ten patients underwent surgery in the baseline period, the mean LOS was 7 days, and the mean SSI rate was 18.8%. There were 330 patients who underwent surgery on the pathway, the LOS was 5 days, and the rate of SSI was 7.3%. Patient experience improved and variable direct costs decreased. Conclusions Our trust-based accountability model, which included both senior hospital leadership and frontline providers, provided an enabling structure to rapidly implement an integrated recovery pathway and quickly improve outcomes, value, and experience of patients undergoing colorectal surgery. The study findings have significant implications for spreading surgical quality improvement work.
Abstract Purpose The aim of this study was to describe the design and lessons learned from implementing a large-scale patient safety collaborative and the impact of an intervention on teamwork ...climate in intensive care units (ICUs) across the state of Michigan. Materials and Methods This study used a collaborative model for improvement involving researchers from the Johns Hopkins University and Michigan Health and Hospital Association. A quality improvement team in each ICU collected and submitted baseline data and implemented quality improvement interventions. Primary outcome measures were improvements in safety culture scores using the Teamwork Climate Scale of the Safety Attitudes Questionnaire (SAQ); 99 ICUs provided baseline SAQ data. Baseline performance for adherence to evidence-based interventions for ventilated patients is also reported. The intervention to improve safety culture was the comprehensive unit-based safety program. The rwg statistic measures the extent to which there is a group consensus. Results Overall response rate for the baseline SAQ was 72%. Statistical tests confirmed that teamwork climate scores provided a valid measure of teamwork climate consensus among caregivers in an ICU, mean rwg was 0.840 (SD = 0.07). Teamwork climate varied significantly among ICUs at baseline (F98, 5325 = 5.90, P < .001), ranging from 16% to 92% of caregivers in an ICU reporting good teamwork climate. A subset of 72 ICUs repeated the culture assessment in 2005, and a 2-tailed paired samples t test showed that teamwork climate improved from 2004 to 2005, t (71) = −2.921, P < .005. Adherence to using evidence-based interventions ranged from a mean of 25% for maintaining glucose at 110 mg/dL or less to 89% for stress ulcer prophylaxis. Conclusion This study describes the first statewide effort to improve patient safety in ICUs. The use of the comprehensive unit-based safety program was associated with significant improvements in safety culture. This collaborative may serve as a model to implement feasible and methodologically rigorous methods to improve and sustain patient safety on a larger scale.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Since the publication of “A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals” in 2008, prevention of healthcare-associated infections (HAIs) has become a ...national priority. Despite improvements, preventable HAIs continue to occur. The 2014 updates to the Compendium were created to provide acute care hospitals with up-to-date, practical, expert guidance to assist in prioritizing and implementing their HAI prevention efforts. They are the product of a highly collaborative effort led by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise, including the Centers for Disease Control and Prevention (CDC), the Institute for Healthcare Improvement (IHI), the Pediatric Infectious Diseases Society (PIDS), the Society for Critical Care Medicine (SCCM), the Society for Hospital Medicine (SHM), and the Surgical Infection Society (SIS).
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Background Minority groups in the US have comparatively poorer access to a range of health care services. Access can be considered a function of opportunity and use and can vary with the level of ...segregation within a county. We hypothesized that with varying levels of segregation, increasing the proportion of the minority population within a county was accompanied by decreasing levels of access to surgical care. Study Design A cross-sectional analysis was performed on data from the 2004 Area Resource File. Each county in the US was categorized into one of three levels: most, moderately, or least segregated, using the Isolation Index. Multivariable linear regression analysis was performed to examine the association between access to surgical services and proportion of minority population with varying levels of segregation adjusting for socioeconomic and health characteristics. Results In the most segregated counties, each percentage point increase in Hispanic or African-American population was associated with a statistically significant decrease in outpatient surgery volume (p < 0.0001), ambulatory surgical facilities (p < 0.0001), and number of general surgeons (p < 0.0001). In the least segregated counties, these associations showed no statistical significance. A significant increase (p < 0.0001) in the volume of emergency medical visits was associated with increasing proportions of African-American and Hispanic populations within the most segregated counties. Conclusions In the most segregated counties, an increase in the African-American or Hispanic population was associated with a decrease in the availability and use of surgical services and an increase in emergency visits after adjustment for socioeconomic and health characteristics.
Background Although RBC transfusions can be lifesaving, recent evidence suggests that their use is associated with added morbidity and mortality and that a lower transfusion threshold is safe. It is ...unclear if this new evidence has translated into decreased RBC use among surgical patients. The purpose of this study is to measure the change in use of RBCs during the last decade. Study Design We performed a cross-sectional cohort study of all patients who underwent inpatient operations in the 52 hospitals in Maryland in 1997 to 1998 and 2004 to 2005. The primary outcomes variable was whether or not the patient received an allogeneic RBC transfusion. We controlled for confounders related to RBC transfusion, including age, gender, race, type of admission, comorbid conditions, and surgeon patient-volume. Results Patients receiving RBCs were older (63 versus 52 years), were more likely to be admitted through the emergency department (37% versus 24%) or as a readmission (12% versus 6.9%), had more Romano-Charlson index comorbidities, and had a higher unadjusted mortality (6.5% versus 1.1%). Comparing 1997 to 1998 to 2004 to 2005, RBC use in surgical patients increased (8.9% versus 14%), although unadjusted mortality decreased (2.0% versus 1.5%). Factors associated with higher adjusted relative risk (RR) of transfusion include age older than 65 years (RR = 2.45), unscheduled admissions (emergency department RR = 1.32, readmission RR = 1.62), Romano-Charlson comorbidities (RR = 1.04 to 2.71), third quartile of surgeon volume (RR = 1.10), death (RR = 1.24), and having operations in 2004 to 2005 (RR = 1.42). Conclusions Despite evidence supporting more restrictive use of RBC transfusions, RBC use among surgical patients has increased during the last decade.
Far too many patients suffer preventable harm from medical errors that add to needless suffering and cost of care. Underdeveloped residency training programmes in patient safety are a major ...contributor to preventable harm. Consequently, the Institute of Medicine has called for health professionals to reform their educational programmes to advance health-care safety and quality. Additionally, the Accreditation Council for Graduate Medical Education (ACGME) now requires education in ‘systems-based practice’ and ‘practice-based learning and improvement’ as core competencies of residency training programmes. The specific aim of this article is to describe the implementation of a novel programme designed to enhance residency education, meet ACGME core competencies and improve quality and safety education in one residency programme at an academic medical institution.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
9.
Monitoring patient safety Berenholtz, Sean M; Pronovost, Peter J
Critical care clinics,
07/2007, Volume:
23, Issue:
3
Journal Article
Peer reviewed
The opportunity to improve patient safety is significant and the pressure to improve it is increasing. An approach to evaluate an organization's progress with patient safety efforts has not been ...clearly articulated, and existing efforts to monitor safety are likely inadequate. We present a framework to monitor patient safety, combining valid rate-based measures to evaluate outcomes and processes of care, and non-rate-based measures to evaluate structure and context of care. We present an example of how the safety scorecard from this framework is used to monitor patient safety at The Johns Hopkins Hospital and in over 150 ICUs in Michigan, New Jersey, and Rhode Island.
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