Evidence-based Quality Indicators Research Articles

Developing a customised set of evidence-based quality indicators for measuring workplace violence towards healthcare workers: a modified Delphi method

BackgroundWorkplace violence (WPV) is a complex global challenge in healthcare that can only be addressed through a quality improvement initiative composed of a complex intervention. However, multiple WPV-specific quality indicators...

Reducing insulin omission errors among patients with diabetes mellitus in general surgical wards: a best practice implementation project.

Omission of insulin, a high-alert medication with one of the highest locally reported errors, could lead to severe hyperglycemia, which could result in coma or death if not treated timeously. This study aimed to identify, evaluate, and implement strategies to reduce the occurrence of insulin omission errors in diabetic adult patients requiring insulin. This project followed the JBI Evidence Implementation Framework and conducted context analysis, strategy implementation, and evaluation of outcomes according to evidence-based quality indicators. The JBI PACES and JBI GRiP situational analysis tools were used to support data collection and implementation planning. There was one evidence-based criterion and five sub-criteria, with a sample size of 22 patients. There was increased compliance with best practices to reduce interruptions and distractions from baseline audit (50%) to follow-up audits 1 (45.4%) and 2 (31.8%), and no insulin omission incidences during the implementation period. In the post-implementation analysis, there were notable improvements in compliance with strategies related to nurses; however, reduced compliance was observed related to patients. Key barriers to implementation included patients still disturbing nurses despite the nurses wearing the medication vests and patients forgetting instructions not to disturb nurses during medication administration. Strategies to improve compliance included ensuring coverage in each cubicle during insulin preparation and administration, tending to patients' needs prior to insulin administration, and use of posters as reminders. There was an overall increase in compliance with best practice to reduce interruptions and distractions and no insulin omission incidences related to interruptions and distractions during the implementation phase. http://links.lww.com/IJEBH/A219.

Flushing and locking management related to central venous catheter occlusion rate among adult patients in acute care: a best practice implementation project.

A central venous catheter (CVC)-a type of central venous access device (CVAD)-is the most common intervention for critical illnesses. Obstruction of the CVC can lead to fatal consequences. Thus, it is critical to maintain catheter lumen patency. The CVC occlusion rate in a hospital in Taiwan was 33%. This project aimed to decrease the CVC occlusion rate in acute care. This project was conceptually informed by the JBI Evidence-Based Model of Healthcare, in particular, the conceptualization of evidence implementation as inclusive of context analysis, implementation, and evaluation of outcomes using evidence-based quality indicators. As part of the seven-phase implementation process, we used audit and feedback in a pre- and post-test design to measure baseline compliance. Based on the initial audit, we developed an implementation strategy responsive to the identified gaps in compliance. We then undertook a final audit to measure changes in compliance to evaluate our implementation effects. The JBI software, PACES, and the situational analysis software, GRiP, were used for data collection and implementation planning. There were six evidence-based criteria, with a sample size of 30 nurses for each criterion. The team carried out the project from September 2022 to January 2023. Post-implementation audit compliance rates increased to 100% for the following criteria: the organization had a standardized flushing and locking solution protocol (0%), the CVAD lumen was locked upon completion of the final flush (10%), a single-dose system was used for flushing and locking the CVAD (60%), and preservative-free 0.9% sodium chloride was used to flush the CVAD (60%). Furthermore, the CVC occlusion rate decreased from 33% to 5%. The project successfully decreased the rate of CVC occlusion and increased the competence of nurses in acute care settings. The implementation of best practices in clinical care should focus on leadership, cross-department coordination, education, and innovation.

Health care providers' communication with pediatric patients and carers: a best practice implementation project.

Health care providers need a high level of communication skills in dealing with pediatric patients and their carers. The objective of this project was to evaluate current practice and implement best practices promoting health care provider communication with pediatric patients and carers in a children's hospital in Tabriz, Iran. This project used the JBI Model of Evidence-Based Healthcare, which guided the conceptualization of evidence implementation, context analysis, project implementation, and evaluation of outcomes using evidence-based quality indicators. An audit and feedback strategy was adopted to measure baseline compliance with best practices, develop strategies to address areas of non-compliance, and conduct a final audit to measure any changes in compliance. Four criteria were developed for the baseline and follow-up audits. Criteria 1 and 2 were evaluated using a sample of 30 health care providers, while Criteria 3 and 4 were evaluated using a sample of 80 pediatric patients and carers. All four criteria improved at the end of the project. Criterion 1 (health care staff receive communication skills training) had the highest mean score at baseline and follow-up (63% and 83%, respectively). Criterion 2 (implementation of local strategies by health care organizations) increased from 45% to 55%. However, this rate of improvement was the lowest of all the criteria. Criterion 3 (pediatric patients receive relevant education) improved from low to moderate, rising from 18% to 49%. A more significant improvement was noted for Criterion 4 (parents receive relevant education), which rose from 19% to 56%. The strategies implemented in this project successfully improved health care provider communication with pediatric patients and their carers. To ensure project sustainability, repeat audits will be conducted after 3, 6, and 12 months. http://links.lww.com/IJEBH/A199.

Establishing Nursing-Sensitive Quality Indicators for the Central Sterile Supply Department: A Modified Delphi Study.

Previous studies have shown that improving quality management in the central sterile supply department (CSSD) is an effective measure to control and decrease hospital-acquired infections. This study aimed to establish nursing-sensitive quality indicators for CSSD nursing in China. We drafted nursing-sensitive quality indicators on the basis of the Structure-Process-Outcome model, and then conducted 2 rounds of consultation with experts using a modified Delphi method to determine the indicators and scientific methods of measurement. We identified five CSSD nursing-sensitive quality indicators. Recovery rates of the 2 rounds of valid questionnaires were 100%. Expert authority coefficients were 0.810 and 0.902, respectively. Kendall's coefficients of concordance were 0.168 and 0.210, respectively ( P < .05). Evidence-based nursing-sensitive quality indicators for the CSSD were established.

Development and pilot-testing of an evidence-based quality indicator set for home mechanical ventilation care: the OVER-BEAS project

BackgroundThe number of patients depending on home mechanical ventilation (HMV) has increased substantially in Germany in recent years. These patients receive long-term care in different nursing facilities (nursing home, shared living community, private home). However, there are limited data available on the quality of care of HMV patients. The aim of the OVER-BEAS project was to identify quality indicators (QIs) of HMV care using an evidence-based approach.MethodsA multidisciplinary board consisting of professionals and experts of HMV provision compiled a set of QIs between March and September 2019. In a structured, transparent process a set of QIs covering structures, processes and outcome of HMV patient’s care were proposed and evaluated based on the best available evidence. QIs were defined as relevant, reliable and valid measurements of the quality of HMV care and furthermore to be comprehensive and applicable in practice.ResultsThe experts proposed 40 QIs and consented a final set of 26 QIs. Based on the final set, questionnaires to document the QIs were developed: (1) to assess the quality and describe the structure of the nursing facility; and (2) to gather information on patient-related processes and outcomes. The feasibility of the questionnaires was tested in 5 nursing facilities treating HMV patients. The remarks from the nursing specialists were categorised in three groups: (1) term missing accuracy, (2) problem of understanding, and (3) not documented or documented elsewhere. Mean documentation time by the nursing specialists for one patient was 15 min. Based on this feedback, the questionnaires were finalised.ConclusionsWe proposed a set of QIs relating to long-term HMV care and developed two questionnaires to collect this information. In a pilot study, we found the set of questionnaires to be feasible in assessing the quality of HMV care according to current evidence. The development of standardised evidence-based QIs to evaluate HMV care is a step towards implementing a standardised quality assurance program to document the quality of care of HMV patients.

A multidisciplinary Delphi consensus to define evidence-based quality indicators for diabetic foot ulcer care.

Valid measures to assess quality of care delivered to patients with diabetes suffering from diabetic foot ulcer (DFU) are scarce. This study aimed to achieve consensus on relevant and feasible quality indicators (QIs) among stakeholders involved in DFU care and was conducted as the second part of a Belgian QI selection study that sought to identify QIs for DFU care. A stakeholder panel, including caregivers from primary care and specialized disciplines active in diabetic foot care as well as a patient organization representative, was recruited. By using the RAND/UCLA Appropriateness Method, stakeholders were asked to rate a list of 42 candidate evidence-based indicators for appropriateness through a 9-point Likert scale. QIs were classified based on the median ratings and the disagreement index, calculated by the inter-percentile range adjusted for symmetry. At the end of a three-phase process, 17 QIs were judged as appropriate. Among them, five were not previously described, covering the following topics: integration of wound care specialty in the multidisciplinary team, systematic evaluation of the nutritional status of the patient, administration of low-density lipoprotein-cholesterol lowering medication and protocolized care (implementation of care and prevention management protocols). The identified evidence-based QIs provide an assessment tool to evaluate and monitor quality of care delivered to DFU patients. Future research should focus on their complementarity with the existing QIs and their implementation in clinical practice.

Clinicians’ Evaluation of Lung Cancer Clinical Quality Indicators and Comparative Performance Data in Practice

Objective. Lung cancer is commonly diagnosed and is the leading cause of cancer-related death, morbidity, and burden of disease globally. There is an ongoing need to ensure patients receive optimal evidence-based care and to identify and reduce unwarranted clinical variation to achieve best possible outcomes. The EnRICH program has developed evidence-based clinical quality indicators to measure processes and outcomes of lung cancer care, and a feedback dashboard to report comparative performance data, which highlight variation in both care and outcomes. The aims of this study were to evaluate the acceptability and utility of the quality indicators and feedback dashboard and identify benchmarks for performance monitoring and priorities for future quality improvement interventions to address observed clinical variation. Method. Clinicians from lung cancer multidisciplinary teams (MDTs) at six tertiary clinical sites across regional and metropolitan NSW were invited to participate in evaluation interviews. Interviews were conducted via videoconference and recorded with consent. Data were analysed thematically using framework methods. Results. Thirteen clinicians participated in interviews, with representation from each clinical site and specialty. All participants considered the quality indicators to be clinically meaningful. Three main themes were identified: (i) the importance of timely, local, quality data; (ii) implementable versus nonimplementable clinical practice changes; and (iii) the need for ongoing performance monitoring. Clinicians prioritised two areas of unwarranted clinical variation that could be immediately addressed through easily implementable quality improvement interventions to positively impact patient care: (i) a process to ensure that all stage III patients are discussed by a multidisciplinary team prior to commencing treatment; (ii) a referral pathway to palliative care within eight weeks for patients diagnosed with stage IV disease. The importance of lung cancer nurse specialists for improved care coordination was highlighted. Conclusion. Clinicians would like to continue to receive close-to-real-time quality data for ongoing performance monitoring to identify and address unwarranted clinical variation.

Challenges in the Care of Patients with AKI Receiving Outpatient Dialysis: AKINow Recovery Workgroup Report.

Up to one third of survivors of AKI that required dialysis (AKI-D) during hospitalization remain dialysis dependent at hospital discharge. Of these, 20%-60%, depending on the clinical setting, eventually recover enough kidney function to stop dialysis, and the remainder progress to ESKD. To describe the challenges facing those still receiving dialysis on discharge, the AKINow Committee conducted a group discussion comprising 59 participants, including physicians, advanced practitioners, nurses, pharmacists, and patients. The discussion was framed by a patient who described gaps in care delivery at different transition points and miscommunication between care team members and the patient. Group discussions collected patient perspectives of ( 1 ) being often scared and uncertain about what is happening to and around them and ( 2 ) the importance of effective and timely communication, a comfortable physical setting, and attentive and caring health care providers for a quality health care experience. Provider perspectives included ( 1 ) the recognition of the lack of evidence-based practices and quality indicators, the significant variability in current care models, and the uncertain reimbursement incentives focused on kidney recovery and ( 2 ) the urgency to address communication barriers among hospital providers and outpatient facilities. The workgroup identified key areas for future research and policy change to ( 1 ) improve communication among hospital providers, dialysis units, and patients/care partners; ( 2 ) develop tools for risk classification, subphenotyping, and augmented clinical decision support; ( 3 ) improve education to providers, staff, and patients/care partners; ( 4 ) identify best practices to improve relevant outcomes; ( 5 ) validate quality indicators; and ( 6 ) assess the effect of social determinants of health on outcomes. We urge all stakeholders involved in the process of AKI-D care to align goals and work together to fill knowledge gaps and optimize the care to this highly vulnerable patient population.

Measuring quality of care in autologous breast reconstruction: a Delphi consensus

Measuring and benchmarking quality of care in surgical oncology has been gaining popularity. In autologous breast reconstruction (ABR), a standardized set of indicators to assess quality of care is lacking. In this study, we defined a set of evidence-based quality indicators for autologous breast reconstruction.First, we performed a systematic review to identify factors related to quality of care in ABR. Variables were categorized depending on their function: indicators related to outcome, indicators related to process and case-mix variables. The review was followed by a 3-round Delphi Consensus to determine which indicators and case-mix-variables were considered relevant and feasible for inclusion in an ABR standard set of indicators.932 unique articles were identified, of which 110 papers were included in the study. Indicators were categorized by function: outcome, process and case-mix variables. In total, 8 process indicators and 41 outcome indicators were extracted. 30 case-mix-variables were included. Following 3 rounds of questioning in the Delphi Consensus, all respondents agreed on type of ABR, oncological outcomes and patient satisfaction for the standard set. Indicators related to complications were consistently ranked highly. Most process indicators were not chosen after 3 rounds of questioning. 11 case-mix-variables were included in the final set.Following the Delphi Consensus, it was possible to identify 33 process and outcome indicators and 11 case-mix-variables for inclusion for a standard set of quality indicators. With the inclusion of both objective and patient-reported outcome measures, this set of indicators provides a multidimensional measurement tool for quality assessment for ABR.

DETERMINE PRE-ANALYTICAL ERRORS ' PERCENTAGE IN CLINICAL BIOCHEMISTRY LABS AND DEVELOP REMEDIAL PROCEDURES FOR THEIR PREVENTION

Diagnostic inaccuracies pose a formidable issue in Laboratory Medicine, necessitating immediate initiatives to expand understanding and minimize these discrepancies. Our study delves into the nuances of errors associated with laboratory testing processes, from the test request to result interpretation, underlining the imperative for reducing such errors. Our investigation seeks to identify the incidence of errors in a round-the-clock lab setting over four months, covering pre-analytical, analytical, and post-analytical phases.Over a span period from Jan 2021 to Jan 2022, a broad spectrum of errors within pre-analytical, analytical, and post-analytical phases was methodically logged using a bespoke proforma. The collected data was systematically analyzed utilizing SPSS version 22.All venous and arterial blood samples were processed in the 24-hour lab throughout this period. From the 185,012 samples received, 2,450 were deemed unsuitable for testing, accounting for a 1.32% rejection rate. These samples were disqualified due to an array of pre-analytical errors, including misidentification (0.07%), incorrect tube usage (0.11%), missing samples (0.07%), drawing from an intravenous site (0.10%), inadequate sample volume (0.51%), improper timing of sample collection (0.10%), hemolysed samples (0.31%), and lipemic samples (0.11%).Utilizing an agreed list of evidence-based Quality Indicators, compliant with the current International Standard (ISO 15189:2012), for incorporation into accreditation programs of clinical laboratories stands as a potent approach to augment quality, mitigate error risks, and bolster patient safety.

P24 A pharmacist-led acne service as a novel and highly effective model of care utilizing the full potential of a multiprofessional workforce

Abstract The aim of this study was to establish a pharmacist-led acne clinic in the dermatology department in our teaching hospital, evaluate its quality and measure patient satisfaction with the new service. Two pharmacist independent prescribers (PIPs) underwent training in dermatologist-led clinics. An acne service was established, where dermatologists refer patients to PIPs for a course of treatment with isotretinoin. A set of evidence-based quality indicators (QIs) was developed and peer-reviewed by a multidisciplinary team and then used to evaluate service quality. Adherence to QIs was established through retrospective review of medical records for all patients seen by PIPs over a 12-month period. Patient satisfaction with the pharmacist-led clinic was measured by administration of anonymized questionnaires over a 1-month period. Patients rated (poor, fair, good, excellent) 11 items and provided free-text comments. During a 12-month period, 81 patients [70% females, median age 23 years (range 14–44)] were referred to a pharmacist-led clinic and PIPs delivered 307 appointments, saving an estimated 100 h of dermatologist time. Five patients required an additional dermatologist appointment and seven required additional dermatologist advice. We report ≥ 90% adherence to 11 of 14 QIs focusing on isotretinoin prescribing and patient monitoring, including mental health assessment using the Patient Health Questionnaire-9 tool. We identified the lowest adherence to QI 5 (45%; a final pregnancy test 5 weeks after stopping isotretinoin); however, six female patients disengaged with the service without completing the treatment. We report 70% adherence to QI 3 [use of Medicines and Healthcare products Regulatory Agency (MHRA)-recommended contraception] and 76% adherence to QI 1 (indication for isotretinoin). Corrective measures were implemented to improve adherence to QI 5 (a patient invitation for a final pregnancy test) and QI 3 (patient consent form compliant with MHRA recommendations on contraception). PIP consultations were rated as excellent by 76% of responders with acne (69% response rate; 33 surveys completed). All free-text comments (n = 10) were positive, with one suggestion for improvement (booking appointments in advance). Thematic analysis of comments revealed appreciation of ‘care and compassion’ (n = 10), ‘multidisciplinary team service delivery’ (n = 4), ‘ensuring patient understanding’ (n = 3), ‘pharmacist knowledge’ (n = 3), ‘professionalism’ (n = 2) and ‘medical team input’ (n = 1). There have been no patient complaints or adverse outcomes related to the pharmacist-led acne clinic since it was launched. PIPs successfully deliver a high-quality acne service that increases the overall dermatology service capacity. Patients report high satisfaction and appreciation of PIP knowledge and skills. The developed QIs and patient satisfaction questionnaire can be used for quality monitoring by other clinicians.

Audit, Feedback, and Education to Improve Quality and Outcomes in Transurethral Resection and Single-Instillation Intravesical Chemotherapy for Nonmuscle Invasive Bladder Cancer Treatment: Protocol for a Multicenter International Observational Study With an Embedded Cluster Randomized Trial.

Nonmuscle invasive bladder cancer (NMIBC) accounts for 75% of bladder cancers. It is common and costly. Cost and detriment to patient outcomes and quality of life are driven by high recurrence rates and the need for regular invasive surveillance and repeat treatments. There is evidence that the quality of the initial surgical procedure (transurethral resection of bladder tumor [TURBT]) and administration of postoperative bladder chemotherapy significantly reduce cancer recurrence rates and improve outcomes (cancer progression and mortality). There is surgeon-reported evidence that TURBT practice varies significantly across surgeons and sites. There is limited evidence from clinical trials of intravesical chemotherapy that NMIBC recurrence rate varies significantly between sites and that this cannot be accounted for by differences in patient, tumor, or adjuvant treatment factors, suggesting that how the surgery is performed may be a reason for the variation. This study primarily aims to determine if feedback on and education about surgical quality indicators can improve performance and secondarily if this can reduce cancer recurrence rates. Planned secondary analyses aim to determine what surgeon, operative, perioperative, institutional, and patient factors are associated with better achievement of TURBT quality indicators and NMIBC recurrence rates. This is an observational, international, multicenter study with an embedded cluster randomized trial of audit, feedback, and education. Sites will be included if they perform TURBT for NMIBC. The study has four phases: (1) site registration and usual practice survey; (2) retrospective audit; (3) randomization to audit, feedback, and education intervention or to no intervention; and (4) prospective audit. Local and national ethical and institutional approvals or exemptions will be obtained at each participating site. The study has 4 coprimary outcomes, which are 4 evidence-based TURBT quality indicators: a surgical performance factor (detrusor muscle resection); an adjuvant treatment factor (intravesical chemotherapy administration); and 2 documentation factors (resection completeness and tumor features). A key secondary outcome is the early cancer recurrence rate. The intervention is a web-based surgical performance feedback dashboard with educational and practical resources for TURBT quality improvement. It will include anonymous site and surgeon-level peer comparison, a performance summary, and targets. The coprimary outcomes will be analyzed at the site level while recurrence rate will be analyzed at the patient level. The study was funded in October 2020 and began data collection in April 2021. As of January 2023, there were 220 hospitals participating and over 15,000 patient records. Projected data collection end date is June 30, 2023. This study aims to use a distributed collaborative model to deliver a site-level web-based performance feedback intervention to improve the quality of endoscopic bladder cancer surgery. The study is funded and projects to complete data collection in June 2023. ClinicalTrials.org NCT05154084; https://clinicaltrials.gov/ct2/show/NCT05154084. DERR1-10.2196/42254.

Quality of Narratives in Assessment: Piloting a List of Evidence-Based Quality Indicators.

Appraising the quality of narratives used in assessment is challenging for educators and administrators. Although some quality indicators for writing narratives exist in the literature, they remain context specific and not always sufficiently operational to be easily used. Creating a tool that gathers applicable quality indicators and ensuring its standardized use would equip assessors to appraise the quality of narratives. We used DeVellis' framework to develop a checklist of evidence-informed indicators for quality narratives. Two team members independently piloted the checklist using four series of narratives coming from three different sources. After each series, team members documented their agreement and achieved a consensus. We calculated frequencies of occurrence for each quality indicator as well as the interrater agreement to assess the standardized application of the checklist. We identified seven quality indicators and applied them on narratives. Frequencies of quality indicators ranged from 0% to 100%. Interrater agreement ranged from 88.7% to 100% for the four series. Although we were able to achieve a standardized application of a list of quality indicators for narratives used in health sciences education, it does not exclude the fact that users would need training to be able to write good quality narratives. We also noted that some quality indicators were less frequent than others and we suggested a few reflections on this.

Applying Quality Indicators to Examine Quality of Care During Active Surveillance in Low-Risk Prostate Cancer: A Population-Based Study.

Although a few studies have reported wide variations in quality of care in active surveillance (AS), there is a lack of research using validated quality indicators (QIs). The aim of this study was to apply evidence-based QIs to examine the quality of AS care at the population level. QIs were measured using a population-based retrospective cohort of patients with low-risk prostate cancer diagnosed between 2002 and 2014. We developed 20 QIs through a modified Delphi approach with clinicians targeting the quality of AS care at the population level. QIs included structure (n=1), process of care (n=13), and outcome indicators (n=6). Abstracted pathology data were linked to cancer registry and administrative databases in Ontario, Canada. A total of 17 of 20 QIs could be applied based on available information in administrative databases. Variations in QI performance were explored according to patient age, year of diagnosis, and physician volume. The cohort included 33,454 men with low-risk prostate cancer, with a median age of 65 years (IQR, 59-71 years) and a median prostate-specific antigen level of 6.2 ng/mL. Compliance varied widely for 10 process QIs (range, 36.6%-100.0%, with 6 [60%] QIs >80%). Initial AS uptake was 36.6% and increased over time. Among outcome indicators, significant variations were observed by patient age group (10-year metastasis-free survival was 95.0% for age 65-74 years and 97.5% in age <55 years) and physician average annual AS volume (10-year metastasis-free survival was 94.5% for physicians with 1-2 patients with AS and 95.8% for those with ≥6 patients with AS annually). This study establishes a foundation for quality-of-care assessments and monitoring during AS implementation at a population level. Considerable variations appeared with QIs related to process of care by physician volume and Qis related to outcome by patient age group. These findings may represent areas for targeted quality improvement initiatives.

MP37-09 DEVELOPMENT OF URINARY INCONTINENCE CLINICAL DECISION SUPPORT TOOLS FOR USE IN PRIMARY CARE

MP37-09 DEVELOPMENT OF URINARY INCONTINENCE CLINICAL DECISION SUPPORT TOOLS FOR USE IN PRIMARY CARE

Promoting oral and dental healthcare among the elderly in a residential care home in Isfahan: a best practice implementation project.

Oral health is an important aspect of general health, which affects the wellbeing and quality of life of older adults. Residents in aged care facilities often suffer from overall dental neglect and insufficient oral healthcare, leading to moderate-to-high levels of oral diseases. Furthermore, physical or mental health concerns may result in difficulties in maintaining good oral health. This implementation project aims to audit and improve the oral healthcare status of the elderly living in a residential care home in Isfahan, Iran using the JBI evidence summary. The methods are preimplementation and postimplementation design using audit and feedback with a situational analysis to guide implementation planning. Seven evidence-based quality indicators were used to measure preintervention compliance with the best practice. Situational analysis was used to identify and target barriers through locally developed practice change strategies following which a repeat audit was conducted at 4 months. Four nursing staff, 11 caregivers, and 38 residents were interviewed for both the baseline and the follow-up audit. Compliance rates improved for all seven criteria except the use of a soft-bristled toothbrush (criterion 6). All eight categories of criterion 2 measuring assessment of oral health improved by at least 10%, with the largest improvements in saliva assessment and gingiva assessment. Criterion 1 (oral health training for caregivers) reached the greatest compliance rate (100%). The implemented strategies included improving knowledge and changing the attitudes of the caregivers through organizing educational sessions. These strategies were developed to address process and structural barriers to best practice and were helpful for staff uptake of evidence.

Associations Between Adherence to Evidence-Based, Stroke Quality Indicators and Outcomes of Acute Reperfusion Therapy.

Background:Quality indicators (QIs) are an accepted tool for measuring a hospital’s performance in routine care. We examined national trends in adherence to the QIs developed by the Close The Gap-Stroke program by combining data from the health insurance claims database and electronic medical records, and the association between adherence to these QIs and early outcomes in patients with acute ischemic stroke in Japan.Methods:In the present study, patients with acute ischemic stroke who received acute reperfusion therapy in 351 Close The Gap-Stroke-participating hospitals were analyzed retrospectively. The primary outcomes were changes in trends for adherence to the defined QIs by difference-in-difference analysis and the effects of adherence to distinct QIs on in-hospital outcomes at the individual level. A mixed logistic regression model was adjusted for patient and hospital characteristics (eg, age, sex, number of beds) and hospital units as random effects.Results:Between 2013 and 2017, 21 651 patients (median age, 77 years; 43.0% female) were assessed. Of the 25 defined measures, marked and sustainable improvement in the adherence rates was observed for door-to-needle time, door-to-puncture time, proper use of endovascular thrombectomy, and successful revascularization. The in-hospital mortality rate was 11.6%. Adherence to 14 QIs lowered the odds of in-hospital mortality (odds ratio [95% CI], door-to-needle <60 min, 0.80 [0.69–0.93], door-to-puncture <90 min, 0.80 [0.67–0.96], successful revascularization, 0.40 [0.34–0.48]), and adherence to 11 QIs increased the odds of functional independence (modified Rankin Scale score 0–2) at discharge.Conclusions:We demonstrated national marked and sustainable improvement in adherence to door-to-needle time, door-to-puncture time, and successful reperfusion from 2013 to 2017 in Japan in patients with acute ischemic stroke. Adhering to the key QIs substantially affected in-hospital outcomes, underlining the importance of monitoring the quality of care using evidence-based QIs and the nationwide Close The Gap-Stroke program.

Epidemiology, monitoring, and treatment strategy in cardiogenic shock. A multinational cross-sectional survey of ESC-acute cardiovascular care association research section

Cardiogenic shock (CS) is a life-threatening condition burdened by mortality in up to 50% of cases. Few recommendations exist with intermediate-low level of evidence on CS management and no data on adherence across centres exist. We performed a survey to frame CS management at multinational level. An international cross-sectional survey was created and approved by European Society of Cardiology-Acute Cardiovascular Care Association board. A total of 337 responses from 60 countries were obtained. Data were assessed by the hospital level of care of the participants. The most common cause of CS was AMI (AMI-CS-79.9%) with significant difference according to hospital levels (P = 0.001), followed by acutely decompensated heart failure (HF) (13.4%), myocarditis (3.5%), and de novo HF (1.75%). In 37.8%, percutaneous coronary intervention (PCI) is performed to all CS-patients as a standard approach, whereas 42.1% used PCI if electrocardiogram suggestive of ischaemia and 20.1% only if Universal definition of myocardial infarction criteria are fulfilled. Management (catecholamine titration and mechanical circulatory support escalation) is driven by mean arterial pressure (87.1%), echocardiography (84.4%), and lactate levels (83.4%). Combination of vasopressor and inotrope is chosen with the same frequency (37.7%) than inotrope alone as first-line pharmacological therapy (differences amongst hospital levels; P > 0.5). Noradrenaline is first-line vasopressor (89.9%) followed by dopamine (8.5%), whereas dobutamine is confirmed as the first-line inotrope (65.9%). Cardiogenic shock management is heterogenous and often not adherent to current recommendations. Quality improvement on an international level with evidence-based quality indicators should be developed to standardize diagnostic and therapeutic pathways.

Development of primary care quality indicators for chronic obstructive pulmonary disease using a Delphi-derived method

High-quality care for patients with COPD is necessary. To achieve quality improvement in primary care, the general practitioner and the electronic health record (EHR) play an important role. The aim of this study was to develop a set of evidence-based and EHR extractable quality indicators (QIs) to measure and improve the quality of COPD primary care. We composed a multidisciplinary expert panel of 12 members, including patients, and used a RAND-modified Delphi method. The SMART principle was applied to select recommendations and QIs from international guidelines as well as existing sets of QIs, and these recommendations and QIs were added to an individual written questionnaire. Based on the median score, prioritization and degree of agreement, the recommendations and QIs were rated as having a high, uncertain or low potential to measure the quality of COPD primary care and were then discussed in an online consensus meeting for inclusion or exclusion. After a final validation, a core set of recommendations was translated into QIs. From 37 recommendations, obtained out of 10 international guidelines, and 5 existing indicators, a core set of 18 recommendations and 2 QIs was derived after the rating procedure. The expert panel added one new recommendation. Together, the recommendations and QIs were translated and merged into a final set of 21 QIs. Our study developed a set of 21 evidence-based and EHR-extractable QIs for COPD in primary care. These indicators can be used in an automated quality assessment to measure and improve the quality of COPD primary care.