Local Quality Improvement Research Articles

Air quality and health burden during COVID-19 response, leverage for future air quality management

Background: Elucidating the links between the coronavirus disease (COVID-19) response, improvement in local air quality and potential health burden may leverage future air quality management. Speculation about improvement in environmental pollution amid COVID-19 outbreak is widespread. Pakistan observed national lockdown since March 15th, 2020 to prevent the transmission of COVID-19. The objectives of this study was to determine the change in particulate matter <2.5 microns and consequent change in the associated attributable fraction of morbidity and mortality in four major cities of Pakistan: Karachi, Lahore, Peshawar and Islamabad. Methods: Particulate matter <2.5 microns (PM2.5) levels before (from 01 Jan 2020 till 14th March, 2020) and during (15th March till 23rd April, 2020) the lockdown were obtained from fixed monitors from these cities. Pakistan’s health related statistics (for 2019) were obtained from Global Burden of Disease Study of Institute of Health Metrics (IHME), US. We estimated the attributable fraction of morbidity and mortality (using AirQ+) for ischemic heart disease (IHD), stroke, chronic obstructive pulmonary disease (COPD) and lung cancer before and during the lockdown and the differences thereof. Results: The average concentration of PM2.5 in four cities reduced from 155.18 µg/m3 to 96.15 µg/m3 (38.03% reduction). Consequently the average estimated reduction in morbidity and mortality in four cities were: IHD= ranged from 3.4% to 6.8%, higher for younger age group; stroke= ranged from 3.8% to 7.7%, higher for younger age group, higher for younger; COPD=8.3%; and lung cancer = 18.7%. Conclusions: The response to COVID-19 provides evidence for estimated reduction in morbidity and mortality of known cardiorespiratory diseases in four cities. Lockdown and social distancing provides an opportunity for environmental and health policymakers to delve into the social and economic activities that threatens the health of the humans. Smart interventions are needed to improve city environment and human health.

Evaluating the CYP-IAPT transformation of child and adolescent mental health services in Cambridgeshire, UK: a qualitative implementation study

BackgroundThe Children and Young People’s Improving Access to Psychological Therapies (CYP-IAPT) programme was introduced to transform Child and Adolescent Mental Health Services (CAMHS) across England. The programme comprised a set of principles that local CAMHS partnerships were expected to operationalise and embed with the aim of increasing access to services and improving the quality of care. This study explored how the implementation of the CYP-IAPT programme was executed and experienced by CAMHS professionals in the county of Cambridgeshire (UK), and the extent to which the CYP-IAPT principles were perceived to be successfully embedded into everyday practice.MethodsWe analysed 275 documents relating to the CYP-IAPT programme issued between 2011 and 2015. We also conducted a thematic analysis of 20 qualitative interviews, undertaken at two time points, with professionals from three CAMHS teams in Cambridgeshire. Analysis was informed by implementation science frameworks.ResultsDocument analysis suggested that the CYP-IAPT programme was initially not clearly defined and lacked guidance on how to operationalise key programme principles and apply them in everyday practice. There was also a degree of programme evolution over time, which made it difficult for local stakeholders to understand the scope and aims of CYP-IAPT. Interviews with staff showed low coherent understanding of the programme, variable levels of investment among stakeholders and difficulties in collaborative working. Barriers and facilitators to programme implementation were identified at individual, service and strategic levels. These in turn impacted the local implementation efforts and sustainability of the programme in Cambridgeshire.ConclusionsWe identified factors relating to programme design and national and local implementation planning, as well as features of inner and outer context, which impacted on the delivery and sustainability of the programme. These findings can be drawn upon to inform the development and delivery of other local and national quality improvement (QI) initiatives relating to children and young people’s mental health.

Quality of English inpatient mental health services for people with anxiety or depressive disorders: Findings and recommendations from the core audit of the National Clinical Audit of Anxiety and Depression

BackgroundClinical audit is a sustained cyclical quality improvement process seeking to improve patient care and outcomes by evaluating services against explicit standards and implementing necessary changes. National audits aim to improve population-level clinical care by identifying unwarranted variations and making recommendations for clinicians, managers and service commissioners. The National Clinical Audit of Anxiety and Depression aimed to improve clinical care for people admitted to English hospitals for treatment of anxiety and depression, to provide comparative data on quality of care, and to support local quality improvement initiatives by identifying and sharing examples of best practice. ProceduresThirteen standards were developed based on NICE guidelines, literature review and feedback from a steering committee and reference group of service users and carers. All providers of NHS inpatient mental health services in England were asked to submit details of between 20 and 100 eligible service users/patients admitted between April 2017 and September 2018. To ascertain data reliability, participating services re-audited 5 sets of case-notes with a second auditor, and the coordinating team checked 10 randomly-selected sets of case-notes from 3 services, also selected at random. The reference group and steering committee identified key findings and developed a series of recommendations, which were discussed in regional quality improvement workshops and on-line webinars. FindingsData from 3795 case notes were analysed. A sizeable proportion of records indicated that at least one important aspect of initial assessment was not documented. Many service users/patients who could have benefited from an intervention targeted at optimising physical health did not receive it. Only a minority (39%) were referred for psychological therapy. Use of outcome measures varied considerably but no single outcome measure was being used routinely. Most individuals had a care plan recorded in the notes, but a review date was documented in only two-thirds, and almost half of individuals had not received a copy. ConclusionsThere was considerable variation between English mental health services across many variables, and much scope for improvement. Clinicians should ensure that care plans are developed collaboratively with service users/patients and identified carers should be provided with information about support services. Health services should investigate the reasons for low referral rates for psychological therapies. Clinicians should ensure all service users have jointly developed crisis plans in place at discharge. Service managers should agree outcome measures to evaluate the treatment provided and clinicians should use these measures at initial assessment and review appointments. The implementation of such changes provides an opportunity for collaborative research into mental health service delivery and quality.

Developing a Sustainable Antimicrobial Stewardship (AMS) Programme in Ghana: Replicating the Scottish Triad Model of Information, Education and Quality Improvement.

(1) Background: Our aim was to develop robust and reliable systems for antimicrobial stewardship (AMS) in Keta Municipal Hospital and Ghana Police Hospital. Objectives were to build capacity through training staff in each hospital, establish AMS teams, collect data on antibiotic use and support local quality improvement initiatives. (2) Methods: The Scottish team visited Ghana hospitals on three occasions and the Ghanaian partners paid one visit to Scotland. Regular virtual meetings and email communication were used between visits to review progress and agree on actions. (3) Results: Multi-professional AMS teams established and met monthly with formal minutes and action plans; point prevalence surveys (PPS) carried out and data collected informed a training session; 60 staff participated in training delivered by the Scottish team and Ghanaian team cascaded training to over 100 staff; evaluation of training impact demonstrated significant positive change in knowledge of antimicrobial resistance (AMR) and appropriate antibiotic use as well as improved participant attitudes and behaviours towards AMR, their role in AMS, and confidence in using the Ghana Standard Treatment Guidelines and antimicrobial app. (4) Conclusions: Key objectives were achieved and a sustainable model for AMS established in both hospitals.

Air quality variations in Northern South America during the COVID-19 lockdown

Lockdown measures led to air pollution decrease in several countries around the world such as China and India, whereas other regions experimented an increase in pollutant concentrations. Northern South America (NSA) was one of those areas where pollution changed during lockdown due to high fire activity. This study aims to analyze, for the first time in NSA, the behavior of selected criteria air pollutants during the implementation of the SARS-CoV-2 lockdown in two high populated cities of the region: Bogotá and Medellín in Colombia. A set of tools including surface measurements, as well as satellite and modeled data were used. 24-hour average concentrations of PM10, PM2.5, and NO2 were collected from air quality stations for the lockdown period ranging from February 21 to June 30, 2020. The Copernicus Atmosphere Monitoring Service (CAMS) was used to analyze the fire flux OC as a biomass burning (BB) indicator, and tropospheric NO2 concentrations were retrieved from TROPOMI. The HYSPLIT model was used to analyze back trajectories and fire data were obtained from MODIS sensor measurements. Our analysis shows short-term background NO2, PM10, and PM2.5 concentration reductions of 60%, 44%, and 40%, respectively, for the strict lockdown; and 62%, 58%, and 69% for the relaxed lockdown. Corresponding long-term reductions were of 50%, 32%, and 9% for the strict lockdown; and 37%, 29%, and 19% for the relaxed lockdown. Regional BB increased PM2.5 concentrations by 20 μg/m3 during the strict lockdown, and the Saharan dust event increased PM10 concentrations up to 168 μg/m3 in Bogotá, and 104 μg/m3 in Medellín, bringing an additional risk of morbidity and mortality for population. Regional BB has several causes that need to be properly managed to benefit local air quality improvement plans. Future cleaner transport policies equivalent to reduced lockdown mobility could bring pollution close to WHO guidelines.

Assessing patient understanding of their antimicrobial treatment: How are we doing and how might we improve?

The Antimicrobial Stewardship Clinical Care Standard states that patients should receive certain information about their antimicrobial therapy. How well the patient communication recommendations of the standard are followed in clinical practice is not well established. The aim of this pilot quality improvement study was to assess current practices around communication with hospitalised patients about their antimicrobial therapy, to determine compliance with current recommendations, and develop and implement quality improvement actions focused on patient communication for antimicrobial stewardship in Australia. Adult inpatients receiving one or more antimicrobials for greater than 72h were recruited. A survey was conducted to assess rates of compliance with requirements to inform patients about the indication, duration and potential side effects of current antimicrobial therapy; modes of delivery of information; and rates of patient satisfaction with the information provided. A paper-based survey was conducted on the general medical, infectious diseases, geriatric evaluation and management, and rehabilitation wards in a 500-bed tertiary Australian hospital. A sample size of 50 was determined as adequate for a baseline analysis of patient communication practices and the development of quality improvement resources and actions. Responses to categorical questions were analysed quantitatively, with additional feedback from patients was collated and analysed qualitatively. A total of 54 patients were surveyed. A majority (83%) of patients had been informed that they were taking antimicrobials, and, of these, 96% said they knew the indication, 18% were informed of potential side effects, and 36% knew the duration. Only 22% were informed of the review plan and 27% knew if antimicrobials would be continued on discharge. Written information was given to 11% of patients. Over half (62%) of patients either wanted more information or had concerns about their antimicrobial therapy. Patients reported difficulty in obtaining information. Fifty-eight percent of patients received antimicrobial information from doctors, 13% from nurses and 12% from pharmacists. This study identified gaps in communication with patients regarding in-hospital antimicrobial therapy, and highlighted the need for development and delivery of local quality improvement activities to address this gap.

Quality Improvement in Multidisciplinary Care—Raise Your Hand if You Were Responsible for That

The overall goal of quality improvement (QI) in healthcare is to systematically improve the ways care is delivered to patients. 1 Agency for Healthcare Research and QualityPractice Facilitation Handbook. Module 4. Approaches to Quality Improvement. https://www.ahrq.gov/ncepcr/tools/pf-handbook/mod4.htmlDate accessed: May 18, 2020 Google Scholar This may sound simple and straightforward, but doing so in the context of constantly changing healthcare delivery systems and ever more complex care models is anything but. The question is really how to create local, regional, or national QI initiatives such that they have their desired effect. Specifically, how do you design changes to systems that can hopefully make delivering care more efficient for providers and have that translate into higher quality, more effective care for our patients? Virtual Colorectal Cancer Surveillance: Bringing Scope Rate to TargetJournal of the American College of SurgeonsVol. 231Issue 2PreviewAlthough endoscopy is recommended at 1 year after colorectal cancer (CRC) resection to detect locally recurrent CRC, earlier work at our Veterans Affairs (VA) facility demonstrated that 35% of patients achieve this metric. Full-Text PDF Open Access

Updates on pediatric sepsis.

Sepsis, defined as an infection with dysregulated host response leading to life‐threatening organ dysfunction, continues to carry a high potential for morbidity and mortality in children. The recognition of sepsis in children in the emergency department (ED) can be challenging, related to the high prevalence of common febrile infections, poor specificity of discriminating features, and the capacity of children to compensate until advanced stages of shock. Sepsis outcomes are strongly dependent on the timeliness of recognition and treatment, which has led to the successful implementation of quality improvement programs, increasing the reliability of sepsis treatment in many US institutions. We review clinical, laboratory, and technical modalities that can be incorporated into ED practice to facilitate the recognition, treatment, and reassessment of children with suspected sepsis. The 2020 updated pediatric sepsis guidelines are reviewed and framed in the context of ED interventions, including guidelines for antibiotic administration, fluid resuscitation, and the use of vasoactive agents. Despite a large body of literature on pediatric sepsis epidemiology in recent years, the evidence base for treatment and management components remains limited, implying an urgent need for large trials in this field. In conclusion, although the burden and impact of pediatric sepsis remains substantial, progress in our understanding of the disease and its management have led to revised guidelines and the available data emphasizes the importance of local quality improvement programs.

A Structured Quality Improvement Educational Curriculum Increases Surgical Resident Involvement in QI Processes

Patient safety and quality improvement (QI) processes are vitally important to healthcare systems. Training and experience in QI processes are mandated by the Accreditation Council for Graduate Medical Education (ACGME) for general surgery residents. The execution and efficacy of these training programs in residencies have thus far been inconsistent. The purpose of this study was to assess the effectiveness of our surgical residency's QI educational program. We instituted a formalized QI educational program for all residents in our academic general surgery residency program from 2018 to 2019. The curriculum included didactics, online educational resources, peer-group collaboration, and faculty mentorship. Residents performed a self-assessment survey of their knowledge, skill, and comfort levels with QI processes before and after the program using a 10-point Likert scale. The number of QI projects conducted, presented, and subsequently prepared for publication was enumerated. The ACGME resident survey program results regarding resident involvement in QI processes before and after program implementation were compared. After 1 year of the program, residents demonstrated significant increases in average self-assessed knowledge of QI processes (6.4 vs. 4.0, p < 0.05), knowledge of local QI resources (5.4 vs. 3.3, p < 0.05), and confidence in their ability to develop and implement a QI project (6.3 vs. 3.9, p < 0.05). The average number of QI projects each resident participated in the year preceding the program vs. during the program increased from 0.4 to 1.8 (p < 0.05). Ten of 26 residents (38%) reported no direct involvement in a QI project the preceding year before the QI program implementation, while 26/26 (100%) of residents reported direct involvement in at least 1 QI project during the implementation year. Residency program ACGME survey results regarding resident participation in QI increased from 86% (just below the national average of 87%) before the development of the QI program to 97% after program implementation. Implementation of a formalized, structured quality improvement education program for surgery residents significantly increased residents' participation in QI projects, as well as increasing their confidence in their knowledge and skillset to perform QI processes. The residency program's ACGME resident survey results regarding resident involvement in QI also improved during program implementation.

What antimicrobial stewardship strategies do NHS commissioning organizations implement in primary care in England?

To identify and explore strategies that English NHS commissioning organizations implemented to improve antimicrobial stewardship (AMS) within primary care. Questionnaire sent to the medicines management teams (MMTs) of all 209 clinical commissioning groups (CCGs) in England, in 2017. A total of 89% (187/209) of all English CCGs responded to the questionnaire; 74% of responding CCGs (123/167) had a prescribing incentive/engagement scheme, with MMTs representing 88% (90/102) considering incentive schemes successful or very successful for prioritizing AMS in primary care, especially when linked to prescribing NHS Quality Premium indicators. AMS audits were considered successful or very successful by 91% (126/138) of responding CCGs, as they identify reasons for inappropriate prescribing and opportunities for future improvement. All responding MMTs (169/169 CCGs) reported feeding back local/national antimicrobial prescribing data to the general practices they commission, 85% (142/168) to their CCG/Commissioning Support Unit (CSU) board and only 33% (56/169) to out-of-hours services. Benchmarking prescribing data was reported as a powerful tool to engage practices, facilitating an element of competition and peer pressure. National antimicrobial resistance improvement schemes, in particular the NHS England Quality Premium, have influenced CCG improvement priorities. Most CCGs now report successful improvement strategies including the use of both local and national antibiotic prescribing data to motivate improvements; these should be continued and extended to out-of-hours providers. As local audit data have helped to identify reasons for inappropriate prescribing and inform improvement planning, all organizations should adopt this strategy and include it in local quality improvement schemes, ensuring performance reporting to organizational board level.

MP48: Head computerized tomography overuse in adults with mild traumatic brain injury in a single Quebec emergency department

Introduction: Choosing Wisely Canada has reported rates of unnecessary head computed tomography (CT) scans for low-risk mild traumatic brain injury (mTBI) patients in Ontario and Alberta ranging from 14% to 46%. Local data for Quebec is currently not available. We sought to estimate the overuse of CT scans among adults with mTBI in the emergency department (ED) of a single level II trauma center in Quebec. Methods: We performed a retrospective chart review of adults who visited the ED of Hôtel-Dieu de Lévis from 04/01/2016 to 03/31/2017. Using an administrative database (Med-GPS, Montreal), we randomly sampled ED patients aged over 18 that had an initial Glasgow Coma Scale score of 13 to 15 and had suffered from a mTBI in the last 24 hours. We excluded patients with an unclear history of trauma, a bleeding disorder/anticoagulation, a history of seizure, any acute focal neurological deficit, a return visit for reassessment of the same injury, unstable vital signs, or a pregnancy. Data was extracted by two reviewers who analyzed separate charts. They used the Canadian CT Head Rule (CCHR) to determine relevance of CT scans. Overuse was determined if a patient without any high or medium risk CCHR criteria underwent a scan. A third reviewer verified a 10% random sample of the data extraction for each primary reviewer and inter-rater reliability was assessed using the kappa statistic. Results: From the 942 eligible mTBI patients, we randomly selected 418 patient charts to review, of which 217 met all inclusion and exclusion criteria (56% were men and the mean age was 48 years old (SD = 21)). Among included patients, 101 were determined as low risk. The overuse proportion was 26% (26/101), 95% CI [18-35]. Two CT scans were assessed as abnormal, but none revealed life-threatening injuries and only one was considered clinically significant with a subdural hematoma of 9 mm. Inter-rater reliability was substantial to perfect (kappa = 0.6 and 1.0) for each primary reviewer. Conclusion: We identified head CT scan overuse in this ED. This will support local quality improvement initiatives to reduce unnecessary head CT scans for adults with mTBI.

Identifying contextually relevant improvement measures, illustrated by a case of executive walkrounds.

A method to engage salient organisational stakeholders in identifying and ranking measures of healthcare improvement programs is described. The method is illustrated using Executive WalkRounds (EWRs) in a multi-site Australian Health District. Subject matter experts (SMEs) conducted document analysis, identified potential EWRs measures, created driver diagrams and then eliminated weak measures. Next, a panel of executives skilled in EWRs ranked and ratified the potential measures using a modified Delphi technique. EWRs measurement selection demonstrated the feasibility of the method. Of the total time to complete the method 79% was contributed by SMEs, 14% by administration personnel and 7% by executives. Document analysis revealed three main EWRs aims. Ten of 28 potential measures were eliminated by the SME review. After repeated Delphi rounds the executive panel achieved consensus (75% cut-off) on seven measures. One outcome, one process and one implementation fidelity metric were selected to measure and monitor the impact of EWRs in the health district. Perceptions of weak relationships between measures and intended improvements can lead to practitioner scepticism. This work offers a structured method to combine the technical expertise of SMEs with the practical knowledge of healthcare staff in selecting improvement measures. This research describes and demonstrates a novel method to systematically leverage formal and practical types of expertise to select measures that are strongly linked to local quality improvement goals. The method can be applied in diverse healthcare settings.

A patient-level key performance indicator set to measure the effectiveness of fracture liaison services and guide quality improvement: a position paper of the IOF Capture the Fracture Working Group, National Osteoporosis Foundation and Fragility Fracture Network

SummaryThe International Osteoporosis Foundation (IOF) Capture the Fracture® Campaign with the Fragility Fracture Network (FFN) and National Osteoporosis Foundation (NOF) has developed eleven patient-level key performance indicators (KPIs) for fracture liaison services (FLSs) to guide quality improvement.IntroductionFracture Liaison Services (FLSs) are recommended worldwide to reduce fracture risk after a sentinel fracture. Given not every FLS is automatically effective, the IOF Capture the Fracture working group has developed and implemented the Best Practice Framework to assess the organisational components of an FLS. We have now developed a complimentary KPI set that extends this assessment of performance to the patient level.MethodsThe Capture the Fracture working group in collaboration with the Fragility Fracture Network Secondary Fragility Fracture Special Interest Group and National Osteoporosis Foundation adapted existing metrics from the UK-based Fracture Liaison Service Database Audit to develop a patient-level KPI set for FLSs.ResultsEleven KPIs were selected. The proportion of patients: with non-spinal fractures; with spine fractures (detected clinically and radiologically); assessed for fracture risk within 12 weeks of sentinel fracture; having DXA assessment within 12 weeks of sentinel fracture; having falls risk assessment; recommended anti-osteoporosis medication; commenced of strength and balance exercise intervention within 16 weeks of sentinel fracture; monitored within 16 weeks of sentinel fracture; started anti-osteoporosis medication within 16 weeks of sentinel fracture; prescribed anti-osteoporosis medication 52 weeks after sentinel fracture. The final KPI measures data completeness for each of the other KPIs. For these indicators, levels of achievement were set at the < 50%, 50–80% and > 80% levels except for treatment recommendation where a level of 50% was used.ConclusionThis KPI set compliments the existing Best Practice Framework to support FLSs to examine their own performance using patient-level data. By using this KPI set for local quality improvement cycles, FLSs will be able to efficiently realise the full potential of secondary fracture prevention and improved clinical outcomes for their local populations.

Chemical nature of PM2.5 and PM10 in the coastal urban Xiamen, China: Insights into the impacts of shipping emissions and health risk

With objective of estimating the impact of ship emissions on ambient PM2.5 and PM10 levels and human health at a coastal urban site in Xiamen Island, a one year long sampling campaign was carried out from January 2017 to January 2018. Samples were subject to chemical analysis for various chemical components including water-soluble inorganic ions, carbonaceous species, and elements. The annual average PM2.5 and PM10 mass concentrations were, respectively, 32.8 ± 18.9 μg m−3 and 54.5 ± 29.6 μg m−3. The highest seasonal average concentrations were found in winter-spring and the lowest in summer due to the seasonal monsoon and gas-particle conversion. The rapid accumulation of vehicle exhaust and the stable existence of NH4NO3 in the ground layer within the urban area contributed to the incremental PM. Sulfate, nitrate, ammonium and organic carbon in PM2.5 have decreased since 2011–2013, while elemental carbon increased significantly. This suggests that the motor vehicle and/or ship emissions contributions to PM2.5 have increased relative to coal combustion over the past five years. The temporal variations of PM and its associated components during the BRICS summit control period further confirmed the important role of traffic related emissions in PM mass. Primary particulates resolved by PMF analysis plus secondary sulfate derived from secondary sulfate formation were estimated to account for 7.56% and 8.31% of PM2.5 and PM10, respectively. Selected heavy metals (As, Cd, Ni, V, Mn, hexavalent Cr, Ba and Pb) originating from ship emissions contributed 64.4% for PM2.5 and 53.2% for PM10 of the total non-cancer risk. Carcinogenic risk (lifetime cancer risk) for ship emissions associated with these hazard metals accounted for 50.6% for PM2.5 and 44.5% for PM10. Therefore, control measures applied to the ship emissions can benefit the local air quality improvement and reduce health burden to people around the port.

Activity Recognition From Newborn Resuscitation Videos.

Birth asphyxia is one of the leading causes of neonatal deaths. A key for survival is performing immediate and continuous quality newborn resuscitation. A dataset of recorded signals during newborn resuscitation, including videos, has been collected in Haydom, Tanzania, and the aim is to analyze the treatment and its effect on the newborn outcome. An important step is to generate timelines of relevant resuscitation activities, including ventilation, stimulation, suction, etc., during the resuscitation episodes. We propose a two-step deep neural network system, ORAA-net, utilizing low-quality video recordings of resuscitation episodes to do activity recognition during newborn resuscitation. The first step is to detect and track relevant objects using Convolutional Neural Networks (CNN) and post-processing, and the second step is to analyze the proposed activity regions from step 1 to do activity recognition using 3D CNNs. The system recognized the activities newborn uncovered, stimulation, ventilation and suction with a mean precision of 77.67%, a mean recall of 77,64%, and a mean accuracy of 92.40%. Moreover, the accuracy of the estimated number of Health Care Providers (HCPs) present during the resuscitation episodes was 68.32%. The results indicate that the proposed CNN-based two-step ORAA-net could be used for object detection and activity recognition in noisy low-quality newborn resuscitation videos. A thorough analysis of the effect the different resuscitation activities have on the newborn outcome could potentially allow us to optimize treatment guidelines, training, debriefing, and local quality improvement in newborn resuscitation.

Missed posterior shoulder fracture dislocations: a new protocol from a London major trauma centre

BackgroundA high incidence of missed posterior shoulder dislocations is widely recognised in the literature. Concern was raised by the upper limb multidisciplinary team at a London major trauma centre that...

Guideline adherence in the management of head injury in Australian children: A population-based sample survey.

Head injuries in children are a common and potentially devastating presentation. The CareTrack Kids (CTK) study assessed care of Australian children aged 0-15 years, in 2012 and 2013, to evaluate the proportion in line with guideline-based indicators for 17 common conditions. Overall adherence to guideline-based recommended practice occurred 59.8% of care encounters (95% CI: 57.5-62.0), and 78.3% (95% CI: 75.1-81.2) for head injury. This paper presents results for head injury, at indicator level. A modified version of the RAND-UCLA method of indicator development was used. Indicators, measurable components of a standard or guideline, were developed from international and national guidelines relating to head injury in children and were ratified by clinical experts using a Delphi process. Paediatric nurses extracted data from medical records from general practitioners (GPs), emergency departments (EDs) and inpatient wards in Queensland, New South Wales and South Australia, for children under 15 years receiving care in 2012-13. Our purpose was to estimate the percentage adherent for each indicator. The medical records of 629 children with head injury were examined. Fifty-one percent of children were under 5 years old, with more males (61%) than females. Thirty-eight indicators were assessed. Avoidance of nasotracheal airways (100%; 95% CI: 99.4-100) or nasogastric tubes (99.7%; 95% CI: 98.5-100) for children with a head injury had the highest adherence. Indicators relating to primary and secondary assessment of head injuries were mostly adhered to. However, adherence to other indicators was poor (e.g., documentation of the past history of children (e.g., presence or absence of seizures) before the injury; 29.9% (95% CI: 24.5-35.7)), and for others was difficult to estimate with confidence due to small sample sizes (e.g., Children with a head injury who were intubated had PaO2 above 80mm Hg; 56.0% (95% CI: 28.6-80.9)). Indicators guiding clinical decision making regarding the need for CT scan had insufficient data to justify reporting. This study highlights that management of head injury in children mostly follows guidelines, but also flags some specific areas of inconsistency. Individual sites are encouraged to use these results to guide investigation of local practices and inform quality improvement endeavours.

Checklist for Head Injury Management Evaluation Study (CHIMES): a quality improvement initiative to reduce imaging utilisation for head injuries in the emergency department

Over 90% of patients with head trauma seen in emergency departments (EDs) are diagnosed with minor head injuries. Over-utilisation of CT scans results in unnecessary exposure to radiation and increases...

Survey-based Work System Assessment to Facilitate Large-scale Dissemination of Healthcare Quality Improvement Programs.

The dissemination of quality improvement (QI) interventions to a broader range of healthcare settings requires a proactive assessment of local work systems and processes. The objective of this study was to examine the feasibility of using a survey-based work system assessment (WSA) tool to facilitate the dissemination of a program for optimizing blood culture (BC) use. Informed by findings from an onsite, interview-based WSA at 2 hospitals, a 50-item WSA survey was devised and administrated to 15 hospitals participating in a QI collaborative. WSA survey data were summarized, shared, and discussed with individual hospitals to inform the adaptation and implementation of the BC program. Physician champions leading the local QI team assessed the use of the WSA survey by completing an 8-item survey. A total of 347 clinicians completed the WSA survey, and physician champions at 12 hospitals evaluated the use of the WSA survey. Both the WSA survey data and the evaluation of the WSA survey showed that the survey-based WSA tool could help participating hospitals understand their current BC ordering practices and identify potential barriers to implementing the program from the perspectives of different clinicians. We demonstrated how a survey-based tool could be used to facilitate WSA in the dissemination of a program for improving BC use to a multisite collaborative. A survey-based WSA tool can be used to facilitate future large-scale intervention dissemination efforts.

Patterns in medication incidents: A 10-yr experience of a cross-national anaesthesia incident reporting system

BackgroundMedication-related adverse events (MRE) in anaesthesia care are frequent and require a deeper understanding if we are to prevent medication harm. MethodsWe searched for reported MRE from the Spanish Anaesthesia Incident Reporting System (SENSAR) database over a 10-yr period. SENSAR is a cross-national, multicentre system focused on perioperative and critical care. A descriptive analysis of independent variables, phase of medication process, type of MRE, and medication group involved, and their relationships with morbidity was conducted. ResultsA total of 1970 MRE were identified from 7072 reported incidents. Patient harm was reported in 31% of the MRE. The administration phase was more frequent (42%) and showed the highest harm rate (44%) compared with other medication process phases. The most frequent types of MRE were wrong treatment regimen and wrong medication (55% of cases). The medication groups most commonly reported were those that alter haemostasis (18%), vasoconstrictor agents (13%), and opioids (10%). Vasoconstrictor agents, benzodiazepines, and neuromuscular blocking agents were the medication groups involved in patient harm four-fold more, and opioids three-fold more, than medications that alter haemostasis. The 1970 incidents were investigated and led to implementation of 4223 local corrective patient safety and quality improvement measures. ConclusionsPatient harm in the perioperative setting from medications remains a major issue for patients, hospital leaders, and clinicians. We found patterns and specific causes that can be mitigated through proven systems solutions, and should be taken into consideration in designing sustainable solutions for safe perioperative care. Clinical trial registrationNCT03615898.