Valuable Tool For Quality Improvement Research Articles

740 Implementation and Retrospective Assessment of a Modified Graft Loss Grading System

Abstract Introduction Success of split-thickness skin grafting (STSG) is a cornerstone of modern burn care and sets the stage for success in acute, rehabilitative and reconstructive care. Shupp et al, proposed a graft loss grading system, which the authors then modified to reflect true clinical practice and changes in management. Purpose of the quality improvement (QI) project was to design, implement and assess this grading system. Methods A modified graft loss grading system was developed and implemented. Burn patients requiring STSG were tracked over a five month period, and initial (first takedown) and subsequent (either outpatient or 7 days after initial assessment) graft loss grades and contributing factors were noted. Assessments were performed an APP and burn surgeon with agreement of an assigned grade. Patient demographic data was recorded. Results 63 patients underwent 66 STSG procedures during the review period (44 males, 19 females). Average age was 33.3 years (range: 1-86). Average % TBSA burn was 10.2% (range 0.2-67%). Obesity was present in 33.3% of patients, cardiac disease (hypertension, coronary artery disease or congestive heart failure) in 21.2%, DM in 21.2% and 24.2% of patients were active smokers. Flame burns represented the etiology in the majority (51.5%) of patients. Overall, 10 patients (16%) on initial assessment and 18 patients (29%) on subsequent assessment had evidence of graft loss. Etiology of graft loss included wound bed viability - the default etiology (10 patients/55%), infection (3 patients/17%) and hematoma/seroma (4 patients/22%). Of the 18 patients, 5 (28%) required re-grafting. Of patients with graft loss, 89% had a comorbidity including DM (28%) and smoking history (28%). Malnutrition was felt to contribute in 3 (17%) of patients. Conclusions A graft loss grading system is a beneficial quality improvement project to characterize the surgical results of burn patients undergoing STSG. This modified grading system better characterizes graft loss outcomes and subsequent changes in management if applicable. Wound bed viability remains a major factor in graft loss, although the majority of these patients had a contributing comorbidity. Applicability of Research to Practice Implementation of a graft loss grading system can be a valuable quality improvement tool that can be employed by burn centers to assessment surgical results.

Development and testing of the rheumatoid arthritis quality of care survey

ObjectivesThe Rheumatoid Arthritis (RA) Quality of Care Survey (RAQCS) was developed to measure care quality according to a previously developed national RA quality improvement framework. MethodsThe development of the RAQCS occurred over 3 phases. First, the survey was developed by a team of healthcare providers, researchers, and two patient partners based on the existing national quality framework's 21 performance measures (PMs) and strategic objectives. Second, cognitive debriefing interviews were conducted with individuals living with RA to identify survey clarity, appropriateness of survey questions, and response options. Third, the survey was revised and distributed to participants recruited from Rheum4U (rheumatology longitudinal cohort). Results were tabulated and compared with a chart audit of participant medical records. ResultsFifty-three participants completed the RAQCS. High performance (i.e., ≥70% meeting PM) was observed for 13 of 20 PMs. Lower performance was seen for the remaining PMs, which included documentation of body mass index (BMI) and smoking status, discussion of physical activity goals, comorbidity management including risk assessments for cardiovascular health and fragility fractures and disease activity assessment. There was high agreement (≥70%) between the RAQCS and chart review for 9 of 20 PMs. ConclusionsHigh agreement was observed between the RAQCS and chart review for selected PMs. The RAQCS may also be a valuable tool for quality improvement for measures where data are not usually available through other sources. Further testing of the RAQCS is needed to ascertain its reliability and validity as a patient self-reported tool to measure RA care quality.

Clinical Audit a Valuable Tool for Quality Improvement of Care: Radiation Oncologists' Perspective.

Null.

LO02: Direct laryngoscopy: is it becoming a lost art in resident education?

Introduction: Intubation is one of the highest-risk procedures performed in the emergency department (ED) on a regular basis. The British Columbia Airway Registry for Emergencies (BCARE) Network collects data from every ED intubation at two tertiary care centres and one community centre and serves as a valuable quality improvement tool. We compared intubation techniques, success, and complication rates between emergency medicine physicians and trainees. Methods: We completed an observational study of all patients intubated in the ED by resident trainees or attending physicians over a period of 28 months from July 2017 to November 2019. Respiratory therapists (RTs) completed a standardized data collection form after every intubation and the data was used to analyze techniques, success, and complication rates. Form completion compliance was periodically reviewed by cross-referencing patient names in the BCARE network with the radiology database for chest x-rays that were performed after intubation in the hospital. Results: 642 intubations were performed by EM physicians: 66 by PGY1-2 residents,141 by PGY3-5 residents, and 435 by staff physicians. Airway assessment prior to intubation was completed by PGY1-2 in 78.1% of cases, PGY3-5 in 67.9%, and staff in 62.6%. Direct laryngoscopy (DL) was chosen as first-choice technique 24.2% by PGY1-2, 24.8% by PGY3-5, and 30.1% by attending physicians. Bougie was used 2.7% of cases for all groups. First-pass success was 78.8% for PGY1-2, 86.5% for PGY3-5, and 85.7% for staff. Mean number of attempts were similar at 1.24, 1.18, and 1.20 for R1-2, R3-5, and staff, respectively. There were similar complication rates between all groups, on average 16.9%, with the most common being hypoxemia prior to induction, and desaturation following induction. There was a higher rate of staff performing second intubation attempts following junior residents (50.0%) than senior residents (26.3%). Conclusion: Trainees have a stronger preference to use video laryngoscopy (VL) than staff physicians as their first-line technique. Success rates were similar between senior residents and attending physicians, but significantly lower in junior residents, despite number of attempts being similar between the three groups. Complication rates were similar among all 3 groups. This data may suggest that a stronger emphasis for DL use among trainees is important.

Quality Improvement through Intensive Care Registries: The Value of Big Data in Clinical Decision Making

Background: Quality of Intensive care has got more attention in case of the high cost of healthcare and the potential for harm. Poor-quality care causes high cost and quality improvement initiatives in the ICU lead to an improvement in outcomes as well as a decrease in costs. One of the crucial tools that allow physicians and nurses to monitor change in a quality improvement effort is the development of an electronic database for data collection and reporting. The objective of Intensive Care Registries is to create a high-quality registry of patients through a collaboration of academic health centers performing uniform data collection with the purpose of improving the quality and accuracy of healthcare decisions and provide a data-driven clinical decision support system for critical care medicine.
 Methods: This article reviews real-world data sources in healthcare and considers registry as the main tool to address health services and outcomes research questions in critical care, and briefly describes objective, inputs and outputs of intensive care registries. As it can be comprehended from library research, the combination of patient clinical care data, quality parameters, and ICU operating costs, integrated into an electronic database, provides a valuable tool for quality improvement and overall efficiency of offered care.
 Results: Using Big Data effectively within ICUs for supporting clinical decision making can lead to predict numerous diseases and help to discover new patterns in healthcare. The ability to process multiple high-speed clinical data streams from multiple centers could dramatically improve both healthcare efficiency and patient outcomes.
 Conclusion: To gain this goal, developing reliable and standardized health analytics platforms as well as quality improvement processes that translate analytical results into new clinical guidelines, is recommended.

P164: Development of the BC-Airway Registry for Emergencies (BCARE) network

Introduction: Intubation is one of the highest-risk procedures performed in the ED. Few Canadian centres monitor intubation frequency, indications, methods used, success, and/or complication rates. An airway registry that tracks patient outcomes and variation in practice would be a valuable quality improvement (QI) tool. We describe the development of the BC-Airway Registry for Emergencies (BCARE) network, an emergency intubation database at two tertiary-care and one community hospital. Methods: Respiratory Therapists (RTs) are present at every intubation outside of the OR and complete a standardized post-intubation form. The airway forms were developed collaboratively with input from RTs, emergency physicians, intensivists, and anesthetists. Completed forms are collected from participating sites and data is entered into a secure online database where patient outcomes are analyzed in real-time. Results: We collected data from 737 unique intubations over 19 months with ongoing enrolment at the time of abstract submission. Mean age was 59.4 (Range 17-95, SD 17.6), Male 66.2%, intubation locations were ED (396, 53.7%), ICU (221, 30.0%), Ward (120, 16.3%). The most common indications for ED intubation were ICH/stroke (14.6%), seizure (10.9%), and sepsis (9.5%). Intubations are done by attending physicians more frequently in the ED (48.0%) compared to in the ICU (11.8%), and ward (8.6%). ED intubations were more commonly performed using video laryngoscopy (57.7%) with a smaller proportion using direct laryngoscopy (39.0%). First-pass success was 81.8% in the ED, 79.2% in the ICU, and 77.5% on the wards. Of ED intubations, 56 (14.1%) had complications and 73 (18.4%) were considered to be a difficult airway. Conclusion: The BCARE network tracks intubation performance across hospitals and is a valuable QI tool. BCARE can be used to ensure that all centres are meeting a benchmark success rate, for assessing the impact of practice changes such as pre-intubation checklists, and for implementing systematic methods to identify patients who previously had a “difficult airway.”

Patient Perspectives on Causes of Suboptimal Bowel Preparation for Screening Colonoscopies: A Qualitative Study

Introduction: Current guidelines favor screening for colorectal cancer with colonoscopy, but 10-30% of patients have suboptimal bowel-preparation (prep.) precluding colonoscopy completion. This study aims to identify causes of suboptimal prep. using patient's perspective. Methods: A qualitative cross-sectional study with semi-structured interviews was performed at an academic high-volume endoscopy center with open access provider referrals. Physicians conducted telephone interviews with patients who had suboptimal prep. using an interview guide. Domains covered were pre-procedural instructional material, actual prep. process, perceived reasons for poor prep, and patient opinions on repeat colonoscopies. Interviews were analyzed using a qualitative thematic analysis. Results: Thematic saturation was reached after interviewing 20 patients (Table 1). Nine patients (45%) received incorrect instructions, incurred errors included wrong prep. duration (standard versus extended prep.), incorrect dietary instruction, contradictory or inadequate instructions from different providers, and prescription mistakes. There was no standardization in delivering instruction materials to patients. A paucity of patients received a reminder phone call prior to the colonoscopy, although many patients had pre-procedural questions or concerns. Non-compliance was present only in a minority of cases. Patients who had received the correct mailed instructions from providers thought the instructions were generally clear and well-understood, but a few patients had difficulty understanding the timing of the extended prep. Demographics including educational level and insurance were representative of our patient population. Patients underwent either one-day or two-day golytely prep.; no patients were instructed to undergo split-dose prep. Conclusion: Several etiologies of suboptimal prep. were identified. Deficient or incorrect instruction material is a modifiable system error that could be remedied by enforcing standardized delivery of verbal and written instructions. Endoscopy centers with open access referrals may experience more prep-instruction errors due to inaccurate information from outside providers. Most patients demonstrated insight into their errors including diet or medications changes or suboptimal prep.; many were motivated to amend this in a future colonoscopy. Qualitative analysis of patient perspectives can serve as a valuable quality improvement tool for screening colonoscopies.

Investigation of Drivers and Determinants of Inpatient and Outpatient Satisfaction in Public Ambulatory and Hospital Departments

The last two decades have been marked by increased attention towards patient satisfaction as a valuable tool for quality improvement in health care organizations and delivering patient-centred care. However, few articles have investigated the factors of patient's satisfaction among outpatients and inpatients, especially in developing economies. This cross-sectional, quantitative research contributes by analysing patient satisfaction in the context of a developing country and its public health care system among 1318 patients from the Clinic for Plastic and Reconstructive Surgery in Skopje. The study had two main objectives. The first was to analyse factors that influenced patient's satisfaction. The second objective was to analyse the differences in the reported patient satisfaction between outpatients and inpatients within the Clinic for Plastic and Reconstructive Surgery in Skopje. The results indicated higher satisfaction among outpatients scores compared to inpatients. The findings confirm the importance of socio-demographic variables and health status on patient's satisfaction. Improved awareness of these factors may improve the patient experience and increase therapeutic benefits. Furthermore, this research provides an initial insight and understanding into the drivers of patient's satisfaction in the context of developing countries.

Scale Development and Psychometrics for Parents' Satisfaction with Developmental Care in Neonatal Intensive Care Unit.

Developmental care comprises a wide range of medical and nursing interventions used in the neonatal intensive care unit (NICU) to mitigate and reduce stressors affecting preterm or ill neonates. Because patient satisfaction survey is a valuable quality improvement tool, we aimed to develop and test the psychometric properties of a tool for measuring parent satisfaction of developmental care in the NICU. In this psychometric methodological study, the item pool and initial questionnaire were designed based on a comprehensive literature review and exploring NICU parent satisfaction questionnaires. The validity of the designed questionnaire was determined using face, content (qualitative and quantitative), and construct validity. Exploratory factor analysis was performed using responses from 400 parents of infants hospitalized in the NICUs of 34 hospitals in 2015 in Tehran, Iran. The reliability of the questionnaire was identified using Cronbach's alpha and stability measures. The initial questionnaire was designed with 72 items in five domains. After testing the face validity, 3 items were omitted. The results of validity testing were acceptable. The exploratory factor analysis was performed on 69 items, and 5 factors (care and treatment with 20 items, information with 15 items, hospital facilities with 9 items, parental education with 7 items, and parental participation with 8 items) were extracted. The reliability was supported by high internal consistency (α = 0.92). This questionnaire could be valid and reliable tool for measuring parents' satisfaction.

Contra-lateral Auditory Brainstem Responses in Dyslexia.

Developmental care comprises a wide range of medical and nursing interventions used in the neonatal intensive care unit (NICU) to mitigate and reduce stressors affecting preterm or ill neonates. Because patient satisfaction survey is a valuable quality improvement tool, we aimed to develop and test the psychometric properties of a tool for measuring parent satisfaction of developmental care in the NICU. In this psychometric methodological study, the item pool and initial questionnaire were designed based on a comprehensive literature review and exploring NICU parent satisfaction questionnaires. The validity of the designed questionnaire was determined using face, content (qualitative and quantitative), and construct validity. Exploratory factor analysis was performed using responses from 400 parents of infants hospitalized in the NICUs of 34 hospitals in 2015 in Tehran, Iran. The reliability of the questionnaire was identified using Cronbach's alpha and stability measures. The initial questionnaire was designed with 72 items in five domains. After testing the face validity, 3 items were omitted. The results of validity testing were acceptable. The exploratory factor analysis was performed on 69 items, and 5 factors (care and treatment with 20 items, information with 15 items, hospital facilities with 9 items, parental education with 7 items, and parental participation with 8 items) were extracted. The reliability was supported by high internal consistency (α = 0.92). This questionnaire could be valid and reliable tool for measuring parents' satisfaction.

Root cause analysis in infusion nursing: applying quality improvement tools for adverse events.

The application of root cause analysis (RCA) to health care began in the Veteran's Administration system and spread to Joint Commission-accredited organizations when it became a requirement for accreditation. The success of this valuable quality improvement tool relies on understanding the principles of patient safety, assembling a team, and producing and completing action items aimed at correcting root causes of adverse events. This article describes optimal RCA techniques based on published literature and expert opinion and then provides a sample RCA for a fictitious but common adverse event: catheter-associated bloodstream infection.

Voluntary peer review as innovative tool for quality improvement in the intensive care unit--a retrospective descriptive cohort study in German intensive care units.

Introduction: Quality improvement and safety in intensive care are rapidly evolving topics. However, there is no gold standard for assessing quality improvement in intensive care medicine yet. In 2007 a pilot project in German intensive care units (ICUs) started using voluntary peer reviews as an innovative tool for quality assessment and improvement. We describe the method of voluntary peer review and assessed its feasibility by evaluating anonymized peer review reports and analysed the thematic clusters highlighted in these reports.Methods: Retrospective data analysis from 22 anonymous reports of peer reviews. All ICUs – representing over 300 patient beds – had undergone voluntary peer review. Data were retrieved from reports of peers of the review teams and representatives of visited ICUs. Data were analysed with regard to number of topics addressed and results of assessment questionnaires. Reports of strengths, weaknesses, opportunities and threats (SWOT reports) of these ICUs are presented. Results: External assessment of structure, process and outcome indicators revealed high percentages of adherence to predefined quality goals. In the SWOT reports 11 main thematic clusters were identified representative for common ICUs. 58.1% of mentioned topics covered personnel issues, team and communication issues as well as organisation and treatment standards. The most mentioned weaknesses were observed in the issues documentation/reporting, hygiene and ethics. We identified several unique patterns regarding quality in the ICU of which long-term personnel problems und lack of good reporting methods were most interestingConclusion: Voluntary peer review could be established as a feasible and valuable tool for quality improvement. Peer reports addressed common areas of interest in intensive care medicine in more detail compared to other methods like measurement of quality indicators.

Cumulative Sum Charts and Its Healthcare Applications; A Systematic Review

Application of Statistical process control (SPC) is increasing being advocated in health science as a valuable quality improvement tool. The use of control charts in health science related applications differs somewhat from industrial. In SPC, cumulative sum (CUSUM) charts rather than Shewhart chart are used to detect smaller shifts in the process. In order to improve the detection capability relative to that of the Shewhart control charts, several control charts have been developed such as CUSUM charts, Exponentially weighted moving average(EWMA) charts and Sequential probability ratio test (SPRT) etc. Among them, the CUSUM charts are popular and effective. The CUSUM procedure has recently made its appearance in the field of medicine. The main purpose of this paper is to elucidate the common uses of CUSUM charts in healthcare and to describe different forms of CUSUM charts for monitoring performance over time when the outcome is related to health science. DOI: http://dx.doi.org/10.4038/sljastats.v15i1.6793

Physicians' Assessment of Pediatric Returns to the Emergency Department

BackgroundReturn visits to the Emergency Department (ED) requiring admission are frequently reviewed for the purpose of quality improvement. Treating physicians typically perform this review, but it is unclear if they accurately identify the reasons for the returns. ObjectivesTo assess the characteristics of pediatric return visits to the ED, and the ability of treating physicians to identify the root causes for these return visits. MethodsThis retrospective cohort study reviewed all returns within 96h of an initial visit over a 2-year period at a tertiary care pediatric ED. Baseline characteristics were determined from review of patients' charts. The treating physicians, the primary author, and independent reviewers identified the root cause for the returns. ResultsThere were 97,374 patients that presented to the ED during the study, and 1091 (1.1%) of these children returned to the ED and were admitted. Returns were most common among children aged<5 years, arriving between 3:00p.m. and 11:00p.m. via private transportation, with infectious diseases. The physician involved in the care of the patient attributed 3.1% of returns to potential deficiencies in medical management, whereas the independent reviewers attributed 13% to potential deficiencies. ConclusionsBoth returns and the subset of returns due to potential deficiencies in management are more common than previously estimated, rendering review of returns a valuable quality improvement tool. However, EDs should not rely exclusively on the treating physicians to identify the reason for returns, as they seem to underestimate the frequency of returns due to potential deficiencies in medical management.

Validation of the NVSCA Registry for Common Oral Clefts: Study Design and First Results

Since 1997 the Dutch Association for Cleft Palate and Craniofacial Anomalies (NVSCA) has maintained a national registry of congenital craniofacial anomalies. This study validates data on three common oral cleft categories (cleft lip/alveolus = CL/A; cleft lip/alveolus and palate = CL/AP; and cleft palate = CP) and general items. Retrospective observational study. All 15 Dutch cleft palate teams registered presurgery patients with common oral clefts (n = 2553) from 1997 to 2003. A random sample of 250 cases was used; 13 cases were excluded. The corresponding medical data were reviewed; these medical data served to validate the NVSCA registry data. Prevalence comparisons, 2 x 2 tables and validity measures were performed. The cleft categories most accurately recorded were CL/A and CP. Both categories had an observed agreement of 98%, kappa of 0.94, and a sensitivity and specificity of 97%. Cleft lip/alveolus and palate had an observed agreement of 95%, kappa of 0.89, a sensitivity of 90%, and a specificity of 99%. Regarding the general items, observed agreement and kappa were highest for adoption/foster child (99%; 0.76) and lowest for remarks about pregnancy (63%; 0.20). Sensitivity ranged from 25% (consanguinity) to 97% (white mother) and specificity was high for all items (>93%) except for white father and mother (approximately 35%). The NVSCA registry is a valuable tool for quality improvement and research because validity on all three common oral cleft categories is very good. Validity on the general items is reasonable to satisfying and appears to be related to the type of information.

Registration in the danish hip arthroplasty registry: completeness of total hip arthroplasties and positive predictive value of registered diagnosis and postoperative complications.

There are few publications regarding the validity of data in hip arthroplasty registers. The Danish Hip Arthroplasty Registry (DHR) is a nationwide clinical database of THAs and revisions in Denmark. We assessed the completeness of registration of primary total hip arthroplasties (THAs) and revisions in the DHR from 1995-2000. In addition, the positive predictive value (PPV) of registered data for diagnoses in patients undergoing primary THA and postoperative complications was analyzed. Completeness was assessed using the Danish National Registry of Patients (NRP) as a reference, which is a nationwide and population-based registry of all somatic hospital admissions since 1977. The positive predictive value of registered data was assessed by review of medical records and preoperative radiographs from samples of randomly selected patients registered in the DHR using a standardized form. The overall completeness of registration for primary THAs and/or revisions was 94% (26,129 patients registered in both NRP and DHR and 27,757 patients registered in the NRP). There was a lower degree of completeness for revisions than for primary THAs (81% versus 94%). The completeness did not vary substantially according to gender and age. Completeness of registration was lower for university hospitals than for other hospitals (91% versus 95%), and for low-volume hospitals (87%) relative to those with medium (92%) and high volumes (96%). Overall, the diagnoses in patients undergoing primary THA could be confirmed in 84% (387/459) of the patients who were reviewed. The diagnosis of fresh fracture of the proximal femur was confirmed in only one third (22/73) of the cases. Postoperative complications were confirmed in two-thirds (36/54) of the patients reviewed. The specificity of the registration of postoperative complications was, however, only one-third (8/26). We conclude that the Danish Hip Arthroplasty Registry is a potentially valuable tool for quality improvement and research due to the high degree of completeness of registrations regarding THA, and its moderate-to-high positive predictive value of registration for diagnoses in patients undergoing primary THA. However, information on several diagnoses for primary THA and on postoperative complications should be used with caution.

Benchmarking in Ambulatory Surgery

The health care industry is relatively new to benchmarking. More clinical benchmarking is needed because little is known about which practices and processes lead to which outcomes. Benchmarking is a valuable quality improvement tool that can be used to improve practices and performances when instituted properly. This article describes the benchmarking process, its usefulness, and how ambulatory surgery centers can improve performance by using benchmarking.

Are intrapartum and neonatal deaths in breech delivery at term potentially avoidable?--a blinded controlled audit.

The aim of the study was to investigate whether deaths in term breech deliveries could have been avoided with improved care during pregnancy and delivery. All cases of intrapartum/early neonatal death of nonmalformed infants in breech presentation delivered at term in Denmark in the period 1982-92 were studied. For each of the 12 deaths two controls matched by presentation and planned mode of delivery were selected. Eleven obstetricians assessed the care through narratives that ended when the infant was delivered to umbilicus and stated if the infant died, and whether the "possible death" was potentially avoidable. The majority thought that 42% of cases and 9% of the controls had died. Antenatal and intrapartum care was suboptimal respectively in 17% and 25% of cases and 4% and 26% of controls. The assumed death was found to have been potentially avoidable in 58% of cases and 17% of controls. Care in pregnancies with IUGR, pre-eclampsia, placental abruption, post-maturity, the time from decision to performance of cesarean section, and compliance between patient and professionals were more often criticized in cases than in controls. Controlled audit seemed to be a valuable tool for quality improvement and for validation of litigation activities. In conclusion, infant death at term breech delivery was to a large extent potentially avoidable. However, even in controls, suboptimal care was not uncommon.

Consumer satisfaction with occupational health services: should it be measured?

OBJECTIVESTo find answers in the literature to the questions if, why, and how consumer satisfaction with occupational health services (OHSs) should be measured.METHODSPublications about the concept of consumer satisfaction with...