The "door-to-needle blitz" in acute myocardial infarction: the impact of a CQI project

What is the value and impact of quality and safety teams? A scoping review

BACKGROUND

The purpose of this study was to conduct a scoping review of the literature about the establishment and impact of quality and safety team initiatives in acute care.

METHODS

Studies were identified through electronic searches of Medline, Embase, CINAHL, PsycINFO, ABI Inform, Cochrane databases. Grey literature and bibliographies were also searched. Qualitative or quantitative studies that occurred in acute care, describing how quality and safety teams were established or implemented, the impact of teams, or the barriers and/or facilitators of teams were included. Two reviewers independently extracted data on study design, sample, interventions, and outcomes. Quality assessment of full text articles was done independently by two reviewers. Studies were categorized according to dimensions of quality.

RESULTS

Of 6,674 articles identified, 99 were included in the study. The heterogeneity of studies and results reported precluded quantitative data analyses. Findings revealed limited information about attributes of successful and unsuccessful team initiatives, barriers and facilitators to team initiatives, unique or combined contribution of selected interventions, or how to effectively establish these teams.

CONCLUSIONS

Not unlike systematic reviews of quality improvement collaboratives, this broad review revealed that while teams reported a number of positive results, there are many methodological issues. This study is unique in utilizing traditional quality assessment and more novel methods of quality assessment and reporting of results (SQUIRE) to appraise studies. Rigorous design, evaluation, and reporting of quality and safety team initiatives are required.

A review of interventions and system changes to improve time to reperfusion for ST-segment elevation myocardial infarction

OBJECTIVE

Identify and describe interventions to reduce time to reperfusion for patients with ST-segment elevation myocardial infarction (STEMI).

DATA SOURCE

Key word searches of five research databases: MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE, Web of Science, and Cochrane Clinical Trials Registry.

INTERVENTIONS

We included controlled and uncontrolled studies of interventions to reduce time to reperfusion. One researcher reviewed abstracts and 2 reviewed full text articles. Articles were subsequently abstracted into structured data tables, which included study design, setting, intervention, and outcome variables. We inductively developed intervention categories from the articles. A second researcher reviewed data abstraction for accuracy.

MEASUREMENTS AND MAIN RESULTS

We identified 666 articles, 42 of which met inclusion criteria. We identified 11 intervention categories and classified them as either process specific (e.g., emergency department administration of thrombolytic therapy, activation of the catheterization laboratory by emergency department personnel) or system level (e.g., continuous quality improvement, critical pathways). A majority of studies (59%) were single-site pre/post design, and nearly half (47%) had sample sizes less than 100 patients. Thirty-two studies (76%) reported significantly lower door to reperfusion times associated with an intervention, 12 (29%) of which met or exceeded guideline recommended times. Relative decreases in times to reperfusion ranged from 15 to 82% for door to needle and 13-64% for door to balloon.

CONCLUSIONS

We identified an array of process and system-based quality improvement interventions associated with significant improvements in door to reperfusion time. However, weak study designs and inadequate information about implementation limit the usefulness of this literature.

Use of a triage pain protocol in the ED

PURPOSES

This study was designed to evaluate the ability of a triage pain protocol to improve frequency and time to delivery of analgesia for musculoskeletal injuries in the emergency department (ED).

BASIC PROCEDURES

Frequency and time to analgesic administration were measured before and after use of a triage pain protocol. The protocol allowed analgesic medications to be given at the time of triage.

MAIN FINDINGS

Time to medication administration was 76 minutes (95% confidence interval [CI], 68-84 minutes) before and 40 minutes (95% CI, 32-47 minutes) after the protocol. Five hundred fifty-nine (70%) of 800 patients received analgesics using the protocol compared with 212 of 471 (45%) patients prior.

PRINCIPAL CONCLUSIONS

Use of a triage pain protocol increased the number of patients with musculoskeletal injury who received pain medication in the ED. Use of the protocol also resulted in a decrease in the time to analgesic medication administration.

Evidence‐based re‐engineering: re‐engineering the evidence

PURPOSE

Business process redesign (BPR) is used to implement organizational transformations towards more customer-focused and cost-effective care. Ideally, these innovations should be carefully described and evaluated so that "best practices" can be re-applied. To investigate this, available evidence was collected on patient care redesign projects.

DESIGN/METHODOLOGY/APPROACH

The Ebsco Business Source Premier, Embase and Medline databases were searched. Studies on innovations related to re-engineering patient care that used before-after design as minimum prerequisites were selected. General characteristics, logistic parameters and other outcome measures to determine the objectives and results and interventions used were looked at.

FINDINGS

A total of 86 studies that conformed to the criteria were found: a minority mentioned measurable parameters in their objectives. In the majority of studies, multiple interventions were combined within single studies, making it impossible to compare the effects of individual interventions. Only three randomized controlled trials were found. Furthermore, inconsistencies were noted between the study objectives and the reported results. Many more issues were reported in the results than were mentioned in the study aims. It would appear that publications were hard to find owing to a lack of specific MeSH headings. Nearly 7,500 abstracts were scanned and from these it was concluded that clear and univocal research methods, terms and reporting guidelines are advisable and must be developed in order to learn and benefit from BPR innovations in health care organizations.

ORIGINALITY/VALUE

This appears to be the first time available evidence about redesign projects in hospitals has been systematically collected and assessed.

Quality improvement implementation and hospital performance on quality indicators

OBJECTIVE

To examine the association between the scope of quality improvement (QI) implementation in hospitals and hospital performance on selected indicators of clinical quality.

DATA SOURCES

Secondary data from 1997 mailed survey of hospital QI practices, Medicare Inpatient Database, American Hospital Association's Annual Survey of Hospitals, the Bureau of Health Professions' Area Resource File, and two proprietary data sets compiled by Solucient Inc. containing data on managed care penetration and hospital financial performance.

STUDY DESIGN

Cross-sectional study of 1,784 community hospitals to assess relationship between QI implementation approach and six hospital-level quality indicators. DATA COLLECTION/ABSTRACTION METHODS: Two-stage instrumental variables estimation in which predicted values (instruments) of four QI scope variables and control (exogenous) variables used to estimate hospital-level quality indicators.

PRINCIPAL FINDINGS

Involvement by multiple hospital units in QI effort is associated with worse values on hospital-level quality indicators. Percentage of hospital staff and percentage of senior managers participating in formally organized QI teams are associated with better values on quality indicators. Percentage of physicians participating in QI teams is not associated with better values on the hospital-level quality indicators studied.

CONCLUSIONS

Results supported the proposition that the scope of QI implementation in hospitals is significantly associated with hospital-level quality indicators. However, the direction of the association varied across different measures of QI implementation scope.

The delay in transfer between the emergency department and the critical care unit for patients with an acute cardiac event--in hospital factors

The Lyell McEwin Health Service (LMHS) is a major public hospital located in the northern suburbs of Adelaide, a region where the death rate from ischaemic heart disease (IHD) is higher than the expected death rate in the population. A retrospective case note study conducted at this hospital investigated the duration that patients with unstable angina pectoris (UA) or acute myocardial infarction (AMI) spent in the emergency department (ED) before admission to the critical care unit (CCU) and the factors that contributed to delays of greater than 70 minutes. All patients admitted to the LMHS over an 18 month period with a discharge diagnosis related group (DRG) for AMI and UA were included in the study. A total of 667 case notes were examined; 403 of these cases met the inclusion criteria for the study. The mean duration between arrival in the ED and subsequent admission to the CCU was found to be 161 minutes. DRG was a major factor in the length of time spent in the ED. The mean duration for patients with AMI was 124 minutes, whilst for UA the duration was 190 minutes (difference = 66 minutes, p<0.001). Other factors that were significant were gender (females = mean duration 29 minutes > males, p=0.015), and mode of transport to the ED (arrival by ambulance mean duration 30 minutes < private transport, Recommendations arising from this study included that a system be established to enable the rapid assessment of all patients suspected of suffering AMI and UA, inclusive of their expeditious transfer to the CCU. In addition, a staff development programme was proposed to ensure medical and nursing staff became aware of a bias in this hospital toward transferring male patients in a shorter timeframe than females with the same DRG.