Complex Clinical Environment Research Articles

Implementing Service Engineering in Healthcare Services: The Case of Neonatal Intensive Care Unit (NICU)

The study presents a real life case of the human side of service engineering. The NICU of Hillel Yaffe Medical Center serves premature babies until they reach maturity and may return home and the community. The NICU has been approved to the International Quality Management Standard ISO 9001 which created the infrastructure for conducting continuous improvement process. The service of a NICU department is very complex due to the fact that in addition to treating the premature infant there is a very high involvement of the family members. Naturally, the infant is unable to communicate and his/her parents are acting as the voice of the customer. Thus, the staff must take care on the family members’ needs during the hospitalization of their child. This fact created the Service Concept of the department: our customer is the premature infant together with his parents. Thus, the concept's components include processes supporting this complex clinical environment as: Admission process controlled and measured by Yield measures (Medical Yield and Nursing Yield), family escorting process to support the family with updated data on a regular planned basis regarding the child clinical condition and training sessions prior to the child discharge. Special attention and control is given to the supply of food and liquids (pending on the child's clinical condition). Prior to discharge the parents get a special training session in order to smooth as much as possible the process of returning home and start their life in the community including the medical support of the authorities outside the hospital. A computerized system was developed to support the management and control of all processes including a digital patient record. The various processes’ Yields are presented to the staff (physicians and nurses) every month and a discussion is conducted to verify needed improvement and correction activities. Satisfaction surveys are conducted prior to discharge in order to get inputs regarding all the subjects related to the family's service perception while their child was hospitalized. Results show improvement of the various yield measures.

Capacity planning for maternal-fetal medicine using discrete event simulation.

Maternal-fetal medicine is a rapidly growing field requiring collaboration from many subspecialties. We provide an evidence-based estimate of capacity needs for our clinic, as well as demonstrate how simulation can aid in capacity planning in similar environments. A Discrete Event Simulation of the Center for Fetal Diagnosis and Treatment and Special Delivery Unit at The Children's Hospital of Philadelphia was designed and validated. This model was then used to determine the time until demand overwhelms inpatient bed availability under increasing capacity. No significant deviation was found between historical inpatient censuses and simulated censuses for the validation phase (p = 0.889). Prospectively increasing capacity was found to delay time to balk (the inability of the center to provide bed space for a patient in need of admission). With current capacity, the model predicts mean time to balk of 276 days. Adding three beds delays mean time to first balk to 762 days; an additional six beds to 1,335 days. Providing sufficient access is a patient safety issue, and good planning is crucial for targeting infrastructure investments appropriately. Computer-simulated analysis can provide an evidence base for both medical and administrative decision making in a complex clinical environment.

Optimising acute care and secondary prevention for patients with acute coronary syndrome.

Ascertaining a patient's risk of ischaemic complications after admission with an acute coronary syndrome is an important determinant of management. The treating clinician must determine whether and how urgently to send the patient for coronary angiography and whether to select more intensive antithrombotic therapies in the acute phase, and facilitate secondary prevention strategies. Risk stratification is infrequently applied and, as a consequence, undertreatment of higher-risk patients is common. Ensuring routine application of risk stratification across hospitals may improve treatment of patients who have the most to gain from evidence-based therapies. This requires embedding standard practices into complex clinical environments, and includes the routine implementation of treatment algorithms in a permissive environment with clinical champions and support from the hospital administration. The implementation of routine systems of care defining prehospital, interhospital and individual hospital practice is challenging, but essential to minimise deficits in care.

Managing Interruptions in Healthcare

While there are several theoretical accounts of interruptions and numerous empirical studies that have examined the impact of interruptions in laboratory settings, our understanding of interruptions in healthcare is in its infancy. Understanding and managing interruptions in healthcare can be particularly challenging because of the diversity of clinical environments and the importance of interruptions in delivering effective care in some settings. Our expert panel will review the theoretical and practical aspects of interruptions and facilitate a meaningful discussion on how to advance the study of interruptions in healthcare. The discussion will focus on patient safety implications of interruptions and methods to better manage interruptions in complex clinical environments.

PREPARATION OF CLINICAL PRECEPTORS

Nursing students in South Africa are mostly dissatisfied with clinical teaching and accompaniment in clinical practice. Consequently final year students feel ill prepared for their roles as registered nurses. Many factors, for example the shift from hospital based training to higher education, staff shortages, high acuity levels, greater treatment sophistication etc contribute to the dilemma of inadequate support of students during clinical placements. Preceptors that are either appointed by the nursing education institution or health service may address the issue of inadequate support of students. However, preceptors should be well trained to facilitate learning in the complex and dynamic clinical environment. This article gives an outline for the preparation of preceptors and includes selection criteria for candidates, the content of a training programme, as well as the assessment of programme outcomes.

Existing data sources for clinical epidemiology: Aarhus University Clinical Trial Candidate Database, Denmark.

Denmark is facing a reduction in clinical trial activity as the pharmaceutical industry has moved trials to low-cost emerging economies. Competitiveness in industry-sponsored clinical research depends on speed, quality, and cost. Because Denmark is widely recognized as a region that generates high quality data, an enhanced ability to attract future trials could be achieved if speed can be improved by taking advantage of the comprehensive national and regional registries. A “single point-of-entry” system has been established to support collaboration between hospitals and industry. When assisting industry in early-stage feasibility assessments, potential trial participants are identified by use of registries to shorten the clinical trial startup times. The Aarhus University Clinical Trial Candidate Database consists of encrypted data from the Danish National Registry of Patients allowing an immediate estimation of the number of patients with a specific discharge diagnosis in each hospital department or outpatient specialist clinic in the Central Denmark Region. The free access to health care, thorough monitoring of patients who are in contact with the health service, completeness of registration at the hospital level, and ability to link all databases are competitive advantages in an increasingly complex clinical trial environment.

Decontamination of a Hospital Room Using Gaseous Chlorine Dioxide: Bacillus anthracis, Francisella tularensis, and Yersinia pestis

This study assessed the efficacy of gaseous chlorine dioxide for inactivation of Bacillus anthracis, Francisella tularensis, and Yersinia pestis in a hospital patient care suite. Spore and vegetative cells of Bacillus anthracis Sterne 34F2, spores of Bacillus atrophaeus ATCC 9372 and vegetative cells of both Francisella tularensis ATCC 6223 and Yersinia pestis A1122 were exposed to gaseous chlorine dioxide in a patient care suite. Organism inactivation was then assessed by log reduction in viable organisms postexposure to chlorine dioxide gas compared to non-exposed control organism. Hospital room decontamination protocols utilizing chlorine dioxide gas concentrations of 377 to 385 ppm maintained to exposures of 767 ppm-hours with 65% relative humidity consistently achieved complete inactivation of B. anthracis and B. atrophaeus spores, as well as vegetative cells of B. anthracis, F. tularensis, and Y. pestis. Decrease in exposure (ppm-hours) and relative humidity (<65%) or restricting airflow reduced inactivation but achieved >8 log reductions in organisms. Up to 10-log reductions were achieved in a hospital room with limited impact on adjacent areas, indicating chlorine dioxide concentrations needed for decontamination of highly concentrated (>6 logs) organisms can be achieved throughout a hospital room. This study translates laboratory chlorine dioxide fumigation studies applied in a complex clinical environment.

Basic Principles for Conducting Human Research in Orthopaedic Medicine

Researchers and clinicians operate in an increasingly complex clinical and regulatory environment in which understanding the principles governing human research is essential. However, most orthopaedic surgeons have not received in-depth training in regulatory requirements and scientific research methods. Ensuring that research is conducted in accordance with state and federal laws and ethical principles is essential to guard compromising patient information and avoid severe penalties for noncompliance. The researcher must understand the regulations for compliance and proper data management, including the requirements of the Health Insurance Portability and Accountability Act, proper application of informed consent, use of the Institutional Review Board, and data protection guidelines. Tools such as a regulatory binder can assist investigators in complying with requirements, maintaining regulatory standards, and ensuring a robust study design and conduct.

Basic Principles for Conducting Human Research in Orthopaedic Medicine

Researchers and clinicians operate in an increasingly complex clinical and regulatory environment in which understanding the principles governing human research is essential. However, most orthopaedic surgeons have not received in-depth training in regulatory requirements and scientific research methods. Ensuring that research is conducted in accordance with state and federal laws and ethical principles is essential to guard compromising patient information and avoid severe penalties for noncompliance. The researcher must understand the regulations for compliance and proper data management, including the requirements of the Health Insurance Portability and Accountability Act, proper application of informed consent, use of the Institutional Review Board, and data protection guidelines. Tools such as a regulatory binder can assist investigators in complying with requirements, maintaining regulatory standards, and ensuring a robust study design and conduct.

A new segmentation framework based on sparse shape composition in liver surgery planning system

To improve the accuracy and the robustness of the segmentation in living donor liver transplantation (LDLT) surgery planning system, the authors present a new segmentation framework that addresses challenges induced by the complex shape variations of patients' livers with cancer. It is designed to achieve the accurate and robust segmentation of hepatic parenchyma, portal veins, hepatic veins, and tumors in the LDLT surgery planning system. The segmentation framework proposed in this paper includes two important modules: (1) The robust shape prior modeling for liver, in which the sparse shape composition (SSC) model is employed to deal with the complex variations of liver shapes and obtain patient-specific liver shape priors. (2) The integration of the liver shape prior with a minimally supervised segmentation algorithm to achieve the accurate segmentation of hepatic parenchyma, portal veins, hepatic veins, and tumors simultaneously. The authors apply this segmentation framework to our previously developed LDLT surgery planning system to enhance its accuracy and robustness when dealing with complex cases of patients with liver cancer. Compared with the principal component analysis, the SSC model shows a great advantage in handling the complex variations of liver shapes. It also effectively excludes gross errors and outliers that appear in the input shape and preserves local details for specific patients. The proposed segmentation framework was evaluated on the clinical image data of liver cancer patients, and the average symmetric surface distance for hepatic parenchyma, portal veins, hepatic veins, and tumors was 1.07 ± 0.76, 1.09 ± 0.28, 0.92 ± 0.35 and 1.13 ± 0.37 mm, respectively. The Hausdorff distance for these four tissues was 7.68, 4.67, 4.09, and 5.36 mm, respectively. The proposed segmentation framework improves the robustness of the LDLT surgery planning system remarkably when dealing with complex clinical liver shapes. The SSC model is able to handle non-Gaussian errors and preserve local detail information of the input liver shape. As a result, the proposed framework effectively addresses the problems caused by the complex shape variations of livers with cancer. Our framework not only obtains accurate segmentation results for healthy persons and common patients, but also shows high robustness when dealing with specific patients with large variations of liver shapes in complex clinical environments.

Academic Centers Play a Vital Role in the Study of Drug Safety and Effectiveness

Prescription drugs have enormous potential to improve health and longevity, and the past decades have witnessed remarkable innovations in the pharmaceutical marketplace. Despite this, the past decades are also replete with examples of therapies, ranging from thalidomide to rofecoxib to sibutramine, that have raised important safety concerns. The recent outbreak of fungal meningitis linked to unsterile practices at a compounding pharmacy serves as yet another cautionary tale that all drugs have risks and that drugs are manufactured, produced, delivered, and administered in a complex regulatory and clinical environment.

Transplantation at the Nexus of Behavioral Economics and Health Care Delivery

The transplant surgeon's decision to accept and utilize an organ typically is made within a constrained time window, explicitly cognizant of numerous health-related risks and under the potential influence of considerable regulatory and institutional pressures. This decision affects the health of two distinct populations, those patients receiving organ transplants and those waiting to receive a transplant; it also influences the physician's life and their institute's productivity. The numerous, at times nonaligned, incentives established by the complex clinical and regulatory environment, have been derived specifically to influence physicians' behaviors, and though well intended, may lead to responses that are nonoptimal when considering the myriad stakeholders being influenced. This may compromise the quality of care provided to the population at risk, and has potential to influence the physician-patient relationship. A synergistic collaboration between transplant physicians and economists that is focused on this decision environment may help to alleviate these strains. This viewpoint discusses behavioral economic principles and how they might be applied to transplantation. Specifically, the previous medical decision-making literature on transplantation will be reviewed and a discussion on how a behavioral model of physician decision making can be utilized will be explored. To date this approach has not been integrated into transplantation decision making.

Review article: Perioperative checklist methodologies

Checklists are increasingly being used by surgical teams in the perioperative period to improve clinical care and increase patient safety. In this article, we review some of the mechanisms by which checklists work and evaluate evidence supporting their use. There is a growing body of evidence showing the importance of team-based checklists in clinical care. In multiple complex clinical environments, from the operating room to the intensive care unit, checklists can help ensure adherence to known standards of care and improve communication amongst team members. In addition, the efficacy of checklists is being shown in both developed and developing settings. Checklists can aid clinicians involved in complex processes and multidisciplinary team interactions to improve the quality and safety of care by prompting dialogue and exchange of information.

Counting Matters: Lessons from the Root Cause Analysis of a Retained Surgical Item

Retained surgical items (RSIs), such as a sponge, instrument, or needle, after a surgery or invasive procedure is an uncommon but potentially serious event associated with significant morbidity and mortality. A 27-year-old woman was discovered to have a retained vaginal sponge a week after she underwent the repair of a vaginal tear following normal vaginal delivery. The retained sponge was removed with no further complications. The fundamental error involved the obstetric team's failure to perform the standard protocol of counting sponges before, as well as after, the procedure. This was attributed to a lack of reminders to perform the count, relatively recent implementation of the sponge-count policy, and a breakdown in teamwork and communication between physicians and nurses. The corrective actions focused on systems improvement, as opposed to the human error of the memory lapse. The sponge-counting process was reinforced by incorporating a sign-out at the end of obstetric procedures to ensure that the counts have been done and any discrepancies addressed. A specialized delivery note with mandatory field to document sponge count was implemented in the electronic health record as an additional reminder. All staff participated in a teamwork and communication training program. Since the incident's occurrence in 2010, the staff has demonstrated 100% compliance with the corrective actions, and a retained surgical item complication has not recurred. Individual accountability must be balanced with systems improvement, given that most medical errors are a result of fallible humans working in chaotic, unpredictable, and complex clinical environment.

Die Balanced Scorecard – Anwendungsmöglichkeiten in der Radiologie

The balanced scorecard (BSC) represents a comprehensive management tool for organizations with the aim to focus all activities on a chosen strategy. Targets for various perspectives of the environment such as the customer, financial, process, and potential perspective are linked with concrete measures, and cause-effect relationships between the objectives are analyzed. This article shows that the BSC can also be used for the comprehensive control of a radiology department and thus provides a meaningful contribution in organizing the various diagnostic and treatment services, the management of complex clinical environment and can be of help with the tasks in research and teaching.

Editors' commentary

Editors' commentary

The impact of maternity crisis resource management training

The Maternity Crisis Resource Management (MaCRM) programme for midwives and doctors was developed in response to the critical need to address unacceptable levels of preventable adverse events in maternity care, a high proportion of which result from poor communication between medical and midwifery staff. Quantitative and qualitative methods were used in this study to explore the outcomes for programme participants in terms of their satisfaction and importantly, the application of their learnings in the complex clinical environment of the birth suite. MaCRM graduates have pre-empted some serious complications, and dealt effectively with complications over which they had no control. An important outcome of this study is the reinforcement of the urgent need for all who have clinical contact with obstetric patients to receive regular compulsory up-skilling in the management of maternity emergencies.

Deviations from protocol in a complex Trauma environment: Errors or innovations?

Protocol standardizations are important for consistent and safe practices. However, complex clinical environments are highly dynamic in nature and often require clinicians, confronted with non-standard situations, to adjust and deviate from standard protocol. Some of these deviations are errors which can result in harmful outcomes. On the other hand, some of the deviations can be innovations, which are dynamic adjustments to the protocols made by people to adapt the current operational conditions and achieve high accuracy and efficiency. However, there is very little known about the underlying cognitive processes that are related to errors and innovations. In this study we investigate the extent to which deviations are classified as errors or innovations, as a function of expertise in a Trauma setting. Field observations were conducted in a Level 1 Trauma unit. A total of 10 Trauma cases were observed and collected data was analyzed using measures that included customized activity-error-innovation ontology, timestamps and expertise of the team members. The results show that expertise of the caregivers and criticality of a patient’s condition in critical care environment influence the number and type of deviations from standard protocol. Experts’ deviations were a combination of errors and innovations; whereas the novices’ deviations were mostly errors . This research suggests that a novel approach must be taken into consideration for the design of protocols (including standards) and compliance measurements in complex clinical environments.

Developing the practice context to enable more effective pain management with older people: an action research approach

BackgroundThis paper, which draws upon an Emancipatory Action Research (EAR) approach, unearths how the complexities of context influence the realities of nursing practice. While the intention of the project was to identify and change factors in the practice context that inhibit effective person-centred pain management practices with older people (65 years or older), reflective critical engagement with the findings identified that enhancing pain management practices with older people was dependent on cultural change in the unit as a whole.MethodsAn EAR approach was utilised. The project was undertaken in a surgical unit that conducted complex abdominal surgery. Eighty-five percent (n = 48) of nursing staff participated in the two-year project (05/NIR02/107). Data were obtained through the use of facilitated critical reflection with nursing staff.ResultsThree key themes (psychological safety, leadership, oppression) and four subthemes (power, horizontal violence, distorted perceptions, autonomy) were found to influence the way in which effective nursing practice was realised. Within the theme of 'context,' effective leadership and the creation of a psychologically safe environment were key elements in the enhancement of all aspects of nursing practice.ConclusionsWhilst other research has identified the importance of 'practice context' and models and frameworks are emerging to address this issue, the theme of 'psychological safety' has been given little attention in the knowledge translation/implementation literature. Within the principles of EAR, facilitated reflective sessions were found to create 'psychologically safe spaces' that supported practitioners to develop effective person-centred nursing practices in complex clinical environments.

Improving on Reality

Improving on Reality