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Bottle A, Kristensen PK. Variation in quality of care between hospitals: how to identify learning opportunities. BMJ Qual Saf 2024; 33:413-415. [PMID: 38458746 DOI: 10.1136/bmjqs-2024-017071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2024] [Indexed: 03/10/2024]
Affiliation(s)
- Alex Bottle
- School of Public Health, Imperial College London Faculty of Medicine, London, UK
| | - Pia Kjær Kristensen
- Clinical Epidemiology, Aarhus Universitetshospital, Aarhus, Denmark
- Orthopedic, Region Hospital Horsens, Horsens, Denmark
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2
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Albsoul RA, FitzGerald G, Alshyyab MA. Missed nursing care: a snapshot case study in a medical ward in Australia. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2022; 31:710-716. [PMID: 35797073 DOI: 10.12968/bjon.2022.31.13.710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND Missed nursing care is a global issue in acute healthcare settings. It is a complex phenomenon that refers to nursing care that is required by patients but left undone or significantly delayed. AIM To investigate the nature of missed nursing care and influencing factors in a general medical ward in an acute care hospital in Brisbane, Australia. METHOD This is a descriptive case study. The study was carried out in a 29-bed inpatient general medical/cardiology/telemetry ward in an acute care tertiary hospital. RESULTS The study ward has been identified as a high complexity unit. The survey data found that the most frequent nursing care elements missed, as reported by the patients, were oral care, response to machine beep, and response to call light. The most frequent nurse-reported missed care items were ambulation, monitoring fluid intake/output and attendance at interdisciplinary conferences. CONCLUSION Despite mandating nurse-to-patient ratios in the study ward, inadequate staffing was still perceived as being problematic and one of the most frequent reasons leading to missed nursing care. This possible disconnect between mandated staffing ratios and the persistence of perceived missed care suggests a more complex relationship than can be managed by macro (large-scale) resourcing formulas alone.
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Affiliation(s)
- Rania Ali Albsoul
- Assistant Professor in Healthcare Management, Department of Family and Community Medicine, School of Medicine, The University of Jordan, Amman, Jordan
| | - Gerard FitzGerald
- Professor in Public Health, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia
| | - Muhammad Ahmed Alshyyab
- Assistant Professor in Health Services Management, Department of Public Health and Community Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
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3
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Asheim A, Nilsen SM, Aam S, Anthun KS, Carlsen F, Janszky I, Vatten LJ, Bjørngaard JH. High ward occupancy, bedspacing, and 60 day mortality for patients with myocardial infarction, stroke, and heart failure. ESC Heart Fail 2022; 9:1884-1890. [PMID: 35345059 PMCID: PMC9065853 DOI: 10.1002/ehf2.13894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 02/14/2022] [Accepted: 03/02/2022] [Indexed: 11/20/2022] Open
Abstract
Aims To study the consequences of crowded wards among patients with cardiovascular disease. Methods and results This is a cohort study among 201 801 patients with 258 807 admissions who were acutely admitted for myocardial infarction (N = 107 895), stroke (N = 87 336), or heart failure (N = 63 576) to any Norwegian hospital between 2008 and 2016. The ward admitting most patients with the given clinical condition was considered a patient's home ward. We compared patients with the same condition admitted when home ward occupancy was different, at the same hospital and during comparable time periods. Occupancy was standardized such that a one‐unit difference corresponded to the interquartile range in occupancy in the given month. One interquartile increase in home ward occupancy was associated with 7% higher odds of admission to an alternate ward [odds ratio (OR) 1.07, 95% confidence interval (CI) 1.09 to 1.11], and length of stay was shorter (−0.10 days, 95% CI −0.18 to −0.09). Patients with heart failure had 15% higher odds of admission to alternate wards (OR 1.15, 95% CI 1.08 to 1.23) and increased mortality [hazard ratio (HR) 1.08, 95% CI 1.03 to 1.15]. We found no apparent effect on mortality for patients with myocardial infarction (HR 0.99, 95% CI 0.94 to 1.05) or stroke (HR 1.00, 95% CI 0.96 to 1.05). Conclusions Patients with heart failure had higher risk of admission to alternate wards when home ward occupancy was high. These patients may be negatively affected by full wards.
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Affiliation(s)
- Andreas Asheim
- Center for Health Care Improvement, St. Olav's Hospital HF, Trondheim University Hospital, Trondheim, Norway.,Department of Mathematical Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Sara Marie Nilsen
- Center for Health Care Improvement, St. Olav's Hospital HF, Trondheim University Hospital, Trondheim, Norway
| | - Stina Aam
- Department of Geriatric Medicine, Clinic of Medicine, St. Olav's Hospital HF, Trondheim University Hospital, Trondheim, Norway.,Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Science, Norwegian University of Science and Technology, Trondheim, Norway
| | - Kjartan Sarheim Anthun
- Department of Public Health and Nursing, Norwegian University of Science and Technology, PO Box 8905, Trondheim, 7491, Norway.,Department of Health Research, SINTEF Digital, Trondheim, Norway
| | - Fredrik Carlsen
- Department of Economics, Norwegian University of Science and Technology, Trondheim, Norway
| | - Imre Janszky
- Center for Health Care Improvement, St. Olav's Hospital HF, Trondheim University Hospital, Trondheim, Norway.,Department of Public Health and Nursing, Norwegian University of Science and Technology, PO Box 8905, Trondheim, 7491, Norway
| | - Lars Johan Vatten
- Department of Public Health and Nursing, Norwegian University of Science and Technology, PO Box 8905, Trondheim, 7491, Norway
| | - Johan Håkon Bjørngaard
- Department of Public Health and Nursing, Norwegian University of Science and Technology, PO Box 8905, Trondheim, 7491, Norway.,Faculty of Nursing and Health Sciences, Nord University, Levanger, Norway
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4
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Nymark C, von Vogelsang AC, Falk AC, Göransson KE. Patient safety, quality of care and missed nursing care at a cardiology department during the COVID-19 outbreak. Nurs Open 2021; 9:385-393. [PMID: 34569190 PMCID: PMC8661578 DOI: 10.1002/nop2.1076] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 07/13/2021] [Accepted: 09/08/2021] [Indexed: 12/25/2022] Open
Abstract
Aim To evaluate missed nursing care and patient safety during the first wave of the COVID‐19 pandemic at in‐patient cardiology wards. Design A cross‐sectional design with a comparative approach. Method Registered nurses and nurse assistants at a cardiology department were invited to answer the MISSCARE Survey‐Swedish version, and questions on patient safety and quality of care during the COVID‐19 pandemic. The data were compared with a reference sample. Results A total of 43 registered nurses and nurse assistants in the COVID‐19 sample and 59 in the reference sample participated. The COVID‐19 sample reported significantly more overtime hours and more absence from work due to illness in comparison with the reference sample. The patient safety and quality of care were perceived significantly worse, 76.7% (N = 33) versus 94.7% (N = 54), and 85.7% (N = 36) versus 98.3% (N = 58, respectively. The COVID‐19 sample reported more missed nursing care in wound care and in basic nursing.
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Affiliation(s)
- Carolin Nymark
- Heart, Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden.,Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - Ann-Christin von Vogelsang
- Heart, Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Ann-Charlotte Falk
- Department for Health Promoting Science, Sophiahemmet University, Stockholm, Sweden
| | - Katarina E Göransson
- Emergency and Reparative Medicine Theme, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine, Karolinska Institutet, Solna, Stockholm, Sweden
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5
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Patry C, Perozziello A, Pardineille C, Aubert C, de Malglaive P, Choquet C, Raynaud-Simon A, Sanchez M. Older medical outliers on surgical wards: impact on 6-month outcomes. Emerg Med J 2021; 39:181-185. [PMID: 34140319 DOI: 10.1136/emermed-2020-210192] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 05/17/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Medical patients are on occasion admitted transiently to surgical wards when more appropriate wards are at capacity, potentially leading to suboptimal care. The aim of this study was to compare 6-month outcomes in older adults diagnosed with medical conditions in the ED then admitted inappropriately to surgical wards (defined as outliers), with outcomes in comparable patients admitted to medical wards (controls). METHODS In a matched cohort study, 100 consecutive medical outliers from the ED aged 75 years and over were matched according to age, sex and diagnosis to 200 controls. Collected data included number of diagnoses reported in acute care, level of patient illness severity, length of stay, mortality and destination of patients discharged from acute care units (home, rehabilitation facility, nursing home or palliative care facility). An assessment was made of patient vital status and living environment (home, nursing home or hospital) at 6 months post-ED admission. RESULTS Mean age was 85.6 years. The most common ED diagnoses were gait disorders/falls (18%), neurological disorders (17%) and exhaustion (16%). Outliers displayed lower illness severity levels (0.001) and shorter lengths of stay from ED admission to acute care discharge (p=0.040). Subsequent to acute care, outliers were less commonly discharged home (45% vs 59%) and more commonly discharged to rehabilitation facilities (42% vs 28%). At 6 months post-ED admission, multivariable regression analysis showed that outlier status (OR=0.44 (0.25-0.83); p=0.011) and numbers of diagnoses reported in acute care (OR=0.87 (0.76-0.98); p=0.028) were independently associated with lower probability of living at home. CONCLUSION Outlying of older patients to surgical wards negatively affects their prospects of living at home at 6 months after hospital admission. Older patients hospitalised via the ED are entitled to appropriate medical care.
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Affiliation(s)
- Claire Patry
- Geriatric Department, Bichat University Hospital, Assistance Publique - Hopitaux de Paris (APHP), Paris, France
| | - Anne Perozziello
- Health Information Management Department, Bichat University Hospital, Assistance Publique - Hopitaux de Paris (APHP), Paris, France
| | - Clio Pardineille
- Geriatric Department, Sainte-Périne University Hospital, Assistance Publqiue - Hopitaux de Paris (APHP), Paris, France
| | - Christiane Aubert
- Geriatric Department, Bichat University Hospital, Assistance Publique - Hopitaux de Paris (APHP), Paris, France
| | - Pauline de Malglaive
- Geriatric Department, Bichat University Hospital, Assistance Publique - Hopitaux de Paris (APHP), Paris, France
| | - Christophe Choquet
- Emergency Department - Bichat University Hospital, Assistance Publique - Hopitaux de Paris (APHP), Paris, France
| | - Agathe Raynaud-Simon
- Geriatric Department, Bichat University Hospital, Assistance Publique - Hopitaux de Paris (APHP), Paris, France.,University of Paris, Paris, France
| | - Manuel Sanchez
- Geriatric Department, Bichat University Hospital, Assistance Publique - Hopitaux de Paris (APHP), Paris, France .,University of Paris, Paris, France
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La Regina M, Vertulli C, Gussoni G, Fontanella A, Ballardini G, Brucato A, Orlandini F, Murialdo G, Campanini M, Manfellotto D. Not-for-profit observational study to evaluate the quality and safety of care in <em>outliers</em> hospitalized with medical diseases - Study Protocol of Safety Issues and SurvIval For Medical Outliers (SISIFO study). ITALIAN JOURNAL OF MEDICINE 2021. [DOI: 10.4081/itjm.2021.1447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The progressive cutting of hospital beds in some health systems, together with the increased needs related to the aging population, has led to the phenomenon of patients hospitalized outside the appropriate ward (outliers). This is particularly relevant in the context of Internal Medicine. Despite its relevance in daily clinical practice, available evidence for the potential impact of this phenomenon is limited. The aim of this study is to evaluate the effects of this situation on patients’ outcomes and possibly identify organizational and managerial aspects related to the presence of outliers. The multicenter, observational, prospective Study Protocol of Safety Issues and SurvIval For Medical Outliers (SISIFO) was promoted by the Italian Federation of Associations of Hospital Doctors on Internal Medicine (FADOI). The primary study endpoint is the evaluation of in-hospital mortality in outliers versus controls. A sample size of 2400 patients has been estimated by assuming a mortality rate of 12% and 8% in outliers and controls, respectively. By virtue of the multicentric dimension, the expected number of patients, and the controlled design, the FADOI-SISIFO study might provide interesting and useful findings to better manage the phenomenon of outliers.
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Fitzgerald A, Verrall C, Henderson J, Willis E. Factors influencing missed nursing care for older people following fragility hip fracture. Collegian 2020. [DOI: 10.1016/j.colegn.2019.12.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Kreindler SA, Star N, Hastings S, Winters S, Johnson K, Mallinson S, Brierley M, Goertzen LN, Anwar MR, Aboud Z. "Working Against Gravity": The Uphill Task of Overcapacity Management. Health Serv Insights 2020; 13:1178632920929986. [PMID: 32587459 PMCID: PMC7294368 DOI: 10.1177/1178632920929986] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 05/04/2020] [Indexed: 11/17/2022] Open
Abstract
While most health systems have implemented interventions to manage situations in which patient demand exceeds capacity, little is known about the long-term sustainability or effectiveness of such interventions. A large multi-jurisdictional study on patient flow in Western Canada provided the opportunity to explore experiences with overcapacity management strategies across 10 diverse health regions. Four categories of interventions were employed by all or most regions: overcapacity protocols, alternative locations for emergency patients, locations for discharge-ready inpatients, and meetings to guide redistribution of patients. Two mechanisms undergirded successful interventions: providing a capacity buffer and promoting action by inpatient units by increasing staff accountability and/or solidarity. Participants reported that interventions demanded significant time and resources and the ongoing active involvement of middle and senior management. Furthermore, although most participants characterized overcapacity management practices as effective, this effectiveness was almost universally experienced as temporary. Many regions described a context of chronic overcapacity, which persisted despite continued intervention. Processes designed to manage short-term surges in demand cannot rectify a long-term mismatch between capacity and demand; solutions at the level of system redesign are needed.
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Affiliation(s)
- Sara A Kreindler
- Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- George & Fay Yee Centre for Healthcare Innovation, Winnipeg Regional Health Authority/University of Manitoba, Winnipeg, MB, Canada
| | - Noah Star
- Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Stephanie Hastings
- Health Systems Evaluation & Evidence, Alberta Health Services, Calgary, AB, Canada
| | - Shannon Winters
- George & Fay Yee Centre for Healthcare Innovation, Winnipeg Regional Health Authority/University of Manitoba, Winnipeg, MB, Canada
| | - Keir Johnson
- George & Fay Yee Centre for Healthcare Innovation, Winnipeg Regional Health Authority/University of Manitoba, Winnipeg, MB, Canada
| | - Sara Mallinson
- Health Systems Evaluation & Evidence, Alberta Health Services, Calgary, AB, Canada
| | - Meaghan Brierley
- Health Systems Evaluation & Evidence, Alberta Health Services, Calgary, AB, Canada
| | | | | | - Zaid Aboud
- Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada
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9
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Kohn R, Harhay MO, Bayes B, Song H, Halpern SD, Kerlin MP, Greysen SR. Influence of bedspacing on outcomes of hospitalised medicine service patients: a retrospective cohort study. BMJ Qual Saf 2020; 30:116-122. [PMID: 32299956 DOI: 10.1136/bmjqs-2019-010675] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 02/24/2020] [Accepted: 03/01/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND Specialty wards cohort hospitalised patients to improve outcomes and lower costs. When demand exceeds capacity, patients overflow and are "bedspaced" to alternate wards. Some studies have demonstrated that bedspacing among medicine service patients is associated with adverse patient-centred outcomes, however, results have been inconsistent and have primarily been performed within national health systems. The objective of this study was to assess the association of bedspacing with patient-centred outcomes among United States patients admitted to general medicine services. METHODS We performed a retrospective cohort study of internal medicine, family medicine and geriatric service patients who were bedspaced vs cohorted for the entirety of their hospital stay within three large, urban United States hospitals (quaternary referral centre, tertiary referral centre and community hospital, with different patient demographics and case-mixes) in 2014 and 2015. We performed quantile regression to determine differences in length of stay (LOS) between bedspaced vs cohorted patients and logistic regression for in-hospital mortality and discharge to home. RESULTS Among 18 802 patients in 33 wards, 6119 (33%) patients were bedspaced. Bedspaced patients had significantly longer LOS compared with cohorted patients at the 25th (0.1 days, 95% CI: 0.05 to 0.2, p=0.001), 50th (0.2 days, 95% CI: 0.1 to 0.3, p=0.003) and 75th (0.3 days, 95% CI: 0.2 to 0.5, p<0.001) percentiles; and no statistically significant differences in odds of mortality (OR=0.9, 95% CI: 0.6 to 1.3, p=0.5) or discharge to home (OR=0.9, 95% CI: 0.9 to 1.0, p=0.06) in adjusted analyses. CONCLUSION Bedspacing is associated with adverse patient-centred outcomes. Future work is needed to confirm these findings, understand mechanisms contributing to adverse outcomes and identify factors that mitigate these adverse effects in order to provide high-value, patient-centred care to hospitalised patients.
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Affiliation(s)
- Rachel Kohn
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA .,Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadephia, Pennsylvania, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael O Harhay
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadephia, Pennsylvania, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Brian Bayes
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadephia, Pennsylvania, USA
| | - Hummy Song
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Scott D Halpern
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadephia, Pennsylvania, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Meeta Prasad Kerlin
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadephia, Pennsylvania, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - S Ryan Greysen
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Key Components of the Safe Surgical Ward: International Delphi Consensus Study to Identify Factors for Quality Assessment and Service Improvement. Ann Surg 2020; 269:1064-1072. [PMID: 31082903 DOI: 10.1097/sla.0000000000002718] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The aim of this study was to prioritize key factors contributing to safety on the surgical ward BACKGROUND:: There is a variation in the quality and safety of postoperative care between institutions. These variations may be attributed to a combination of process-related issues and structural factors. The aim of this study is to reach a consensus, by means of Delphi methodology, on the most influential of these components that may determine safety in this environment. METHODS The Delphi questionnaire was delivered via an online questionnaire platform. The panel were blinded. An international panel of safety experts, both clinical and nonclinical, and safety advocates participated. Individuals were selected according to their expertise and extent of involvement in patient safety research, regulation, or patient advocacy. RESULTS Experts in patient safety from the UK, Europe, North America, and Australia participated. The panel identified the response to a deteriorating patient and the care of outlier patients as error-prone processes. Prioritized structural factors included organizational and environmental considerations such as use of temporary staff, out-of-hours reduction in services, ward cleanliness, and features of layout. The latter includes dedicated areas for medication preparation and adequate space around the patient for care delivery. Potential quality markers for safe care that achieved the highest consensus include leadership, visibility between patients and nurses, and nursing team skill mix and staffing levels. CONCLUSION International consensus was achieved for a number of factors across process-related and structural themes that may influence safety in the postoperative environment. These should be championed and prioritized for future improvements in patient safety at the ward-level.
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11
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Maniaci MJ, Dawson NL, Cowart JB, Richie EM, Suryaprasad AG, Hodge DO, Joyce NE, Kernan CA, Stone LA, Burton MC. Goal-Directed Achievement Through Geographic Location (GAGL) Reduces Patient Length of Stay and Adverse Events. Am J Med Qual 2019; 35:323-329. [PMID: 31581786 DOI: 10.1177/1062860619879977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This prospective cohort study aimed to improve hospital outcomes through geographic location of hospitalist patients and conducting daily multidisciplinary team rounds-Goal-directed Achievements through Geographic Location (GAGL). Patients were admitted to a geographic (GAGL) study unit where daily multidisciplinary rounds took place among nursing, case management, a hospitalist, pharmacy, physical and occupational therapy, respiratory therapy, and nutrition services. A total of 985 (56.4%) patients were admitted to the GAGL study unit and 760 patients (43.6%) were admitted to non-GAGL units. Patients admitted to the GAGL study unit had a shorter average length of stay (3.64 days vs 4.35 days, P = .0001) and a lower number of risk events (91 [9.2%] vs 93 [12.2%], P = .038). There was no significant difference in 30-day readmissions, avoidable day events, or code blue team activations. GAGL provides a framework for hospital organizations to improve provider communication, hospital efficiency, and patient safety.
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12
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La Regina M, Guarneri F, Romano E, Orlandini F, Nardi R, Mazzone A, Fontanella A, Campanini M, Manfellotto D, Bellandi T, Gussoni G, Tartaglia R, Squizzato A. What Quality and Safety of Care for Patients Admitted to Clinically Inappropriate Wards: a Systematic Review. J Gen Intern Med 2019; 34:1314-1321. [PMID: 31011980 PMCID: PMC6614225 DOI: 10.1007/s11606-019-05008-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 11/05/2018] [Accepted: 12/27/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND In countries with public health system, hospital bed reductions and increasing social and medical frailty have led to the phenomenon of "outliers" or "outlying hospital in-patients." They are often medical patients who, because of unavailability of beds in their clinically appropriate ward, are admitted wherever unoccupied beds are. The present work is aimed to systematically review literature about quality and safety of care for patients admitted to clinically inappropriate wards. METHODS We performed a systematic review of studies investigating outliers, published in peer-reviewed journals with no time restrictions. Search and screening were conducted by two independent researchers (MLR and ER). Studies were considered potentially eligible for this systematic review if aimed to assess the quality and/or the safety of care for patients admitted to clinically inappropriate units. Our search was supplemented by a hand search of references of included studies. Given the heterogeneity of studies, results were analyzed thematically. We used PRISMA guidelines to report our findings. RESULTS We collected 17 eligible papers and grouped them into six thematic categories. Despite their methodological limits, the included studies show increased trends in mortality and readmissions among outliers. Quality of care and patient safety are compromised as patients and health professionals declare and risk analysis displays. Reported solutions are often multicomponent, stress early discharge but have not been investigated in the control group. CONCLUSIONS Published literature cannot definitely conclude on the quality and safety of care for patients admitted to clinically inappropriate wards. As they may represent a serious threat for quality and safety, and moreover often neglected and under valued, well-designed and powered prospective studies are urgently needed.
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Affiliation(s)
| | - Francesca Guarneri
- Laboratorio Management e Sanita`, Institute of Management of Scuola Superiore Sant'Anna of Pisa, Pisa, Italy
| | - Elisa Romano
- SS Risk Management, ASL5 Liguria, La Spezia, Italy
| | | | | | - Antonino Mazzone
- Dipartimento Medico Ospedale di Legnano, Azienda Socio Sanitaria Territoriale Ovest Milanese, Legnano, MI, Italy
| | - Andrea Fontanella
- Dipartimento di Medicina Interna, Ospedale del Buonconsiglio - Fatebenefratelli Napoli, Naples, NA, Italy
| | - Mauro Campanini
- Dipartimento di Medicina Interna, Azienda Ospedaliera Maggiore della Carità, Novara, Italy
| | - Dario Manfellotto
- UO Medicina Interna, Ospedale Fatebenefratelli Isola Tiberina, Rome, Italy
| | - Tommaso Bellandi
- Centro Gestione Rischio Clinico Regione Toscana, Florence, Italy
| | | | | | - Alessandro Squizzato
- Dipartimento di Medicina Clinica e Sperimentale, Università dell'Insubria, Varese, Italy
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13
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A Retrospective Case-Control Study to Identify Predictors of Unplanned Admission to Pediatric Intensive Care Within 24 Hours of Hospitalization. Pediatr Crit Care Med 2019; 20:e293-e300. [PMID: 31149966 DOI: 10.1097/pcc.0000000000001977] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVES To identify the clinical findings available at the time of hospitalization from the emergency department that are associated with deterioration within 24 hours. DESIGN A retrospective case-control study. SETTING A pediatric hospital in Ottawa, ON, Canada. PATIENTS Children less than 18 years old who were hospitalized via the emergency department between January 1, 2008, and December 31, 2012. Cases (n = 98) had an unplanned admission to the PICU or unexpected death on the hospital ward within 24 hours of hospitalization and controls (n = 196) did not. INTERVENTIONS None. MAIN RESULTS Ninety-eight children (53% boys; mean age 63.2 mo) required early unplanned admission to the PICU. Multivariable conditional logistic regression resulted in a model with five predictors reaching statistical significance: higher triage acuity score (odds ratio, 4.1; 95% CI, 1.7-10.2), tachypnea in the emergency department (odds ratio, 4.6; 95% CI, 1.8-11.8), tachycardia in the emergency department (odds ratio, 2.6; 95% CI, 1.1-6.5), PICU consultation in the emergency department (odds ratio, 8.0; 95% CI, 1.1-57.7), and admission to a ward not typical for age and/or diagnosis (odds ratio, 4.5; 95% CI, 1.7-11.6). CONCLUSIONS We have identified risk factors that should be included as potential predictor variables in future large, prospective studies to derive and validate a weighted scoring system to identify hospitalized children at high risk of early clinical deterioration.
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Chen H, Walabyeki J, Johnson M, Boland E, Seymour J, Macleod U. An integrated understanding of the complex drivers of emergency presentations and admissions in cancer patients: Qualitative modelling of secondary-care health professionals' experiences and views. PLoS One 2019; 14:e0216430. [PMID: 31048875 PMCID: PMC6497383 DOI: 10.1371/journal.pone.0216430] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 04/20/2019] [Indexed: 11/18/2022] Open
Abstract
The number of cancer-related emergency presentations and admissions has been steadily increasing in the UK. Drivers of this phenomenon are complex, multifactorial and interlinked. The main objective of this study was to understand the complexity of emergency hospital use in cancer patients. We conducted semi-structured interviews with 42 senior clinicians (20 doctors, 22 nurses) with diverse expertise and experience in caring for acutely ill cancer patients in the secondary care setting. Data analysis included thematic analysis and purposive text analysis to develop Causal Loop Diagrams. Our Causal Loop Diagrams represent an integrated understanding of the complex factors (13) influencing emergency hospital use in cancer patients. Eight factors formed five reinforcing feedback loops and therefore were high-leverage influences: Ability of patients and carers to self-care and cope; Effective and timely management of ambulatory care sensitive conditions by primary and community care; Sufficient and effective social care for patients and carers; Avoidable emergency hospital use; Bed capacity; Patients accessing timely appropriate specialist inpatient or ambulatory care; Prompt and effective management and prevention of acute episode; Timely and safe discharge with appropriate support. The loops show that reduction of avoidable hospital use helps relieve hospital bed pressure; improved bed capacity then has a decisive, positive influence on patient pathway and thus outcome and experience in the hospital; in turn, better in-hospital care and discharge help patients and carers self-care and cope better back home with better support from community-based health and social care services, which then reduces their future emergency hospital use. To optimise acute and emergency cancer care, it is also essential that patients, carers and other clinicians caring for cancer patients have prompt access to senior cancer specialists for advice, assessment, clinical decision and other support. The findings provide a useful framework and focus for service planners aiming to optimise care.
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Affiliation(s)
- Hong Chen
- Academy of Primary Care, Institute of Clinical and Applied Heath Research, Hull York Medical School, University of Hull, Hull, United Kingdom
- * E-mail:
| | - Julie Walabyeki
- Academy of Primary Care, Institute of Clinical and Applied Heath Research, Hull York Medical School, University of Hull, Hull, United Kingdom
| | - Miriam Johnson
- Wolfson Palliative Care Research Centre, Institute of Clinical and Applied Heath Research, Hull York Medical School, University of Hull, Hull, United Kingdom
| | - Elaine Boland
- Queen's Centre for Oncology and Haematology, Castle Hill Hospital, Hull and East Yorkshire Hospitals NHS Trust, Hull, United Kingdom
| | - Julie Seymour
- Academy of Primary Care, Institute of Clinical and Applied Heath Research, Hull York Medical School, University of Hull, Hull, United Kingdom
| | - Una Macleod
- Academy of Primary Care, Institute of Clinical and Applied Heath Research, Hull York Medical School, University of Hull, Hull, United Kingdom
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Analysis of frequency, type of complications and economic costs of outlying patients in general and digestive surgery. Cir Esp 2019; 97:282-288. [PMID: 30755299 DOI: 10.1016/j.ciresp.2019.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 12/21/2018] [Accepted: 01/03/2019] [Indexed: 11/23/2022]
Abstract
INTRODUCTION The shortage of available beds and the increase in Emergency Department pressure can cause some patients to be admitted in wards with available beds assigned to other services (outlying patients). The aim of this study is to assess the frequency, types of complications and costs of outlying patients. METHODS Using a retrospective cohort model, we analysed the 2015 general and digestive surgery records (source: Minimum Basic Data Set and economic database). After selecting all outlying patients, we compared the complications, length of stay, costs and consequences of complications against a randomized sample of non-outlying patients with the same DRG and date of episode for every outlying patient, obtaining one non-outlying patient for each selected outlying patient. Thirteen outlying patients with no non-outlying patient pair were excluded from the study. RESULTS From a total of 2,915 patients, 363 (12.45%) were outlying patients. A total of 350 outlying patients were analysed versus 350 non-outlying patients. There were no significant differences in complications (9.4 vs. 8.3%), length of stay (4.33 vs. 4.65 days) or costs (€3,034.12 vs. €3,223.27). Outlying patients men presented a significantly higher risk of complications compared to women (RR=2.10). Outlying patients presented complications after 2.5 or more days. CONCLUSIONS When outlying admissions become necessary, the selection of patients with less complex pathologies does not increase complications or their consequences (ICU admissions, readmissions, reoperations or mortality), hospital stays or costs. Only in cases of prolonged outlying stays of more than 2.5 days, or in males, may more complications appear. Therefore, male outliers should be avoided in general, and patients should be transferred to the proper ward if a length of stay beyond 2.5 days is foreseen.
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Cabrera Torres E, García Iglesias MA, Santos Jiménez MT, González Hierro M, Diego Domínguez ML. [Outlier patient admissions and their relationship with the emergence of clinical complications and prolonged hospital stays]. GACETA SANITARIA 2019; 33:32-37. [PMID: 28943019 DOI: 10.1016/j.gaceta.2017.07.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/01/2017] [Revised: 06/30/2017] [Accepted: 07/14/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To analyze the relationship between the type of hospital admission (outlier and non-outlier admissions) and the appearance of clinical complications and the average stay. METHODS From a retrospective epidemiological study of a cohort of patients admitted to the Hospital Complejo Asistencial Universitario de Salamanca (Salamanca, Spain) over a six-month period, outlier and non-outlier patients were identified. This project had access to the admissions department database, the hospital's CMBD (in Spanish, Conjunto Mínimo Básico de Datos) for hospitalisation, the AP-DRG (All Patient-Diagnosis Related Groups) and ALCOR (a clinical-statistics analytics tool). It then proceeded to break down the results by DRG, looking at the five most common DRGs in that period. RESULTS 8.4% of the total 11,842 admissions were medical outliers. In the overall study, the average stay was longer for outlier patients (8. 11 days) than for other patients (7.15 days). The mortality rate was, likewise, higher for outlier patients, although there was a reduced incidence of complications (7.6% for outlier patients as opposed to 8.4% for others). The analysis by DRG corroborated these results in three of the five cases investigated, showing longer average stays but fewer clinical complications in the case of outlier patients. CONCLUSIONS On admission to hospital, a significant proportion of patients were allocated beds on inappropriate wards (outlier patients). It was more common to find medical patients placed on surgical wards than vice versa. The average stay of outlier patients was longer than that of patients admitted to the correct ward. The study found no significant difference between the two groupś in terms of clinical complication rates.
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Affiliation(s)
- Enrique Cabrera Torres
- Servicios de Inspección Médica, Gerencia de Asistencia Sanitaria de Salamanca, Salamanca, España.
| | | | - María Teresa Santos Jiménez
- Servicio de Admisión y Documentación Clínica, Complejo Asistencial Universitario de Salamanca, Salamanca, España
| | - Miguel González Hierro
- Servicios de Inspección Médica, Gerencia de Asistencia Sanitaria de Salamanca, Salamanca, España
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Hassen Y, Singh P, Pucher PH, Johnston MJ, Darzi A. Identifying quality markers of a safe surgical ward: An interview study of patients, clinical staff, and administrators. Surgery 2018; 163:1226-1233. [DOI: 10.1016/j.surg.2017.12.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Revised: 11/09/2017] [Accepted: 12/02/2017] [Indexed: 11/30/2022]
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18
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Blay N, Roche M, Duffield C, Xu X. Intrahospital transfers and adverse patient outcomes: An analysis of administrative health data. J Clin Nurs 2017; 26:4927-4935. [DOI: 10.1111/jocn.13976] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Nicole Blay
- Centre for Health Services Management; Faculty of Health; University of Technology Sydney; Broadway NSW Australia
- Centre for Applied Nursing Research (CANR); Western Sydney University; Liverpool NSW Australia
| | - Michael Roche
- Mental Health, Drug and Alcohol Nursing Northern Sydney Local Health District; School of Nursing, Midwifery and Paramedicine; Australian Catholic University; North Sydney NSW Australia
| | - Christine Duffield
- Nursing and Health Services Management; Centre for Health Services Management; Faculty of Health; University of Technology Sydney; Broadway NSW Australia
- Edith Cowen University; Joondalup WA Australia
| | - Xiaoyue Xu
- Faculty of Health; University of Technology Sydney; Broadway NSW Australia
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Stylianou N, Fackrell R, Vasilakis C. Are medical outliers associated with worse patient outcomes? A retrospective study within a regional NHS hospital using routine data. BMJ Open 2017; 7:e015676. [PMID: 28490563 PMCID: PMC5588983 DOI: 10.1136/bmjopen-2016-015676] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE To explore the quality and safety of patients' healthcare provision by identifying whether being a medical outlier is associated with worse patient outcomes. A medical outlier is a hospital inpatient who is classified as a medical patient for an episode within a spell of care and has at least one non-medical ward placement within that spell. DATA SOURCES Secondary data from the Patient Administration System of a district general hospital were provided for the financial years 2013/2014-2015/2016. The data included 71 038 medical patient spells for the 3-year period. STUDY DESIGN This research was based on a retrospective, cross-sectional observational study design. Multivariate logistic regression and zero-truncated negative binomial regression were used to explore patient outcomes (in-hospital mortality, 30-day mortality, readmissions and length of stay (LOS)) while adjusting for several confounding factors. PRINCIPAL FINDINGS Univariate analysis indicated that an outlying medical in-hospital patient has higher odds for readmission, double the odds of staying longer in the hospital but no significant difference in the odds of in-hospital and 30-day mortality. Multivariable analysis indicates that being a medical outlier does not affect mortality outcomes or readmission, but it does prolong LOS in the hospital. CONCLUSIONS After adjusting for other factors, medical outliers are associated with an increased LOS while mortality or readmissions are not worse than patients treated in appropriate specialty wards. This is in line with existing but limited literature that such patients experience worse patient outcomes. Hospitals may need to revisit their policies regarding outlying patients as increased LOS is associated with an increased likelihood of harm events, worse quality of care and increased healthcare costs.
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Affiliation(s)
- Neophytos Stylianou
- Centre for Healthcare Innovation & Improvement (CHI2), School of Management, University of Bath, Bath, UK
- Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - Robin Fackrell
- Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - Christos Vasilakis
- Centre for Healthcare Innovation & Improvement (CHI2), School of Management, University of Bath, Bath, UK
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Webster J, New K, Fenn M, Batch M, Eastgate A, Webber S, Nesbit A. Effects of frequent PATient moves on patient outcomes in a large tertiary Hospital (the PATH study): a prospective cohort study. AUST HEALTH REV 2017; 40:324-329. [PMID: 26386599 DOI: 10.1071/ah15095] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 06/17/2015] [Indexed: 11/23/2022]
Abstract
Objective The aim of the present study was to investigate the incidence of and patient outcomes associated with frequent patient moves. Methods In a prospective cohort study, any bed move and the reason for the move were documented. Patients were assessed on admission for anxiety, social support and delirium. Adverse events, length of stay and satisfaction were recorded. Patients moved three or more times were compared with those moved less than three times. Results In all, 566 patients admitted to a tertiary referral hospital were included in the study. Of these, 156 patients (27.6%) were moved once, 46 (8.1%) were moved twice and 28 (4.9%) were moved at least three times. Those moved three or more times were almost threefold more likely to have an adverse event recorded compared with those moved fewer times (relative risk (RR) 2.75; 95% confidence interval (CI) 1.18, 6.42; P=0.02) and to have a hospital stay twice as long (RR 7.10; 95% CI 2.60, 11.60; P=0.002). Levels of satisfaction and anxiety were not affected by frequent moves and there was no effect on delirium. Conclusion Frequent bed moves affect patient safety and prolong length of stay. What is known about the topic? Retrospective and qualitative studies suggest that patient safety and costs may be affected by frequent patient moves. What does this paper add? The present study is the first prospective study to assess the negative effects of frequent patient moves on specific patient outcomes, such as adverse events, length of stay and satisfaction with care. What are the implications for practitioners? Within- and between-ward moves may affect patient safety. Patients should be moved only when there is a clear and unavoidable reason for doing so.
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Affiliation(s)
- Joan Webster
- Level 2, Centre for Clinical Nursing, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, Qld 4029, Australia.
| | - Karen New
- School of Nursing Midwifery and Social work, Level 3, Chamberlain building, The University of Queensland, St Lucia, Qld 4072, Australia. Email
| | - Mary Fenn
- Patient Flow Unit, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, Qld 4029, Australia.
| | - Mary Batch
- Level 2, Centre for Clinical Nursing, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, Qld 4029, Australia.
| | - Alyson Eastgate
- Level 2, Centre for Clinical Nursing, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, Qld 4029, Australia.
| | - Selena Webber
- Level 2, Centre for Clinical Nursing, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, Qld 4029, Australia.
| | - Anthony Nesbit
- Patient Flow Unit, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, Qld 4029, Australia.
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Yarmohammadian MH, Rezaei F, Haghshenas A, Tavakoli N. Overcrowding in emergency departments: A review of strategies to decrease future challenges. JOURNAL OF RESEARCH IN MEDICAL SCIENCES : THE OFFICIAL JOURNAL OF ISFAHAN UNIVERSITY OF MEDICAL SCIENCES 2017; 22:23. [PMID: 28413420 PMCID: PMC5377968 DOI: 10.4103/1735-1995.200277] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Revised: 11/07/2016] [Accepted: 11/29/2016] [Indexed: 01/20/2023]
Abstract
Emergency departments (EDs) are the most challenging ward with respect to patient delay. The goal of this study is to present strategies that have proven to reduce delay and overcrowding in EDs. In this review article, initial electronic database search resulted in a total of 1006 articles. Thirty articles were included after reviewing full texts. Inclusion criteria were assessments of real patient flows and implementing strategies inside the hospitals. In this study, we discussed strategies of team triage, point-of-care testing, ideal ED patient journey models, streaming, and fast track. Patients might be directed to different streaming channels depending on clinical status and required practitioners. The most comprehensive strategy is ideal ED patient journey models, in which ten interrelated substrategies are provided. ED leaders should apply strategies that provide a continuous care process without deeply depending on external services.
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Affiliation(s)
- Mohammad H Yarmohammadian
- Health Management and Economics Research Center, Faculty of Management and Medical Informatics, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Fatemeh Rezaei
- Health Management and Economics Research Center, Faculty of Management and Medical Informatics, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Abbas Haghshenas
- Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Nahid Tavakoli
- Health Management and Economics Research Center, Faculty of Management and Medical Informatics, Isfahan University of Medical Sciences, Isfahan, Iran
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Abstract
Hospitals strive to admit patients to the units where caregiver competencies align with the patient's condition. When the hospital's census peaks, internal diversions and the associated risks increase, which are intensified when silos exist, as segregated care negatively impacts collaboration and patient safety. In this study, a 600+-bed academic, tertiary care specialty hospital experienced an increase in internal diversions. Within the neuroscience service line, emergent neuroscience transfers from outside hospitals had been declined or internally diverted because of capacity limitations. Formalized processes for improving collaboration between health care providers related to capacity issues were required to decrease internal diversions and improve patient flow and patient safety. A pilot project was conducted on neuroscience units during a process improvement initiative. A hospital-wide internal diversion plan was developed, identifying primary and secondary placement options for all patients requiring hospitalization to support patient flow and patient safety. Forecasting tools were developed to provide units' leadership with current information on expected admissions. Daily capacity huddles were instituted to increase collaboration between patient care units. The interventions trialed during the pilot decreased internal diversions and improved patient flow. The improved collaboration resulted in an 80% decrease in declinations of emergent intensive care unit transfers from outside hospitals due to capacity limitations and a 50% decrease in the number of these patients being internally diverted to alternate intensive care units. The interventions implemented minimized internal diversions and improved patient flow. The transparency of the patient placement process led to an increased collaboration between all participants.
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23
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Mackintosh N, Sandall J. The social practice of rescue: the safety implications of acute illness trajectories and patient categorisation in medical and maternity settings. SOCIOLOGY OF HEALTH & ILLNESS 2016; 38:252-69. [PMID: 26382089 PMCID: PMC4949570 DOI: 10.1111/1467-9566.12339] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
The normative position in acute hospital care when a patient is seriously ill is to resuscitate and rescue. However, a number of UK and international reports have highlighted problems with the lack of timely recognition, treatment and referral of patients whose condition is deteriorating while being cared for on hospital wards. This article explores the social practice of rescue, and the structural and cultural influences that guide the categorisation and ordering of acutely ill patients in different hospital settings. We draw on Strauss et al.'s notion of the patient trajectory and link this with the impact of categorisation practices, thus extending insights beyond those gained from emergency department triage to care management processes further downstream on the hospital ward. Using ethnographic data collected from medical wards and maternity care settings in two UK inner city hospitals, we explore how differences in population, cultural norms, categorisation work and trajectories of clinical deterioration interlink and influence patient safety. An analysis of the variation in findings between care settings and patient groups enables us to consider socio-political influences and the specifics of how staff manage trade-offs linked to the enactment of core values such as safety and equity in practice.
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Affiliation(s)
| | - Jane Sandall
- Division of Women's HealthKing's College LondonLondonUK
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24
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Abstract
How transfers from ward to ward can affect continuity of care.
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Affiliation(s)
- M Williamson
- Epsom and St Helier University Hospitals NHS Trust, UK
| | - M Ghazaly
- Epsom and St Helier University Hospitals NHS Trust, UK
- Lecturer of Surgery, Tanta University, Egypt
| | - N Bhatt
- Epsom and St Helier University Hospitals NHS Trust, UK
| | - D Nehra
- Epsom and St Helier University Hospitals NHS Trust, UK
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Milne J, Greenfield D, Braithwaite J. An ethnographic investigation of junior doctors’ capacities to practice interprofessionally in three teaching hospitals. J Interprof Care 2015; 29:347-53. [DOI: 10.3109/13561820.2015.1004039] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Pannick S, Beveridge I, Wachter RM, Sevdalis N. Improving the quality and safety of care on the medical ward: A review and synthesis of the evidence base. Eur J Intern Med 2014; 25:874-87. [PMID: 25457434 DOI: 10.1016/j.ejim.2014.10.013] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Revised: 09/13/2014] [Accepted: 10/13/2014] [Indexed: 11/17/2022]
Abstract
Despite its place at the heart of inpatient medicine, the evidence base underpinning the effective delivery of medical ward care is highly fragmented. Clinicians familiar with the selection of evidence-supported treatments for specific diseases may be less aware of the evolving literature surrounding the organisation of care on the medical ward. This review is the first synthesis of that disparate literature. An iterative search identified relevant publications, using terms pertaining to medical ward environments, and objective and subjective patient outcomes. Articles (including reviews) were selected on the basis of their focus on medical wards, and their relevance to the quality and safety of ward-based care. Responses to medical ward failings are grouped into five common themes: staffing levels and team composition; interdisciplinary communication and collaboration; standardisation of care; early recognition and treatment of the deteriorating patient; and local safety climate. Interventions in these categories are likely to improve the quality and safety of care in medical wards, although the evidence supporting them is constrained by methodological limitations and inadequate investment in multicentre trials. Nonetheless, with infrequent opportunities to redefine their services, institutions are increasingly adopting multifaceted strategies that encompass groups of these themes. As the literature on the quality of inpatient care moves beyond its initial focus on the intensive care unit and operating theatre, physicians should be mindful of opportunities to incorporate evidence-based practice at a ward level.
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Affiliation(s)
- Samuel Pannick
- NIHR Patient Safety Translational Research Centre, Imperial College London, and West Middlesex University Hospital NHS Trust, UK.
| | | | - Robert M Wachter
- Division of Hospital Medicine, University of CA, San Francisco, USA.
| | - Nick Sevdalis
- NIHR Patient Safety Translational Research Centre, Imperial College London, UK.
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Silvester K, Harriman P, Walley P, Burley G. Does process flow make a difference to mortality and cost? An observational study. Int J Health Care Qual Assur 2014; 27:616-32. [PMID: 25252567 DOI: 10.1108/ijhcqa-09-2013-0115] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE The purpose of the paper is to investigate the potential relationships between emergency-care flow, patient mortality and healthcare costs using a patient-flow model. DESIGN/METHODOLOGY/APPROACH The researchers used performance data from one UK NHS trust collected over three years to identify periods where patient flow was compromised. The delays' root causes in the entire emergency care system were investigated. Event time-lines that disrupted patient flow and patient mortality statistics were compared. FINDINGS Data showed that patient mortality increases at times when accident and emergency (A&E) department staff were struggling to admit patients. Four delays influenced mortality: first, volume increase and mixed admissions; second, process delays; third, unplanned hospital capacity adjustments and finally, long-term capacity restructuring downstream. RESEARCH LIMITATIONS/IMPLICATIONS This is an observational study that uses process control data to find times when mortality increases coincide with other events. It captures contextual background to whole system issues that affect patient mortality. PRACTICAL IMPLICATIONS Managers must consider cost-decisions and flow in the whole system. Localised, cost-focused decisions can have a detrimental effect on patient care. Attention must also be paid to mortality reports as existing data-presentation methods do not allow correlation analysis. ORIGINALITY/VALUE Previous studies correlate A&E overcrowding and mortality. This method allows the whole system to be studied and increased mortality root causes to be understood.
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Waring J, Marshall F, Bishop S, Sahota O, Walker M, Currie G, Fisher R, Avery T. An ethnographic study of knowledge sharing across the boundaries between care processes, services and organisations: the contributions to ‘safe’ hospital discharge. HEALTH SERVICES AND DELIVERY RESEARCH 2014. [DOI: 10.3310/hsdr02290] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundHospital discharge is a vulnerable stage in the patient pathway. Research highlights communication failures and the problems of co-ordination as resulting in delayed, poorly timed and unsafe discharges. The complexity of hospital discharge exemplifies the threats to patient safety found ‘between’ care processes and organisations. In developing this perspective, safe discharge is seen as relying upon enhanced knowledge sharing and collaboration between stakeholders, which can mitigate system complexity and promote safety.AimTo identify interventions and practices that support knowledge sharing and collaboration in the processes of discharge planning and care transition.SettingThe study was undertaken between 2011 and 2013 in two English health-care systems, each comprising an acute health-care provider, community and primary care providers, local authority social services and social care agencies. The study sites were selected to reflect known variations in local population demographics as well as in the size and composition of the care systems. The study compared the experiences of stroke and hip fracture patients as exemplars of acute care with complex discharge pathways.DesignThe study involved in-depth ethnographic research in the two sites. This combined (a) over 180 hours of observations of discharge processes and knowledge-sharing activities in various care settings; (b) focused ‘patient tracking’ to trace and understand discharge activities across the entire patient journey; and (c) qualitative interviews with 169 individuals working in health, social and voluntary care sectors.FindingsThe study reinforces the view of hospital discharge as a complex system involving dynamic and multidirectional patterns of knowledge sharing between multiple groups. The study shows that discharge planning and care transitions develop through a series of linked ‘situations’ or opportunities for knowledge sharing. It also shows variations in these situations, in terms of the range of actors, forms of knowledge shared, and media and resources used, and the wider culture and organisation of discharge. The study also describes the threats to patient safety associated with hospital discharge, as perceived by participants and stakeholders. These related to falls, medicines, infection, clinical procedures, equipment, timing and scheduling of discharge, and communication. Each of these identified risks are analysed and explained with reference to the observed patterns of knowledge sharing to elaborate how variations in knowledge sharing can hinder or promote safe discharge.ConclusionsThe study supports the view of hospital discharge as a complex system involving tightly coupled and interdependent patterns of interaction between multiple health and social care agencies. Knowledge sharing can help to mitigate system complexity through supporting collaboration and co-ordination. The study suggests four areas of change that might enhance knowledge sharing, reduce system complexity and promote safety. First, knowledge brokers in the form of discharge co-ordinators can facilitate knowledge sharing and co-ordination; second, colocation and functional proximity of stakeholders can support knowledge sharing and mutual appreciation and alignment of divergent practices; third, local cultures should prioritise and value collaboration; and finally, organisational resources, procedures and leadership should be aligned to fostering knowledge sharing and collaborative working. These learning points provide insight for future interventions to enhance discharge planning and care transition. Future research might consider the implementation of interviews to mediate system complexity through fostering enhanced knowledge sharing across occupational and organisational boundaries. Research might also consider in more detail the underlying complexity of both health and social care systems and how opportunities for knowledge sharing might be engendered to promote patient safety in other areas.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Justin Waring
- Centre for Heath Innovation, Leadership and Learning, Nottingham University Business School, Nottingham, UK
| | - Fiona Marshall
- Centre for Heath Innovation, Leadership and Learning, Nottingham University Business School, Nottingham, UK
| | - Simon Bishop
- Centre for Heath Innovation, Leadership and Learning, Nottingham University Business School, Nottingham, UK
| | - Opinder Sahota
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Marion Walker
- Community Health Sciences, University of Nottingham, Nottingham, UK
| | - Graeme Currie
- Warwick Business School, University of Warwick, Coventry, UK
| | - Rebecca Fisher
- Community Health Sciences, University of Nottingham, Nottingham, UK
| | - Tony Avery
- Community Health Sciences, University of Nottingham, Nottingham, UK
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Silvester KM, Mohammed MA, Harriman P, Girolami A, Downes TW. Timely care for frail older people referred to hospital improves efficiency and reduces mortality without the need for extra resources. Age Ageing 2014; 43:472-7. [PMID: 24222658 DOI: 10.1093/ageing/aft170] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND hospitals are under pressure to reduce waiting times and costs. One strategy that may be effective focuses on optimising the flow of emergency patients. OBJECTIVE we undertook a patient flow analysis of older emergency patients to identify and address delays in ensuring timely care, without additional resources. DESIGN prospective systems redesign study over 2 years. SETTING the Geriatric Medicine Directorate in an acute hospital (Sheffield Teaching Hospitals NHS Foundation Trust) with 1920 beds. SUBJECTS older patients admitted as emergencies. METHODS diagnostic patient flow analysis followed by a series of Plan Do Study Act cycles to test and implement changes by a multidisciplinary team using time series run charts. RESULTS 60% of patients aged 75+ years arrived in the Emergency Department during office hours, but two-thirds of the admissions to GM wards were outside office hours highlighting a major delay. Three changes were undertaken to address this, Discharge to Assess, Seven Day Working and the establishment of a Frailty Unit. Average bed occupancy fell by 20.4 beds (95% confidence interval (CI) -39.6 to -1.2, P = 0.037) for similar demand. The risk of hospital mortality also fell by 2.25% (before 11.4% (95% CI 10.4-12.4%), after 9.15% (95% CI 7.6-10.7%) which equates to a number needed to treat of 45 and a 19.7% reduction in relative risk of mortality. The risk of re-admission remained unchanged. CONCLUSION redesigning the system of care for older emergency patients led to reductions in bed occupancy and mortality without affecting re-admission rates or requiring additional resources.
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Affiliation(s)
- Kate M Silvester
- Health Sciences Research Institute, Warwick Medical School, Warwick, Warwickshire, UK University of Warwick, Warwick, Warwickshire, UK
| | | | - Paul Harriman
- Service Improvement, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Anna Girolami
- Service Improvement, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Tom W Downes
- Geriatric Medicine Department, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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Goulding L, Adamson J, Watt I, Wright J. Lost in hospital: a qualitative interview study that explores the perceptions of NHS inpatients who spent time on clinically inappropriate hospital wards. Health Expect 2013; 18:982-94. [PMID: 23611442 DOI: 10.1111/hex.12071] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2013] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND Prior research suggests that the placement of patients on clinically inappropriate hospital wards may increase the risk of experiencing patient safety issues. OBJECTIVE To explore patients' perspectives of the quality and safety of the care received during their inpatient stay on a clinically inappropriate hospital ward. DESIGN Qualitative study using semi-structured interviews. PARTICIPANTS AND SETTING Nineteen patients who had spent time on at least one clinically inappropriate ward during their hospital stay at a large NHS teaching hospital in England. RESULTS Patients would prefer to be treated on the correct specialty ward, but it is generally accepted that this may not be possible. When patients are placed on inappropriate wards, they may lack a sense of belonging. Participants commented on potential failings in communication, medical staff availability, nurses' knowledge and the resources available, each of which may contribute to unsafe care. CONCLUSIONS Patients generally acknowledge the need for placement on inappropriate wards due to demand for inpatient beds, but may report dissatisfaction in terms of preference and belonging. Importantly, patients recount issues resulting from this placement that may compromise their safety. Hospital managers should be encouraged to appreciate this insight and potential threat to safe practice and where possible avoid inappropriate ward transfers and admissions. Where such admissions are unavoidable, staff should take action to address the gaps in safety of care that have been identified.
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Affiliation(s)
- Lucy Goulding
- Department of Health Sciences, University of York, UK
| | - Joy Adamson
- Department of Health Sciences, University of York, UK
| | - Ian Watt
- Department of Health Sciences/Hull York Medical School, University of York, York, UK
| | - John Wright
- Bradford Institute for Health Research, Bradford, UK
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