Health Care Quality Improvement Project Research Articles

Development and implementation of evidence-based, nurse-leading early warning model and healthcare quality improvement project for transplant-associated thrombotic microangiopathy: a mixed-methods, before-and-after study

ObjectiveThe early identification and diagnosis of transplant-associated thrombotic microangiopathy (TA-TMA) are essential yet difficult in patients underwent hematopoietic stem cell transplantation (HSCT). To develop an evidence-based, nurse-leading early warning model for TA-TMA, and implement the healthcare quality review and improvement project.MethodsThis study was a mixed-methods, before-and-after study. The early warning model was developed based on quality evidence from literature search. The healthcare quality review and improvement project mainly included baseline investigation of nurse, improvement action and effectiveness evaluation. The awareness and knowledge of early parameter of TA-TMA among nurses and the prognosis of patients underwent HSCT were compared before and after the improvement.ResultsA total of 1 guideline, 1 evidence synthesis, 4 expert consensuses, 10 literature reviews, 2 diagnostic studies, and 9 case series were included in the best evidence. The early warning model including warning period, high-risk characteristics and early manifestation of TA-TMA was developed. The improvement action, including staff training and assessment, suspected TA-TMA identification and patient education, was implemented. The awareness and knowledge rate of early parameter of TA-TMA among nurses significantly improved after improvement action (100% vs. 26.7%, P < 0.001). The incidence of TA-TMA was similar among patients underwent HSCT before and after improvement action (2.8% vs. 1.2%, P = 0.643), while no fall event occurred after improvement action (0 vs. 1.2%, P < 0.001).ConclusionThe evidence-based early warning model and healthcare quality improvement project could enhance the awareness and knowledge of TA-TMA among healthcare providers and might improve the prognosis of patients diagnosed with TA-TMA.

Decision-maker roles in healthcare quality improvement projects: a scoping review

ObjectivesEvidence suggests that healthcare quality improvement (QI) projects are more successful when decision-makers are involved in the process. However, guidance regarding the engagement of decision-makers in QI projects is lacking....

Implementation of a nurse-led multidisciplinary huddle meeting for improvement of early rehabilitation in ICU: a healthcare quality improvement project

The physical decline of critically ill patients affects their discharge from the intensive care unit (ICU) and their subsequent lives. Therefore, it is essential to actively provide rehabilitation at an...

HIV screening and linkage to care in a health department in Valencia, Spain: Lessons learned from a healthcare quality improvement project.

Spain’s rate of new human immunodeficiency virus (HIV) diagnoses exceeds that of the European Economic Area average (8.6 vs 5.6:100,000 in 2018). The country has failed to meet the first of United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 targets for HIV control by 2020, with 87.0% of people living with HIV knowing their status, and late presentation rates of 47.6% and 51.5% country-wide and in the Valencian autonomous community, respectively. Advancing screening and linkage to care (SLTC) practices is necessary to effectively control the epidemic. The Valencia Viral Screening (CRIVALVIR) project adopted the TEST model for opportunistic and systematic HIV SLTC in individuals aged 18 to 80 who required blood work for any purpose, as of February 2019. SLTC was integrated into routine clinical workflow across primary care centers serving a population of 360,000 people in Valencia, Spain. Our project successfully upscaled total HIV testing by 194% to over 32,000 patients tested in 14 months. We found an overall prevalence of 0.13% (0.08–0.21) among those screened per protocol (n = 13,061), with foreign-born citizens presenting a 12.5 times significantly higher likelihood of acquiring HIV (95% confidence interval 4.63–33.96, P < .0001). We improved late presentation by 18.2 percentage points and prevented an estimated 58 to 70 new secondary infections. HIV screening of the general population in primary care is an effective strategy for achieving timely diagnosis and preventing new infections. Opportunistic, systematic, opt-out approaches are essential to control the HIV epidemic.

Quality Measures: Types, Selection, and Application in Health Care Quality Improvement Projects.

Quality Measures: Types, Selection, and Application in Health Care Quality Improvement Projects.

Outsourcing the Remote Management of Cardiac Implantable Electronic Devices: Medical Care Quality Improvement Project.

BackgroundRemote management is partially replacing routine follow-up in patients implanted with cardiac implantable electronic devices (CIEDs). Although it reduces clinical staff time compared with standard in-office follow-up, a new definition of roles and responsibilities may be needed to review remote transmissions in an effective, efficient, and timely manner. Whether remote triage may be outsourced to an external remote monitoring center (ERMC) is still unclear.ObjectiveThe aim of this health care quality improvement project was to evaluate the feasibility of outsourcing remote triage to an ERMC to improve patient care and health care resource utilization.MethodsPatients (N=153) with implanted CIEDs were followed up for 8 months. An ERMC composed of nurses and physicians reviewed remote transmissions daily following a specific remote monitoring (RM) protocol. A 6-month benchmarking phase where patients’ transmissions were managed directly by hospital staff was evaluated as a term of comparison.ResultsA total of 654 transmissions were recorded in the RM system and managed by the ERMC team within 2 working days, showing a significant time reduction compared with standard RM management (100% vs 11%, respectively, within 2 days; P<.001). A total of 84.3% (551/654) of the transmissions did not include a prioritized event and did not require escalation to the hospital clinician. High priority was assigned to 2.3% (15/654) of transmissions, which were communicated to the hospital team by email within 1 working day. Nonurgent device status events occurred in 88 cases and were communicated to the hospital within 2 working days. Of these, 11% (10/88) were followed by a hospitalization.ConclusionsThe outsourcing of RM management to an ERMC safely provides efficacy and efficiency gains in patients’ care compared with a standard in-hospital management. Moreover, the externalization of RM management could be a key tool for saving dedicated staff and facility time with possible positive economic impact.Trial RegistrationClinicalTrials.gov NCT01007474; http://clinicaltrials.gov/ct2/show/NCT01007474

Romiplostim as a transfusion saving strategy in 20 patients after heart or lung transplantation: a single centre before-after pilot study.

Thrombocytopenia is a common disorder after heart or lung transplantation. Platelet transfusion is often required to maintain haemostasis but represents a specific cause of morbidity and mortality in this setting including alloimmunisation and graft rejection. As part of a health-care quality improvement project, in a single-centre before-after pilot study, the relevance of a platelet transfusion saving strategy based on romiplostim administration after transplantation was assessed in patients with platelet count <100 × 109/L. Transfusions on days 28 and 90 were compared using propensity matched score for adjustment of demographic characteristics at baseline. The primary outcome was platelet transfusion until day 28 after transplantation. Ninety-three patients were analysed (73 before vs. 20 after). The median [interquartile range] number of platelet concentrate was 1 [0;4.0] before versus 0.5 [0;2.0] in the after period, mean difference 0.5 confidence interval 95% [-0.7 to 1.7], p = 0.39. On day 28, median [interquartile range] red blood cell transfusion was significantly higher in the before versus the after period, 7 [2.0;13.5] versus 6 [1.5;8.5], mean difference 3.2 CI 95% [0.4-6.0], p = 0.02. At 6 months, the rate of patients with de novo anti-human leukocyte antigen alloimmunisation was 45% before versus 53% in the after period (p = 0.56). Deep venous thrombosis was detected in nine patients (12%) before versus seven patients (35%) in the after period (p = 0.04). Romiplostim did not significantly reduce platelet transfusion after heart or lung transplantation. Its relevance and safety in a global transfusion strategy remains to be studied in this setting in a large randomised study.

Design and Development of Daily Morning Surgical Rounds in ICU by Quality Function Deployment.

Most healthcare quality improvement projects focus on change management rather than the design of the process. In this article, we describe the development of a new rounding model based on quality function deployment, a Design for Six Sigma tool. We used affinity diagram, focus groups, and Kano analysis to identify critical customer requirements. We also used Kano analysis to determine the design team's ability to meet the requirements. We then completed a correlation matrix (House of Quality). Fifteen quality characteristics were analyzed on a correlation matrix to meet 15 demanded qualities. Numerical values were calculated based on the interactions identified by the design team. We designed a new rounding model based on the House of Quality; this new rounding model resulted in higher provider satisfaction (median 76-80%, P = 0.06). We have described a sophisticated approach to the design of a new change strategy/intervention. This technique can be used as a starting point for other projects attempting to implement meaningful changes for complex processes of medical care.

Pharmacokinetics and toxicity of high-dose baclofen in ICU patients

BackgroundHigh-dose baclofen could prove beneficial in patients with unhealthy alcohol use in intensive care units (ICU). However, the pharmacokinetic properties of baclofen are unknown in this population. Our objectives were to investigate the pharmacokinetics of baclofen and the relationship between baclofen exposure and its toxicity in the ICU. Materials and methodsAs part of a healthcare quality improvement project, we conducted a prospective, single-center study in a surgical intensive care unit at Nantes University Hospital in order to assess our local protocol of sedation in patients with consumption of alcohol above the recommended limits by the National Institute on Alcohol Abuse and Alcoholism (NIAAA). Baclofen pharmacokinetics were investigated by a non-compartment analysis and a population approach in 20 patients under mechanical ventilation. After a baclofen loading dose on day 1, daily doses were divided into 3 intakes adapted to glomerular filtration rate (GFR) and blood samples were withdrawn on day 3 for pharmacokinetic analysis. Baclofen was administered until extubation or tracheostomy and agitation-related events as well as the potential side effects of baclofen were noted. ResultsIn this population, pharmacokinetic parameters [absorption latency time = 0.37 h, absorption constant rate = 2.2 h−1, apparent volume of distribution = 105 L, apparent clearance (l/h) = 13.5 × (GFR/103)0.839] were characterized by modified absorption and the influence of renal function: renal failure significantly increased baclofen exposure (p = .007) and significantly decreased baclofen clearance (p = .007) compared with patients without renal failure. When comparing patients with or without possible signs of baclofen toxicity, no difference was found regarding baclofen exposure (p = .34) and plasma peak concentration (p = .26). ConclusionsThe a priori planned algorithm for dose adaptation according to renal clearance appeared to be suitable in our population. Daily administration of 150 mg of baclofen in ICU patients with preserved renal function did not lead to toxic concentrations in the plasma. A dose reduction of approximately 40%, 60% and 70% in patients with mild, moderate and severe renal failure could be suggested.

The use of process mapping in healthcare quality improvement projects

Introduction Process mapping provides insight into systems and processes in which improvement interventions are introduced and is seen as useful in healthcare quality improvement projects. There is little empirical evidence on the use of process mapping in healthcare practice. This study advances understanding of the benefits and success factors of process mapping within quality improvement projects. Methods Eight quality improvement projects were purposively selected from different healthcare settings within the UK's National Health Service. Data were gathered from multiple data-sources, including interviews exploring participants' experience of using process mapping in their projects and perceptions of benefits and challenges related to its use. These were analysed using inductive analysis. Results Eight key benefits related to process mapping use were reported by participants (gathering a shared understanding of the reality; identifying improvement opportunities; engaging stakeholders in the project; defining project's objectives; monitoring project progress; learning; increased empathy; simplicity of the method) and five factors related to successful process mapping exercises (simple and appropriate visual representation, information gathered from multiple stakeholders, facilitator's experience and soft skills, basic training, iterative use of process mapping throughout the project). Conclusions Findings highlight benefits and versatility of process mapping and provide practical suggestions to improve its use in practice.

Preventing Hospital Infections: Real-World Problems, Realistic Solutions

PREVENTING HOSPITAL INFECTIONS: REAL-WO RLD PROBLEMS, REALISTIC SOLUTIONS Sanjay Saint, Sarah L. Krein, and Robert W. Stock Oxford University Press, 2015, 155 pp., $41.95 (softcover)Healthcare-associated infections (HAI) have become an important focus for health care personnel at all levels from the bedside to the executive suite. The approximately 100,000 Americans estimated to die each year as a result of a HAI experienced the most severe consequence, but the impact of HAI does not end there. Patients who contract HAI stay in the hospital longer, are exposed to more and stronger antibiotics, and generate a greater amount of health care costs than they would if the HAI was prevented. In addition, HAI may affect reimbursement rates and are thus a driver for health care quality improvement projects within many institutions.Implementation of technological advances such as antimicrobial surfaces and new devices less susceptible to contamination play an important role in HAI prevention. In this book, Preventing Hospital Infections, the authors turn the attention to the human factor in HAI prevention and transmission. The best device in the world may fail if used incorrectly, and the hospital protocol that lingers unused in a binder, known only to its creator, cannot change incidence of HAI in a health care facility.The book is written in a readable, conversational style, and arranged into 10 chapters. It begins with a discussion of the burden and impact of HAI and the most common device-related HAI: catheter-associated urinary tract infection (CAUTI), ventilator-associated pneumonia (VAP), and central line-associated bloodstream infection (CLABSI). Research has demonstrated shockingly low adherence to infection prevention practices related to these infections. The authors cite a recent study in which adherence to evidencebased CAUTI prevention practices ranged from 6% to 27% (p. 3).The majority of the book examines organizational and leadership strategies to change behaviors and prevent HAI using CAUTI as the example outcome. Urinary catheters are in wide use in many units of the hospital and long-term care facilities for many indications, not just the intensive care unit, and the strategies discussed are not unique to CAUTI.The following chapters describe how organizations can commit to infection prevention initiatives, types of interventions which may be considered, building teams, team roles of leaders and followers, realistic solutions, sustainability, collaborative approaches to infection prevention, and the future of infection prevention. …

Gestión de la endoscopia digestiva de puertas abiertas y calidad asistencial: equipo de mejora con atención primaria

ObjectiveTo create an improvement team within a healthcare quality improvement project of the Government of Aragon (Spain), aimed at increasing the quality of care and suitability of the indications of gastrointestinal endoscopy in the open access endoscopy system of a secondary hospital in Aragon. DesignThe team developed a consensus document indicating how to use oral endoscopy and colonoscopy correctly, and held information and training sessions with all the primary care physicians involved in this area. LocationSector I health centers and Royo Villanova Hospital, in Zaragoza. ParticipantsThe team consisted of a gastroenterologist and three primary care physicians and, from the outset received the support of the primary care administration and management in the health area. ResultsInappropriate use of endoscopy, particularly colonoscopy, was reduced from 20% to 11.6%. Significant savings were achieved in health costs. The endoscopy waiting list was reduced. The quality of care and the safety of patients undergoing these examinations improved. Training of primary care physicians in these procedures was enhanced, and coordination between primary and specialized was implemented. ConclusionsTo ensure efficient running of an open access gastrointestinal endoscopy system, an interdisciplinary improvement team and the full involvement of the primary care staff managing this resource are required.

Overzealous oversight of healthcare quality improvement projects

PurposeThis paper seeks to describe a recent impasse resulting from failure of a federal oversight agency to distinguish between observational studies documenting the impact of quality improvement activities versus experimental clinical trials research.Design/methodology/approachThis paper provides a review of popular press accounts, regulations, and relevant correspondence; and interviews with project leaders.FindingsA controversial federal decision in the USA quickly galvanized unusually harsh criticism from a very wide range of professional associations, healthcare researchers, and patient safety advocacy groups.Originality/valueThis incident, at a time when application of quality improvement methods and public reporting networks are becoming more widespread in healthcare, illustrates the urgent need for better distinction between clinical trials research versus quality improvement research projects. Institutional review boards are ill‐advised to apply familiar ethical safeguard reviews appropriate to the former to the latter.

Cystic fibrosis

This issue of The Journal of Pediatrics contains many reports concerning cystic fibrosis (CF). An accompanying supplement summarizes a meeting held in Atlanta, Georgia, November 2003 entitled “Cystic Fibrosis Newborn Screening: Evidence for Benefit and Current Experience,” a workshop co-sponsored by the Centers for Disease Control and Prevention and the Cystic Fibrosis Foundation. Authors with papers in the supplement were encouraged to submit related articles for the regular pages of The Journal and these went through the standard review process. In addition, several other papers were ready in time for the deadline of this issue. A paper from Canada comments on a reduction in cystic fibrosis birth rates that has been observed since the onset of genetic testing. The paper, from Anne Dupuis and colleagues at the Hospital for Sick Children, Toronto, and Dalhousie University, Nova Scotia, shows that the overall CF birth rate was stable from 1971-1987 and, beginning in 1988, one year after identification of the CF transmembrane conductance regulator gene, birth rates started a linear decline to an estimated rate of 1 in 3,608. CF birth rates appear to have stabilized in the last few years, but the authors speculate that further decline may occur with implementation of carrier screening in the general population. A group of authors led by Filippo Festini report the gestational and neonatal characteristics of children with CF. This was a retrospective cohort study of all children with CF born in Tuscany, Italy, from 1991 to 2002 that compared them to the entire population of non-CF affected children born in the same period. There were 70 children with CF and 290,059 non-CF children. The mean birth weight of the newborns with CF was 246 g lower than the mean birth weight of the non-CF population. The children with CF also had a higher risk of being preterm with a relative risk of 2.62 associated with a lower birth weight and an increased risk of being small for gestational age. The reduced birth weight was present even in the absence of prematurity and the full term newborns with CF were lighter than the full term non-CF babies. The reduced birth weight in newborns with CF has been reported before, but the greater risk of being preterm is a new observation. An alternative strategy for screening newborns for CF has been studied in France. Sarles and colleagues from several centers report on the strategy of combining pancreatitis-associated protein (PAP) with immunoreactive trypsinogen (IRT) assays on newborn blood screening cards. The screening strategy was testing in all newborns from 5 French regions with 204,749 births. Results showed that combining the results of IRT with PAP and recalling patients for sweat testing when the IRT was greater than 100 ng/mL and PAP greater than 1.0 ng/mL would have a similar performance to the IRT/CFTR mutation strategy with reduced cost and without the genetic issue of identification of carrier through mutation analysis. Returning to North America, considerable effort is going into improving outcomes in CF by improving the consistency and quality of care. It has been estimated that more than a 10-year increase in average life expectancy could be achieved using current approaches if they were applied consistently according to best practice. A leader in this effort, Michael Schechter from Brown University, was invited to write a commentary entitled “Improving Subspecialty Healthcare: Lessons from Cystic Fibrosis.” Schechter describes developing optimal approaches to care, and he uses CF as an example of what can be achieved. Schechter presents several quality improvements that are in progress in CF such as the “Learning and Leadership” collaborative funded by the Cystic Fibrosis Foundation. Schechter's article is the subject of an accompanying editorial by James Acton. He reinforces the concept that unwarranted variation in care leads to adverse outcomes in healthcare and that it is possible to improve results through system-based changes that support evidence-based, patient-centered care. Acton is participating in a healthcare quality improvement project at Cincinnati Children's Hospital Medical Center that is funded by the Robert Wood Johnson Foundation and draws on the experience of his team.

Review: organisational change and patient directed strategies may increase adult immunisation and cancer screening

Stone EG, Morton SC, Hulscher ME, et al. Interventions that increase use of adult immunization and cancer screening services: a meta-analysis. Ann Intern Med2002 ; 136 : 641 –51 [OpenUrl][1][CrossRef][2][PubMed][3][Web...

Mass mailings have little effect on utilization of influenza vaccine among Medicare beneficiaries

Background: We reviewed published and unpublished studies of mass mailings designed to increase utilization of influenza vaccine among Medicare beneficiaries. Methods: Search of computerized indexes for published studies and the Medicare Peer Review Organization Health Care Quality Improvement Project database for unpublished studies. Study selection criteria were: use of a controlled trial design and use of mass mailings direct to Medicare beneficiaries to increase receipt of influenza vaccinations. Study selection and data extraction were performed in duplicate by physician reviewers with consensus resolution. Results: Six controlled trials of mass mailings were identified. One study, published in the Morbidity and Mortality Weekly Report ( MMWR), reported a modest but statistically significant improvement in influenza vaccination rates among patients who received a letter relative to those who did not. This study was cited as justification for mail interventions performed in five subsequent studies, none of which reported clinically meaningful results. None of these five studies was published. Conclusions: Mass mailings have at best had clinically trivial effects on increasing influenza vaccination among Medicare beneficiaries. Publication bias has contributed to continued use of a relatively ineffective intervention.

Interventions that increase use of adult immunization and cancer screening services: a meta-analysis.

The relative effectiveness of the diverse approaches used to promote preventive care activities, such as cancer screening and adult immunization, is unknown. Despite many high-quality published studies, practices and policymakers attempting to improve preventive care have little definitive information on which to base decisions. Thus, we quantitatively assessed the relative effectiveness of previously studied approaches for improving adherence to adult immunization and cancer screening guidelines. MEDLINE, the Cochrane Effective Practice and Organization of Care Review Group register, previous systematic reviews, and the Medicare Health Care Quality Improvement Project database. Controlled clinical trials that assessed interventions to increase use of immunizations for influenza and pneumococcal pneumonia and screening for colon, breast, and cervical cancer in adults. Two reviewers independently extracted data on characteristics and outcomes from unmasked articles. Intervention components to increase use of services were classified as reminder, feedback, education, financial incentive, legislative action, organizational change, or mass media campaign. Of 552 abstracts and articles, 108 met the inclusion criteria. To assess the effect of intervention components, meta-regression models were developed for immunizations and each cancer screening service by using 81 studies with a usual care or control group. The most potent intervention types involved organizational change (the adjusted odds ratios for increased use of services from organizational change ranged from 2.47 to 17.6). Organizational change interventions included the use of separate clinics devoted to prevention, use of a planned care visit for prevention, or designation of nonphysician staff to do specific prevention activities. The next most effective intervention components were patient financial incentives (adjusted odds ratios, 1.82 to 3.42) and patient reminders (adjusted odds ratios, 1.74 to 2.75); the adjusted odds ratios ranged from 1.29 to 1.53 for patient education and from 1.10 to 1.76 for feedback. Rates of adult immunization and cancer screening are most likely to improve when a health care organization supports performance of these activities through organizational changes in staffing and clinical procedures. Involving patients in self-management through patient financial incentives and reminders is also likely to positively affect performance.

Foreword

Foreword

The Use of Health Care Financing Administration Data for the Development of a Quality Improvement Project on the Treatment of Anemia

The Health Care Financing Administration maintains a wide array of data systems that are essential to the functioning of the Medicare program. These data, collected and maintained for the purposes of ensuring entitlements and payment for services, also can be used to monitor programmatic changes and to define potential problem areas. The end-stage renal disease (ESRD) Program Management and Medical Information System (PMMIS) is a subset of the larger Medicare statistical system. It is a historic record of all Medicare ESRD beneficiaries dating back to 1978. Basic Medicare enrollment information on ESRD beneficiaries is enhanced with the addition of information on the cause of renal failure, type of dialysis therapy, transplantation history, and cause of death. The ESRD PMMIS has been put to a number of uses in the past decade or so, ranging from basic descriptive epidemiology to analyses of mortality rates to assessments of programmatic issues such as the composite rate and dialyzer reuse. Because of the limited clinical detail in the PMMIS, there are many specific questions that cannot be adequately addressed. With approval of the Food and Drug Administration and Medicare coverage of erythropoietin, a erythropoietin monitoring system was developed to assess utilization trends of this anemia control drug. Within a few months it became evident that dosing levels for erythropoietin were much lower than expected from the clinical trials. Following a change in the payment method from a fixed amount to one based on dose level, dosing has increased markedly. However, hematocrit levels still remain below optimal levels. This lack of hematocrit response has led the Health Care Financing Administration, in concert with the renal community, to target anemia control as a potential health care quality improvement project. This paper presents an example of the type of data presentation that can be derived from the current PMMIS. The Health Standards and Quality Bureau has made a commitment to a program of continuous quality improvement. Part of this process is the provision of descriptive data that can be the starting point for an iterative approach to quality improvement.