Implementation Of Quality Improvement Measures Research Articles

Impact of Quality Improvement (QI) Initiatives on Neonatal Mortality in NICU: A Retrospective Analysis in Tertiary Care Centre in Western India

Introduction: The global “under-five mortality” has dropped 60% from 93 deaths per 1,000 live births in 1990 to 37 in 2020 in the last three decades. It is vital to adopt proven quality improvement initiatives to provide quality care to improve neonatal mortality and morbidity. Aim of the study was to assess the impact of the quality improvement interventions and strategies in reducing the neonatal mortality statistics.
 Methods: The study was conducted in a 500 bedded Government Hospital in India. The management implemented various tactics, such as enhancing the existing infrastructure, upgrading equipment, augmenting the workforce, and implementing established clinical protocols, to enhance the quality of intensive care services provided in the NICU. The QI points were identified based on the shortcomings that were identified and shortlisted based on the working of NICU pre QI implementation. The outcome was measured as neonatal mortality indicators and the data was compared between pre and post implementation period.
 Results: After implementing quality improvement measures, there were notable enhancements in the total floor area, availability of skilled personnel, and equipment. The number of total admissions to the NICU increased by 79%, and mortality reduced from 20.93% to 7.82%. There was a statistically significant decrease in disease-specific neonatal mortality rates, with a p-value of less than 0.001.
 Conclusions: This study concludes that implementation of proper and comprehensive QI interventions and strategies in NICUs can help in decreasing the neonatal mortality.

Does Social Media Dominate Government Report Cards in Influencing Nursing Home Demand?

Problem definition: Social media has become an indispensable platform for disseminating quality information to consumers across various service sectors. Recently, it has extended its influence to healthcare services, which traditionally relied on government report cards to disclose standardized quality information to the public. This article explores the impact of social media on consumer demand for healthcare services and compares its effectiveness with government report cards. Methodology/results: We analyze quality ratings of U.S. nursing homes collected from two information channels: (1) consumer ratings on Yelp and (2) government ratings on Nursing Home Compare, both of which adopt a five-star quality rating scale and are accessible on the Internet. We employ the method of difference-in-differences with continuous treatment intensity and instrumental variables to analyze the data. Using nursing home resident admissions as a proxy for consumer demand, we find that higher Yelp ratings led to higher consumer demand, particularly among Medicare-covered consumers. Furthermore, the effect of Yelp ratings was primarily driven by extreme ratings (one-star or five-star), as opposed to neutral ratings. We also find that Yelp ratings exerted a stronger effect on consumer demand than government ratings. This dominance of Yelp ratings over government ratings was observed primarily in markets with high Yelp penetration or markets with low and medium consumer education levels. Although higher Yelp ratings were associated with increased net incomes, we find little evidence that nursing homes made quality improvement in response to their Yelp ratings. Managerial implications: We recommend that the Centers for Medicare and Medicaid Services recognize social media platforms as valuable sources of information and collaborate with reputable platforms, such as Yelp, to promote public awareness of government report cards like Nursing Home Compare. Moreover, we advise nursing home operators to proactively manage their reputation on social media by promptly addressing consumer complaints and implementing quality improvement measures. Funding: Y. Li was supported by the National Natural Science Foundation of China [Grant 72301193], the Shanghai Sailing Program [Grant 22YF1451000], and the Fundamental Research Funds for the Central Universities. S. F. Lu was supported by the Gerald Lyles Rising Star fund. Supplemental Material: The online appendix is available at https://doi.org/10.1287/msom.2021.0303 .

Airway management in the operating room setting: An analysis of reported safety events.

Adverse event reporting systems are important tools for identifying areas of risk and opportunities quality improvement. Perioperative airway management (PAM) carries patient risk. We examine the nature of PAM incident reports at an academic tertiary care center. In this retrospective data review, perioperative safety reports filed under "Airway Management" between 2015 and 2020 were analyzed. Data analyzed included severity level (patient harm) and specific event type. There was a total of 7827 safety reports filed from January 2015 to July 2020, with 67 reports related to "Airway Management" (0.85%). The most common specific event type in this safety reporting database was "Intubation Injury (Mouth, Tooth, Airway)" (35.8%). The most common severity level of all reported events was level 2 (temporary or minor harm, 57%). Our safety reporting data demonstrates that adverse events related to PAM are likely to reach the patient and can cause significant harm. Data from our findings can help providers and risk managers to focus efforts on reducing patient harm. Strategies include continued education in technical skills and crisis management, preparation for the difficult airway, increased availability of video laryngoscopes, ongoing safety reporting and collaborative review of adverse events with implementation of quality improvement measures.

Research on the Improvement Effect of Quality Improvement Measures Based on Fishbone Diagram Analysis Method on the Management of Emergency Equipment in Hospital

Objective To explore the application value of quality improvement measures based on fishbone diagram analysis method in improving the management effect of emergency equipment in hospital. Method Facing the problems in the use and management of emergency equipment, a hospital in Xi 'an adopted fishbone diagram analysis method to analyze the root causes of the problems from the five aspects of Man, Machine, Material, Method and Milieu. The corresponding improvement measures were put forward according to the problems. The management effects of emergency equipment before and after the implementation of the improvement measures were compared. Results In the comparison of the use and management effects of emergency equipment to be used, after the implementation of quality improvement measures based on fishbone diagram, the ratio of emergency equipment without stains on surfaces, the ratio of fully charged emergency equipment, the ratio of emergency equipment in the qualified measurement period increased significantly (c2=18.587, c2=72.090, c2=9.207; p<0.05); in the comparison of failure rates of emergency equipment in the whole hospital, the failure rate of emergency equipment in the whole hospital decreased from 2.54% before the implementation of quality improvement measures to 0.79% after the implementation. Conclusions The quality improvement measures based on fishbone diagram analysis method can significantly improve the management effect of emergency equipment, and has great application value in the management of emergency equipment in hospitals.

Simulation versus reality: what can interprofessional simulation teach us about team dynamics in the trauma bay?

PurposeSurgical consultation and the joint management of trauma patients is a common scenario in the emergency department. The goal of this study was to utilize interprofessional trauma team training to understand the role of simulation and its impact on the overall culture of trauma-related care.MethodsInterdisciplinary trauma simulation scenarios were completed by 12 groups of emergency medicine residents, general surgery residents, and emergency medicine nurses across two academic years. Following each simulation, a debriefing session was held to reflect on the scenario, focusing on team interactions. Debriefing sessions were audio-recorded, transcribed, deidentified, and independently, inductively coded by two members of the research team. Using the constant comparative method, a codebook was developed and refined until interrater reliability was confirmed with a kappa of > 0.9. Codes were organized into higher level themes.ResultsThere were 72 participants, including 23 general surgery residents, 19 emergency medicine residents, and 30 emergency medicine nurses. 214 primary codes were collapsed into 29 coding categories, with 6 emerging themes. Pre-trauma bay impact describes how interactions prior to the trauma scenario can impact how team members communicate, trust one another, and ultimately care for the patient. Role and team identity explores the importance of one knowing their individual role in the trauma bay and how it impacts overall team identity. Resource allocation describes the balance of having appropriate resources to efficiently care for patients while not negatively impacting crowd control or role identity. Impact of the simulation experience highlights the impact of the lower stakes simulation scenario on learning and reflection as well as concerns with simulation fidelity. Trauma leader traits and actions outlines inherent traits and learned actions of trauma leaders that impact how the trauma scenario unfolds. Interprofessional team performance describes the overall performance of the trauma team, including but not limited to the type of communication used, teamwork behaviors, and transition of care of the patient.ConclusionsInterdisciplinary trauma simulations and structured debriefing sessions provide insights into team dynamics and interprofessional relationships. Simulations and debriefing sessions can promote understanding, respect, and familiarity of team members’ roles; recognition of key characteristics of high functioning leaders and teams; and discovery of conflict mitigating strategies for future interdisciplinary team improvement. Simulation sessions allow implementation of quality improvement measures and communication and leadership strategy practice in a safe, collaborative learning environment. The lessons learned from these sessions can encourage participants to reexamine how they interact and function as a team within the real-life trauma bay.

Hospital managers’ perspectives with implementing quality improvement measures and a new regulatory framework: a qualitative case study

A new regulatory framework to support local quality and safety efforts in hospitals was introduced to the Norwegian healthcare system in 2017. This study aimed to investigate hospital managers’ perspectives...

State of Personal Protective Equipment Practice in Indian Intensive Care Units amidst COVID-19 Pandemic: A Nationwide Survey.

BackgroundOptimal personal protective equipment (PPE) preparedness is key to minimize healthcare workers (HCW) infection with COVID-19. This two-phase survey evaluated PPE preparedness (adherence to Ministry of Health India (MoH) PPE-recommendations; HCW-training; PPE-inventory; PPE-breach management) in Indian intensive care units (ICU).Materials and methodsThe phase 1 survey was distributed electronically to intensivists from 481 Indian hospitals between March 25, 2020, and April 06, 2020, as part of a multinational survey. Phase 2 was repeated in 320 Indian hospitals between April 20, 2020, and April 30, 2020.ResultsResponse rate was 25% from 22 states. PPE practice varied between states and between private, government, and medical colleges. Between phase 1 and phase 2, all aspects of PPE training improved: donning/doffing 43% vs 66%, respectively; p value <0.01); safe waste disposal practices (38% vs 52%; p value = 0.09); intubation training (18% vs 31%; p value = 0.05); and transport (18% vs 31%; p value = 0.05). Perception of confidence for adequate PPE-training improved from 39 to 53% (p value = 0.26). In all, 47 to 60% ICUs adhered to MoH recommendations. Wearing N95-masks at all times increased from 47 to 60% (p value = 0.89). Very few ICUs provided quantitative/qualitative N95 masks fit testing (12% vs 29%; p value <0.01). Low-cost practices like “buddy-system” for donning-doffing (27% vs 44%; p value = 0.02) and showering after PPE breach (10% vs 8%; p value = 0.63) were underutilized. There was reluctance to PPE reuse. In all, 71% were unaware/diffident about PPE inventory.ConclusionDespite interstate variability, most ICUs conformed to MoH recommendations. This survey conducted during initial pandemic phase demonstrated improved PPE preparedness uniformly across India with scope for further improvement. We suggest implementation of quality improvement measures to improve pandemic preparedness and minimize HCW infection rates, focused on regular PPE training, buddy system, and PPE-breach management.How to cite this articleHaji JY, Subramaniam A, Kumar P, Ramanathan K, Rajamani A. State of Personal Protective Equipment Practice in Indian Intensive Care Units amidst COVID-19 Pandemic: A Nationwide Survey. Indian J Crit Care Med 2020;24(9):809–816.

Temporal trends in receipt of adjuvant chemotherapy for veterans with colorectal cancer.

e19171 Background: For patients with National Comprehensive Cancer Network (NCCN) high risk stage II or stage III colorectal cancer (CRC), adjuvant chemotherapy improves disease free (DFS) and overall survival (OS). Rates of use vary significantly across health care settings. Several demographic and healthcare factors are associated with decreased receipt of chemotherapy; however, few studies have assessed utilization patterns over time. We evaluated receipt of chemotherapy from 2000-2015 among patients treated at a Southeast Regional Veterans Health Administration (VHA) facility to determine local targets for quality improvement initiatives. Methods: We reviewed 1,107 electronic medical records of patients undergoing colorectal surgery from January 1, 2000 to December 31, 2015 at VHA Tennessee Valley Healthcare System. We included patients with NCCN eligible pathologic high risk stage II (T4/perf, R1, &lt; 12LN, LVI) or stage III CRC and excluded for age ≥80, age ≥75 hospitalized in the prior year with a major co-morbidity, and death or hospice within 30 days of surgery. The primary predictor was year of surgery, partitioned 2000-2005 (N = 60), 2006-2010 (N = 64), 2011-2015 (N = 56) to reflect changes in NCCN guidelines. The primary outcome was receipt of any chemotherapy. Results: Of 1,107 colorectal surgeries, we excluded 623 for non-cancers, 212 for stage I or low-risk stage II cancer, 47 for metastatic disease, and 45 for age, co-morbidity, death, and hospice, yielding a final cohort of 121 colon and 59 rectal cancers. Most patients were male (96%), white (79%), with median age 64 years [Interquartile Range 60, 70]. Overall, 117 of 180 (65%) received chemotherapy with a median time to treatment of 50.5 days [40,64]. Adjusting for known correlates, receipt of chemotherapy decreased over time; 2000-2005 (72%), 2006-2010 (69%), 2011-2015 (53%) p = 0.02. Regardless of CRC stage, more patients declined chemotherapy in 2011-2015 (27%) compared to 2000-2005 (6%) and 2006-2010 (8%) p &lt; 0.01. Conclusions: We identified decreased utilization of adjuvant chemotherapy in a non-elderly veteran cohort, which appeared to be due to patients declining chemotherapy regardless of cancer stage. Understanding patient and provider decisions around adjuvant chemotherapy and evaluating trends outside the VHA may offer important insights to implementing quality improvement measures.

2 PDSA Audit Improves Identification and Management of Urinary Incontinence In Post Stroke Patients

Abstract Introduction Urinary incontinence is a prognostic indicator of mortality and functional recovery in stroke. There is a small evidence base that early intervention within the first three months may improve continence status and subsequent physical and psychological consequences. Methods Utilising a proforma and PDSA, data was collected on the identification and assessment of urinary continence status for patients admitted to a stroke unit. Five agreed standards from NICE (2012) and RCP (2016) guidelines formed the basis of audit. Three cycles of prospective data for a total of 66 patients was collected over four months, implementing quality improvement measures after each cycle. Results 22 participants per cycle. Cycle one demonstrated continence status was identified by the nursing team (100%), and the medical team (41%). However, standards regarding further care planning and assessment (22%), MDT input (11%) and subsequent behavioural and practical interventions (11%) was low. Change strategy, i) awareness training, ii) development of MDT prompt sheet. Cycle two, medical identification (82%), MDT discussion (100%), and continence specific interventions (66%), care planning decreased from 22% to 0%. Change strategy, incontinent patients receive an individualised assessment within 7 days by the advanced nurse practitioner, this assessment should consider all available evidence-based interventions, with the aim of reducing urinary incontinence within the early phases of stroke. Cycle three showed an overwhelming improvement to all five standards, nursing and medical identification (100%, 91. Conclusions PDSA style audit led to quality improvement. The identification of urinary continence status post stroke was high, but due to multifactorial elements often did not progress to assessment or intervention from the MDT. Utilising the existing role of the trainee advanced practitioner patients received evidence-based continence reviews in a timely manner, with no additional cost impact to the service.

Validation of a Model for Developing Evidence-Based Clinical Practice Guidelines for School Nursing.

The paucity of scientifically rigorous school nursing clinical practice guidelines (CPGs) presents barriers to evidence-based care of students with special health-care needs. A Model for Developing Evidence-Based Clinical Practice Guidelines for School Nursing (School Nursing CPG Model) was developed under the auspices of the National Association of School Nurses (NASN) to address this need. To test and validate this School Nursing CPG Model, a trial CPG development project was conducted to (1) identify structure and process gaps and areas for improvement within the School Nursing CPG Model and (2) develop an evidence-based CPG for school nursing practice that addresses a priority student health condition: seizures and epilepsy. The School Nursing CPG Model was validated through a trial CPG project which followed the systematic, standardized process of the School Nursing CPG Model while responsively implementing quality improvement measures through the Plan-Do-Study-Act cycle. Both specific aims were accomplished.

Pediatric Hand Injuries Requiring Closed Reduction at a Tertiary Pediatric Care Center.

Background: Hand fractures and dislocations are common injuries in the pediatric population. This study aims to characterize the pediatric hand injuries that required closed reduction and identify those that required multiple reduction attempts. Methods: A retrospective cohort study was carried out in patients younger than 18 years of age with hand fractures or dislocations who underwent closed reduction in the emergency department (ED). Patients who ultimately required surgical reduction and fixation were not included. Results: Of the 310 hand injuries identified, 148 (114 fractures and 34 dislocations) underwent closed reduction in the ED; 7.4% of those required repeat reduction. Hand injuries that most often required repeat reduction included metacarpophalangeal joint dislocations (20.0%) and proximal phalanx neck (16.7%), metacarpal shaft (15.4%), metacarpal neck (6.2%), and proximal phalanx base (5.6%) fractures. No modifiable risk factors predicting the need for repeat reduction were identified. Conclusions: Some pediatric hand injuries are more likely to require repeat closed reduction by a hand surgeon. This retrospective study is the first step toward quality improvement as it provides opportunities for further research into the factors contributing to reductions that are unsuccessful at the first attempt. Identification of these factors and implementation of quality improvement measures are necessary to ensure the effective treatment of all pediatric hand injuries.

External validation of the Hospital Frailty Risk Score and comparison with the Hospital-patient One-year Mortality Risk Score to predict outcomes in elderly hospitalised patients: a retrospective cohort study

ObjectiveFrailty is an important prognostic factor in hospitalised patients but typically requires face-to-face assessment by trained observers to detect. Thus, frail patients are not readily apparent from a systems perspective...

Messen, Bewerten, Handeln: Qualitätsindikatoren zur Koronaren Herzkrankheit im Praxistest

BackgroundThere are only limited possibilities for doctors in outpatient services to establish quality management that is based on data-driven feedback regarding the quality of health care. However, transparency about one's own activities is a prerequisite for refining this quality. The aim of this project was to make the quality of care for patients with coronary heart disease (CHD) more transparent, use this as a basis to initiate improvement processes, and explore the framework conditions and factors promoting or inhibiting the intended improvement of health care quality. Method48 general practitioners (GPs) in 32 GP practices from a Bavarian doctors’ network (Qualität und Effizienz, QuE) participated in the project. On the basis of claims data from the AOK-Bayern (a statutory health insurance in Bavaria), data from disease management programs (DMP) and medically documented data, 11 quality indicators for patients with CHD were calculated. The indicator scores were individually presented in feedback reports for each doctor's practice. These were the basis for two quality circles. The indicators were measured again after 12 months, and changes against the baseline measurement were registered. GPs from Bavaria formed the control group. Focus groups with the quality circle moderators and two participant surveys were used to identify promoting and inhibiting factors. ResultsThe baseline values showed a good level of care. Potential for improvement became apparent for pharmacotherapy with beta blockers and statins. After conducting the quality circles four of the eleven indicators showed an increase as intended (“beta blockers for CHD and cardiac insufficiency”, “beta blockers after myocardial infarction”, “statins”, “successful blood pressure control”). For three of these indicators the increase rates were higher than those in the Bavarian control group. One indicator (“statins”) was striking because of the wide variation of practice values suggesting differences in care within the network.The majority of participating doctors regarded the database as valid. Quality circles were highly appreciated as an opportunity for professional exchange among colleagues. The data-based feedback reports helped to make deficits in health care transparent and to identify actions that need to be taken. Barriers to implementing quality improvement measures in clinical practice became apparent. DiscussionReflecting quality indicators in quality circles can effectively trigger quality improvement processes. Barriers would appear to exist, in particular, to the implementation of measures into daily practice routine. Additional organizational support offered by higher-level quality management structures, IT solutions for patient-related data processing as well as a system of financial compensation, which rewards professional concern for quality, may help to overcome the existing barriers.

Surgical site infection after cesarean delivery: incidence and risk factors at a US academic institution

Purpose: To identify the rate of surgical site infection (SSI) after Cesarean delivery (CD) and determine risk factors predictive for infection at a large academic institution.Methods: This was a retrospective cohort study in women undergoing CD during 2013. SSIs were defined by Centers for Disease Control (CDC) criteria. Chi square and t-tests were used for bivariate analysis and multivariate logistic regression was used to identify SSI risk factors.Results: In 2419 patients, the rate of SSI was 5.5% (n = 133) with cellulitis in 4.9% (n = 118), deep incisional infection in 0.6% (n = 15) and intra-abdominal infection in 0.3% (n = 7). On multivariate analysis, SSI was higher among CD for labor arrest (OR 2.4; 95%CI 1.6–3.5; p <.001). Preterm labor (OR 2.8; 95%CI 1.3–6.0; p = .01) and general anesthesia (OR 4.4; 95%CI 2.0–9.8; p = .003) were predictive for SSI. Increasing BMI (OR 1.1; 95%CI 1.05–1.09; p = .02), asthma (OR 1.9; 95%CI 1.1–3.2; p = .02) and smoking (OR 1.9; 95%CI 1.1–3.2; p = .02) were associated with increased SSI.Conclusions: Several patient and surgical variables are associated with increased rate of SSI after CD. Identification of risk factors for SSI after CD is important for targeted implementation of quality improvement measures and infection control interventions.

Care Transitions: Using Narratives to Assess Continuity of Care Provided to Older Patients after Hospital Discharge.

BackgroundA common scenario that may pose challenges to primary care providers is when an older patient has been discharged from hospital. The aim of this pilot project is to examine the experiences of patients’ admission to hospital through to discharge back home, using analysis of patient narratives to inform the strengths and weaknesses of the process.MethodsFor this qualitative study, we interviewed eight subjects from the Sheldon M. Chumir Central Teaching Clinic (CTC). Interviews were analyzed for recurring themes and phenomena. Two physicians and two resident learners employed at the CTC were recruited as a focus group to review the narrative transcripts.ResultsNarratives generally demonstrated moderate satisfaction among interviewees with respect to their hospitalization and follow-up care in the community. However, the residual effects of their hospitalization surprised five patients, and five were uncertain about their post-discharge management plan.ConclusionBoth secondary and primary care providers can improve on communicating the likely course of recovery and follow-up plans to patients at the time of hospital discharge. Our findings add to the growing body of research advocating for the implementation of quality improvement measures to standardize the discharge process.

Improved Breast Cancer Care Quality Metrics After Implementation of a Standardized Tumor Board Documentation Template.

Cancer treatment requires a coordinated multidisciplinary treatment approach, which led to the development of the Rapid Quality Reporting System by the Commission on Cancer. However, the lack of immediate availability of documented treatment plans and the inefficiency of global medical record reviews represent significant barriers to adherence reporting and the timely implementation of quality improvement measures. Adherence to national guidelines in the areas of radiation treatment, chemotherapy, and hormone therapy was assessed after breast conservation surgery (BCS). Adherence rates within 1 year of BCS were analyzed 10 weeks before and after the implementation of a standardized documentation template at weekly multidisciplinary breast cancer conferences. Documented adherence rates increased postimplementation in patients undergoing consideration for both radiation treatment and hormone therapy within 1 year of BCS (89% v 65%; P = .045% and 85% v 62%; P = .002, respectively). No change was observed in patients undergoing evaluation for cytotoxic chemotherapy (80% v 85%; P = 1.00). The addition of a documentation template to multidisciplinary breast cancer conferences resulted in increased recorded adherence rates to national guidelines. This template provided a means of both accurate and efficient documentation of evidence-based practice, which represents a concept with broad application in quality improvement. Although evaluation of the project was not continued beyond the pilot stage, current quality measure scores remain within the same range.

Surgical Complications Are Associated With Omission of Chemotherapy for Stage III Colorectal Cancer

Appropriate use of adjuvant chemotherapy is a widely recognized quality measure of colorectal cancer care. The objective of this study was to test the hypothesis that surgical complications are associated with omission of chemotherapy for colorectal cancer. We used the 1998 to 2005 Surveillance, Epidemiology and End Results-Medicare database to study adjuvant chemotherapy use among patients with stage III colorectal cancer who underwent surgical resection. Chemotherapy use was compared between patients with and without complications. Univariate analyses and multiple logistic regression were used to test the association between complications and chemotherapy omission, while adjusting for demographics, comorbidity, and other factors. Associations between complications and time to chemotherapy were also studied. We identified 17,108 eligible patients with stage III colorectal cancer (median age, 75 y; 24% rectal/rectosigmoid). Using a parsimonious list of complication codes, 18% of patients had ≥ 1 complication. Thirteen percent of patients had medical complications and 3.8% of patients had complications requiring reoperation or another procedure. Adjuvant chemotherapy was omitted among 46% of patients with complications, compared with 31% of patients with no complications (P < .0001). Having a complication was independently associated with omission of chemotherapy in multivariable analysis (adjusted OR, 1.76; 95% CI 1.59-1.95). Other factors significantly associated with chemotherapy omission were age, race, marital status, urgent/emergent admission, and type of operation. Risk ratios increase with multiple complications (P < .0001). Complications were also associated with an increased risk of chemotherapy delay (P < .0001). Surgical complications are independently associated with omission of chemotherapy for stage III colorectal cancer and with a delay in adjuvant chemotherapy. These data suggest that complications of colorectal surgery may affect both short- and long-term cancer outcomes. Thus, the implementation of quality improvement measures that effectively reduce perioperative complications may also provide a long-term cancer survival benefit.

Intérêt de l’EPP pour l’amélioration de la prise en charge de la douleur postopératoire par analgésie contrôlée par le patient (ACP)

Objectives To evaluate the daily practice of postoperative PCA in Nancy University Hospital, in continuity with a quality program of postoperative pain (POP) care conducted in 2003. Type of study A retrospective audit of patient medical records. Material and methods A review of all the medical records of consecutive surgical patients managed by PCA over a 5 week period in six surgical services. Criteria studied: Evaluation of hospital means (eight criteria) and of medical and nursing staff practice (16 criteria). A second audit was conducted 6 months after the implementation of quality improvement measures. Results Assessment of the hospital means: temperature chart including pain scores and PCA drug consumption, patient information leaflet, PCA protocol, postoperative pre-filled prescription form (PFPF) for post-anaesthesia care including PCA, and optional training of nurses in postoperative pain management. Evaluation of practices One hundred and fifty-nine files of a total of 176 patients were analyzed (88%). Improvements noted after 6 months: trace of POP evaluation progressed from 73 to 87%, advance prescription of PCA adjustment increased from 56 to 68% and of the treatment of adverse effects from 54 to 68%, trace of PCA adaptation by attending nurse from 15 to 43%, trace of the administration of the treatment of adverse effects by attending nurse from 24% to 64%, as did the use of PFPF from 59 to 70%. Conclusions The usefulness of a pre-filled prescription form for post-anaesthesia care including PCA prescription is demonstrated. Quality improvement measures include: poster information and pocket guides on PCA for nurses, training of 3 nurses per service to act as “PCA advisers” who will in turn train their ward colleagues in PCA management and the use of equipment until an acute pain team is established.

A purging procedure for pantoprazole and 4-lumen catheters to prevent IV drug incompatibilities

The purpose of this prospective intervention study was to assess the number of patients with Y-site incompatibilities before and after implementation of quality improvement measures to prevent incompatibilities consisting of a focused instruction for pantoprazole as a drug frequently involved in incompatible drug pairs and of a recommendation to use 4-lumen instead of 3-lumen catheters to increase the number of available central infusion lines. Cardiovascular intensive care unit where several standard operating procedures (SOPs) dealing with compatibility were already in place. In a prospective intervention study, patients' IV medication was assessed for potential incompatibilities using a database containing compatibility information on approximately 60,000 drug pairs. In a first period, routine administration was monitored in 53 consecutive patients (control group). Then, quality improvement measures were implemented recommending a purging procedure before and after bolus administration of pantoprazole as a drug frequently causing incompatibilities in this setting. Additionally, the use of 4-lumen instead of 3-lumen catheters was suggested whenever considered useful by the responsible physicians. The monitoring was repeated during a second period in another 58 patients consecutively admitted to the same unit (intervention group). Overall number of patients with at least one incompatible drug pair and number of patients receiving incompatible pantoprazole combinations. The number of patients receiving incompatible pantoprazole combinations decreased from 15 of the 15 patients receiving pantoprazole (100.0%) in controls to 9/16 (56.2%) in the intervention group (P < 0.01). The overall number of patients with incompatibilities was not influenced by the intervention with 36/58 (62.1%) compared to controls with 38/53 (71.7%, P = 0.28). The fraction of central lines contributed by four lumen central catheters was larger due to the intervention (80/168 lines, 47.6%) compared to controls (16/184, 8.7%, P < 0.001). Only sporadically there were incompatible combinations of drugs governed by the already existing SOPs. In an intensive care setting with good SOP adherence, purging before and after administration decreased the respective incompatibility rate whereas the use of 4-lumen instead of 3- lumen catheters had not the expected benefit on separating drug pairs.

Reduction of postprocedure microemboli following retrospective quality assessment and practice improvement measures for carotid angioplasty and stenting

We have previously demonstrated a 70% incidence of microemboli on diffusion weighted magnetic resonance imaging (DW-MRI) following carotid angioplasty and stenting (CAS). The purpose of this study is to compare the incidence of microemboli in two distinct time periods when procedural modifications were implemented into a CAS program. Following a retrospective quality review of our CAS cohort (n = 27) from November 2004 through April 2006 (period 1), we enrolled patients (n = 20) from May 2006 through February 2008 (period 2) undergoing CAS into a prospective cohort that included obtaining pre- and postprocedure DW-MRI exams. Procedural modifications during period 2 included the preferential use of closed-cell systems (60% vs 0% in period 1), early heparinization at the initiation of arterial access, and elimination of an arch angiogram. The hospital records of these 47 patients were reviewed; symptoms, comorbidities, lesion characteristics, periprocedural information, and postoperative outcomes were collected. The incidence and location of acute, postprocedural microemboli were determined using DW-MRIs. Twenty (74%) CAS patients from period 1 and seven (35%) patients from period 2 demonstrated acute microemboli on postprocedural DW-MRI (P = .02). The mean number of microemboli in period 1 was 4.1 +/- 5.3 vs 1.5 +/- 2.7 during period 2 (P = .04). Two of the 27 patients (7.4%) during period 1 experienced temporary neurologic changes that resolved within 36 hours. None of the patients during period 2 exhibited any neurologic changes. Patient demographics, comorbidities, and presenting symptoms were similar between the two groups except for smoking prevalence, female presence, and obesity (BMI > 30). Period 2 patients when compared with period 1 had more technically challenging anatomy with more calcified lesions (68% vs 27%), longer lesions (15.9 mm vs 8.2 mm), and higher incidence of ulceration (55% vs 27%) (all P < .04). Despite successful performance of 47 consecutive CAS procedures without permanent neurologic sequelae, significant reductions in periprocedural embolic events as identified via DW-MRI lesions may be achieved through implementation of quality improvement measures identified through continuous outcome analysis. The long-term neurologic benefits associated with reduced subclinical neurologic events remains to be determined.