Objectives To evaluate the extent to which intensive care units participating in the initial Keystone ICU project sustained reductions in rates of catheter related bloodstream infections.Design ...Collaborative cohort study to implement and evaluate interventions to improve patients’ safety. Setting Intensive care units predominantly in Michigan, USA.Intervention Conceptual model aimed at improving clinicians’ use of five evidence based recommendations to reduce rates of catheter related bloodstream infections rates, with measurement and feedback of infection rates. During the sustainability period, intensive care unit teams were instructed to integrate this intervention into staff orientation, collect monthly data from hospital infection control staff, and report infection rates to appropriate stakeholders.Main outcome measures Quarterly rate of catheter related bloodstream infections per 1000 catheter days during the sustainability period (19-36 months after implementation of the intervention).Results Ninety (87%) of the original 103 intensive care units participated, reporting 1532 intensive care unit months of data and 300 310 catheter days during the sustainability period. The mean and median rates of catheter related bloodstream infection decreased from 7.7 and 2.7 (interquartile range 0.6-4.8) at baseline to 1.3 and 0 (0-2.4) at 16-18 months and to 1.1 and 0 (0.0-1.2) at 34-36 months post-implementation. Multilevel regression analysis showed that incidence rate ratios decreased from 0.68 (95% confidence interval 0.53 to 0.88) at 0-3 months to 0.38 (0.26 to 0.56) at 16-18 months and 0.34 (0.24-0.48) at 34-36 months post-implementation. During the sustainability period, the mean bloodstream infection rate did not significantly change from the initial 18 month post-implementation period (−1%, 95% confidence interval −9% to 7%).Conclusions The reduced rates of catheter related bloodstream infection achieved in the initial 18 month post-implementation period were sustained for an additional 18 months as participating intensive care units integrated the intervention into practice. Broad use of this intervention with achievement of similar results could substantially reduce the morbidity and costs associated with catheter related bloodstream infections.
Objectives To examine geographic and demographic variation for outpatient tonsillectomy in children nationally. Study design The 2006 National Survey of Ambulatory Surgery was analyzed to describe ...outpatient tonsillectomy in children. Rates by age, sex, region, urban/rural residence, and payment source were calculated with 2006 population estimates from the Census Bureau and the National Health Interview Survey as denominators. Rates were compared with Z tests. Results In 2006, approximately 583 000 (95% CI, 370 000-796 000) outpatient tonsillectomy procedures were performed in children in the United States. Rates per 10 000 children were lower in children 13 to 17 years old (33.8 per 10 000) than in both children 7 to 12 years old (91.3; P < .05) and children 0 to 6 years old (102.9; P < .001). Compared with the South, tonsillectomy rates were lower in the West (29 per 10 000 versus 125 per 10 000; P < .01) and not significantly different in other regions. Compared with large central metropolitan areas, tonsillectomy rates were higher in small/medium metropolitan areas (118 per 10 000 versus 42 per 10 000; P < .05), and not significantly different in large fringe or non-metropolitan areas. Tonsillectomy rates were similar for children insured by Medicaid compared with those insured by private sources. Compared with older children (13-17 years), children in the younger age groups (0-6 years, 7-12 years) underwent tonsillectomy more commonly for airway obstruction (69.5% and 59.2% versus 34.3%, P < .05 for both). Compared with older children, younger children (0-6 years) underwent tonsillectomy less commonly for infection (40.4% versus 61.0% 7-12 years and 72.2% 13-17 years, P < .001 for both). Conclusions Use of tonsillectomy in the ambulatory setting varies across age groups, geographic regions, levels of urbanization, and indication. Further research is warranted to examine these differences.
Abstract Purpose Teamwork is essential for ensuring the quality and safety of health care delivery in the intensive care unit (ICU). This article addresses what we know about teamwork, team tasks, ...and team improvement strategies in the ICU to identify the strengths and limitations of the existing knowledge base to guide future research. Methods A keyword search of the PubMed database was conducted in February 2013. Keyword combinations focused on 3 areas: (1) teamwork, (2) the ICU, and (3) training/quality improvement interventions. All studies that investigated teamwork, team tasks, or team interventions within the ICU (ie, intradepartment) were selected for inclusion. Results Teamwork has been investigated across an array of research contexts and task types. The terminology used to describe team factors varied considerably across studies. The most common team tasks involved strategy and goal formulation. Team training and structured protocols were the most widely implemented quality improvement strategies. Conclusions Team research is burgeoning in the ICU, yet low-hanging fruit remains that can further advance the science of teams in the ICU if addressed. Constructs must be defined, and theoretical frameworks should be referenced. The functional characteristics of tasks should also be reported to help determine the extent to which study results might generalize to other contexts of work.
To determine the causal effects of an intervention proven effective in pre-post studies in reducing central line-associated bloodstream infections in the intensive care unit.
We conducted a ...multicenter, phased, cluster-randomized controlled trial in which hospitals were randomized into two groups. The intervention group started in March 2007 and the control group started in October 2007; the study period ended September 2008. Baseline data for both groups are from 2006.
Forty-five intensive care units from 35 hospitals in two Adventist healthcare systems.
A multifaceted intervention involving evidence-based practices to prevent central line-associated bloodstream infections and the Comprehensive Unit-based Safety Program to improve safety, teamwork, and communication.
We measured central line-associated bloodstream infections per 1,000 central line days and reported quarterly rates. Baseline average central line-associated bloodstream infections per 1,000 central line days was 4.48 and 2.71, for the intervention and control groups (p = .28), respectively. By October to December 2007, the infection rate declined to 1.33 in the intervention group compared to 2.16 in the control group (adjusted incidence rate ratio 0.19; p = .003; 95% confidence interval 0.06-0.57). The intervention group sustained rates <1/1,000 central line days at 19 months (an 81% reduction). The control group also reduced infection rates to <1/1,000 central line days (a 69% reduction) at 12 months.
This study demonstrated a causal relationship between the multifaceted intervention and the reduced central line-associated bloodstream infections. Both groups decreased infection rates after implementation and sustained these results over time, replicating the results found in previous, pre-post studies of this multifaceted intervention and providing further evidence that most central line-associated bloodstream infections are preventable.
Abstract
Background
Insurance claims data have been used to inform an understanding of Lyme disease epidemiology and cost of care, however few such studies have incorporated post-treatment symptoms ...following diagnosis. Using longitudinal data from a private, employer-based health plan in an endemic US state, we compared outpatient care utilization pre- and post-Lyme disease diagnosis. We hypothesized that utilization would be higher in the post-diagnosis period, and that temporal trends would differ by age and gender.
Methods
Members with Lyme disease were required to have both a corresponding ICD-9 code and a fill of an antibiotic indicated for treatment of the infection within 30 days of diagnosis. A 2-year ‘pre- diagnosis’ period and a 2-year ‘post-diagnosis period’ were centered around the diagnosis month. Lyme disease-relevant outpatient care visits were defined as specific primary care, specialty care, or urgent care visits. Descriptive statistics examined visits during these pre- and post-diagnosis periods, and the association between these periods and the number of visits was explored using generalized linear mixed effects models adjusting for age, season of the year, and gender.
Results
The rate of outpatient visits increased 26% from the pre to the post-Lyme disease diagnosis periods among our 317-member sample (rate ratio = 1.26 1.18, 1.36,
p
< 0.001). Descriptively, care utilization increases appeared to persist across months in the post-diagnosis period. Women’s care utilization increased by 36% (1.36 1.24, 1.50,
p
< 0.001), a significantly higher increase than the 14% increase found among men (1.14 1.02, 1.27,
p
= 0.017). This gender difference was mainly driven by adult members. We found a borderline significant 17% increase in visits for children < 18 years, (1.17 0.99, 1.38,
p
= 0.068), and a 31% increase for adults ≥ 18 years (1.31 1.21, 1.42,
p
< 0.001).
Conclusions
Although modest at the population level, the statistically significant increases in post-Lyme diagnosis outpatient care we observed were persistent and unevenly distributed across demographic and place of service categories. As Lyme disease cases continue to grow, so will the cumulative prevalence of persistent symptoms after treatment. Therefore, it will be important to confirm these findings and understand their significance for care utilization and cost, particularly against the backdrop of other post-acute infectious syndromes.
Background/Objectives: The importance of teams for improving quality of care has received increased attention. We examine both the correlates of self-assessed or perceived team effectiveness and its ...consequences for actually making changes to improve care for people with chronic illness. Study Setting and Methods: Data were obtained from 40 teams participating in the national evaluation of the Improving Chronic Illness Care Program. Based on current theory and literature, measures were derived of organizational culture, a focus on patient satisfaction, presence of a team champion, team composition, perceived team effectiveness, and the actual number and depth of changes made to improve chronic illness care. Results: A focus on patient satisfaction, the presence of a team champion, and the involvement of the physicians on the team were each consistently and positively associated with greater perceived team effectiveness. Maintaining a balance among culture values of participation, achievement, openness to innovation, and adherence to rules and accountability also appeared to be important. Perceived team effectiveness, in turn, was consistently associated with both a greater number and depth of changes made to improve chronic illness care. The variables examined explain between 24 and 40% of the variance in different dimensions of perceived team effectiveness; between 13% and 26% in number of changes made; and between 20% and 42% in depth of changes made. Conclusions: The data suggest the importance of developing effective teams for improving the quality of care for patients with chronic illness.
Background It is not clear whether mandatory reporting influences the efforts and performance of hospitals to prevent hospital-acquired infections. This study examines whether mandatory reporting ...impacted participation and performance in reducing central line–associated bloodstream infections (CLABSIs) in a national patient safety collaborative. Methods We analyzed 1,046 adult intensive care units (ICUs) participating in the national On the CUSP: Stop BSI program. We used a difference-in-difference approach to compare changes in CLABSI rates in states with no public reporting mandate, recent mandates, and longer-standing mandates. Chi-square tests were used to examine the differences in the participation rate. Results States enacting a law requiring mandatory public reporting of CLABSI rates around the time of the national program had the highest hospital participation rates (approximately 50%). Compared with units in states with no reporting requirement, units in the states with voluntary reporting systems or with longer periods of mandatory reporting experience had higher CLABSI rates at baseline and greater reductions in CLABSI in the first 6 months. State groups with mandatory public reporting of CLABSI showed a trend toward greater reduction in CLABSI after 1 year of program implementation. Conclusion Mandatory reporting requirements may spark hospitals to turn to proven infection prevention interventions to improve CLABSI rates. Reporting requirements do not teach sites how to reduce rates. ICUs need both motivation and facilitation to reach consumer expectations for infection prevention.
BackgroundPre-diabetes affects one-third of US adults and increases the risk of type 2 diabetes. Effective evidence-based interventions, such as the Diabetes Prevention Program, are available, but a ...gap remains in effectively translating and increasing uptake of these interventions into routine care.MethodsWe applied the Translating Research into Practice (TRiP) framework to guide three phases of intervention design and development for diabetes prevention: (1) summarise the evidence, (2) identify local barriers to implementation and (3) measure performance. In phase 1, we conducted a retrospective cohort analysis of linked electronic health record claims data to evaluate current practices in the management of pre-diabetes. In phase 2, we conducted in-depth interviews of 16 primary care physicians, 7 payor leaders and 31 patients to elicit common barriers and facilitators for diabetes prevention. In phase 3, using findings from phases 1 and 2, we developed the core elements of the intervention and performance measures to evaluate intervention uptake.ResultsIn phase 1 (retrospective cohort analysis), we found few patients with pre-diabetes received diabetes prevention interventions. In phase 2 (stakeholder engagement), we identified common barriers to include a lack of knowledge about pre-diabetes among patients and about the Diabetes Prevention Program among clinicians. In phase 3 (intervention development), we developed the START Diabetes Prevention Clinical Pathway as a systematic change package to address barriers and facilitators identified in phases 1 and 2, performance measures and a toolkit of resources to support the intervention components.ConclusionsThe TRiP framework supported the identification of evidence-based care practices for pre-diabetes and the development of a well-fitted, actionable intervention and implementation plan designed to increase treatment uptake for pre-diabetes in primary care settings. Our change package can be adapted and used by other health systems or clinics to target prevention of diabetes or other related chronic conditions.
Little is known about safety culture in the area of cardiac surgery as compared with other types of surgery. The unique features of cardiac surgical teams may result in different perceptions of ...patient safety and patient safety culture.
We measured and described safety culture in five cardiovascular surgical centers using the Hospital Survey on Patient Safety Culture, and compared the data with the Agency for Healthcare Research and Quality (AHRQ) 2010 comparative database in surgery and anesthesiology (all types). We reported mean scores, standard deviations, and percent positive responses for the two single-item measures and 12 patient safety climate dimensions in the Hospital Survey on Patient Safety Culture.
In the five cardiac surgical programs, the dimension of teamwork within hospital units had the highest positive score (74% positive responses), and the dimension of nonpunitive response to error had the lowest score (38% positive responses). Surgeons and support staff perceived better safety climate than nurses, perfusionists, and anesthesia practitioners. The cardiac surgery cohort reported more positive safety climate than the AHRQ all-type surgery cohort in four dimensions but lower frequency of reporting mistakes. The cardiac anesthesiology cohort scored lower on two dimensions compared with the AHRQ all-type anesthesiology cohort.
This study identifies patient safety areas for improvement in cardiac surgical teams in comparison with all-type surgical teams. We also found that different professional disciplines in cardiac surgical teams perceive patient safety differently.
Objective
To examine the association between Medicaid dental coverage for adult pregnant women with dental care utilization during pregnancy.
Methods
Pregnancy risk assessment monitoring system ...(PRAMS) data (2014–2015) and the Medicaid‐SCHIP state dental association (MSDA) national profiles (2014–2015) were used in this study. The study sample included 16,612 Medicaid‐enrolled women, for a weighted number of 965,046 women from 26 states and New York City. State Medicaid dental coverage was categorized into (1) no coverage for the dental cleaning, (2) coverage for dental cleaning and fillings, (3) extended dental coverage. The adjusted prevalence ratios (aPR) for dental visits for cleaning during pregnancy were examined by Medicaid dental coverage level.
Results
Medicaid‐enrolled women in states with no dental coverage were less likely to visit dentists for cleaning during pregnancy (26.7%) compared with women in states with either limited dental coverage (36.6%) or extended dental coverage (44.9%). Compared with women in state without dental coverage, Medicaid‐enrolled women in states with extended dental coverage (aPR = 1.20, 95% CI 1.16–1.23) and women in states with limited coverage (aPR = 1.10, 95% CI 1.06–1.14) were more likely to visit dentists for cleaning during pregnancy when adjusted for other sociodemographic variables and adequacy of prenatal care. A similar pattern of association was observed for a dental visit to address dental problems during pregnancy.
Conclusions
This study highlights the importance of Medicaid dental coverage for adult pregnant women related to dental service utilization during pregnancy.
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