Decline in ICU adverse events, nosocomial infections and cost through a quality improvement initiative focusing on teamwork and culture change

Use of Rounding Checklists to Improve Communication and Collaboration in the Adult Intensive Care Unit: An Integrative Review

BACKGROUND

Intensive care units are complex settings that require effective communication and collaboration among professionals in many disciplines. Rounding checklists are frequently used during interprofessional rounds and have been shown to positively affect patient outcomes.

OBJECTIVE

To identify and summarize the evidence related to the following practice question: In an adult intensive care unit, does the use of a rounding checklist during interprofessional rounds affect the perceived level of staff collaboration or communication?

METHODS

An integrative review was performed to address the practice question. No parameters were set for publication year or specific study design. Studies were included if they were set in adult intensive care units, involved the use of a structured rounding checklist, and had measured outcomes that included staff collaboration, communication, or both.

RESULTS

Seven studies with various designs were included in the review. Of the 7 studies, 6 showed that use of rounding checklists improved staff collaboration, communication, or both. These results have a variety of practice implications, including the potential for better patient outcomes and staff retention.

CONCLUSIONS

Given the complexity of the critical care setting, optimizing teamwork is essential. The evidence from this review indicates that the use of a relatively simple rounding checklist tool during interprofessional rounds can improve perceived collaboration and communication in adult intensive care units.

Synergistic strategies: Optimizing outcomes through a multidisciplinary approach to clinical rounds

Multidisciplinary rounds (MDR) constitute a patient-centered care model wherein professionals from diverse disciplines collaborate in real time to provide specialized expertise. The MDR team, encompassing care partners, hospitalists, nurses, pharmacists, and more, employs a collaborative approach that optimizes patient care through shared goals, electronic record access, regular reviews, and patient involvement. MDRs have evolved to reduce patient mortality, complications, length of stay, and readmissions, and they enhance patient satisfaction and utilization of ancillary services. Family engagement in MDRs further transforms relationships from adversarial to collaborative, leading to improved comprehension of treatment strategies and smoother navigation of challenging conversations. Despite challenges such as time constraints, limited patient coverage, and hierarchical barriers, MDRs are being increasingly conducted across healthcare settings, with positive outcomes.

Barriers and enablers for safe medication administration in adult and neonatal intensive care units mapped to the behaviour change wheel

BACKGROUND

Intensive care settings have high rates of medication administration errors. Medications are often administered by nurses and midwives using a specified process (the '5 rights'). Understanding where medication errors occur, the contributing factors and how best practice is delivered may assist in developing interventions to improve medication safety.

AIMS

To identify medication administration errors and context specific barriers and enablers for best practice in an adult and a neonatal intensive care unit. Secondary aims were to identify intervention functions (through the Behaviour Change Wheel).

STUDY DESIGN

A dual methods exploratory descriptive study was conducted (May to June 2021) in a mixed 56-bedded adult intensive care unit and a 6-bedded neonatal intensive care unit in Sydney, Australia. Incident monitoring data were examined. Direct semi-covert observational medication administration audits using the 5 rights (n = 39) were conducted. Brief interviews with patients, parents and nurses were conducted. Data were mapped to the Behaviour Change Wheel.

RESULTS

No medication administration incidents were recorded. Audits (n = 3) for the neonatal intensive care unit revealed no areas for improvement. Adult intensive care unit nurses (n = 36) performed checks for the right medication 35 times (97%) and patient identity 25 times (69%). Sixteen administrations (44%) were interrupted. Four themes were synthesized from the interview data: Trust in the nursing profession; Availability of policies and procedures; Adherence to the '5 rights' and departmental culture; and Adequate staffing. The interventional functions most likely to bring about behaviour change were environmental restructuring, enablement, restrictions, education, persuasion and modelling.

CONCLUSIONS

This study reveals insights about the medication administration practices of nurses in intensive care. Although there were areas for improvement there was widespread awareness among nurses regarding their responsibilities to safely administer medications. Interview data indicated high levels of trust among patients and parents in the nurses.

RELEVANCE TO CLINICAL PRACTICE

This novel study indicated that nurses in intensive care are aware of their responsibilities to safely administer medications. Mapping of contextual data to the Behaviour Change Wheel resulted in the identification of Intervention functions most likely to change medication administration practices in the adult intensive care setting that is environmental restructuring, enablement, restrictions, education, persuasion and modelling.

Teamwork Before and During COVID-19: The Good, the Same, and the Ugly…

OBJECTIVES

The COVID 19 pandemic placed unprecedented strain on healthcare systems and workers, likely also impacting patient safety and outcomes. This study aimed to understand how teamwork climate changed during that pandemic and how these changes affected safety culture and workforce well-being.

METHODS

This cross-sectional observational study of 50,000 healthcare workers (HCWs) in 3 large U.S. health systems used scheduled culture survey results at 2 distinct time points: before and during the first year of the COVID 19 pandemic. The SCORE survey measured 9 culture domains: teamwork climate, safety climate, leadership engagement, improvement readiness, emotional exhaustion, emotional exhaustion climate, thriving, recovery, and work-life balance.

RESULTS

Response rate before and during the pandemic was 75.45% and 74.79%, respectively. Overall, HCWs reporting favorable teamwork climate declined (45.6%-43.7%, P < 0.0001). At a facility level, 35% of facilities saw teamwork climate decline, while only 4% saw an increase in teamwork climate. Facilities with decreased teamwork climate had associated decreases in every culture domain, while facilities with improved teamwork climate maintained well-being domains and saw improvements in every other culture domain.

CONCLUSIONS

Healthcare worker teamwork norms worsened during the COVID-19 pandemic. Teamwork climate trend was closely associated with other safety culture metrics. Speaking up, resolving conflicts, and interdisciplinary coordination of care were especially predictive. Facilities sustaining these behaviors were able to maintain other workplace norms and workforce well-being metrics despite a global health crisis. Proactive team training may provide substantial benefit to team performance and HCW well-being during stressful times.

Perceptions of interdisciplinary bedside rounds by head nurses in Flanders: a cross-sectional exploration

ObjectivesInterdisciplinary bedside rounds is gaining ground as a method to improve patient centredness and involvement, quality of care and team collaboration. An exploratory study was conducted in Flemish hospitals to (1) map and (2) examine the current form of rounds and the extent to which these were bedside, patient and family participatory and interdisciplinary.MethodsIn February 2020, a quantitative cross-sectional self-reporting web-based survey was conducted in 23 hospitals in Flanders, 213 head nurses of 213 wards completed the survey. A self-reporting 19-item questionnaire was developed in Lime Survey®. The questionnaire contained a mix of closed-ended questions an open-ended questions. The data were analysed using SPSS 26.0.ResultsMost of the wards in Flanders organise a form of daily rounds at the bedside. In only half of the wards these rounds are organised at a fixed time. The rounds most often include a physician and a nurse. Other disciplines are rarely actively involved. Only a minority of wards uses checklists, structures or protocols to standardise the rounds. The majority of the wards reports that patients (and family) get sufficient time to ask questions and say they are actively stimulated to do so.ConclusionIn current practice, most rounds are (partially) bedside, open for patient and family participatory and often include only a physician and a nurse. However, these elements of interdisciplinary rounds are not yet well integrated and vary strongly amongst ward. Most rounds should be considered as an extended form of physician rounds, rather than being interdisciplinary.

Stakeholder views of the development of a clinical quality registry for interventional radiology: a qualitative study

Background

Clinical quality registries (CQRs) can likely improve quality in healthcare and research. However, studies indicate that effective use of CQRs is hindered by lack of engagement and interest among stakeholders, as well as factors related to organisational context, registry design and data quality. To fulfil the potential of CQRs, more knowledge on stakeholders’ perceptions of the factors that will facilitate or hamper the development of CQRs is essential to the more appropriate targeting of registry implementation and the subsequent use of the data. The primary aim of this study was to examine factors that can potentially affect the development of a national CQR for interventional radiology in Norway from the perspective of stakeholders. Furthermore, we wanted to identify the intervention functions likely to enable CQR development. Only one such registry, located in Sweden, has been established. To provide a broader context for the Norwegian study, we also sought to investigate experiences with the development of this registry.

Methods

A qualitative study of ten Norwegian radiologists and radiographers using focus groups was conducted, and an in-depth interview with the initiator of the Swedish registry was carried out. Questions were based on the Capability, Opportunity and Motivation for Behaviour Model and the Theoretical Domains Framework. The participants’ responses were categorised into predefined themes using a deductive process of thematic analysis.

Results

Knowledge of the rationale used in establishing a CQR, beliefs about the beneficial consequences of a registry for quality improvement and research and an opportunity to learn from a well-developed registry were perceived by the participants as factors facilitating CQR development. The study further identified a range of development barriers related to environmental and resource factors (e.g., a lack of organisational support, time) and individuallevel factors (e.g., role boundaries, resistance to change), as well as several intervention functions likely to be appropriate in targeting these barriers.

Conclusion

This study provides a deeper understanding of factors that may be involved in the behaviour of stakeholders regarding the development of a CQR. The findings may assist in designing, implementing and evaluating a methodologically rigorous CQR intervention.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07423-y.

The Effects of Interdisciplinary Bedside Rounds on Patient Centeredness, Quality of Care, and Team Collaboration: A Systematic Review

BACKGROUND

Research indicates that having multiple healthcare professions and disciplines simultaneously at the patient's bedside improves interprofessional communication and collaboration, coordination of care, and patient-centered shared decision-making. So far, no review has been conducted, which included qualitative studies, explores the feasibility of the method, and looks at differences in definitions.

OBJECTIVES

The aim of the study was to explore available evidence on the effects of interdisciplinary bedside rounds (IBRs) on patient centeredness, quality of care and team collaboration; the feasibility of IBRs; and the differences in definitions.

DATA SOURCES

PubMed, Web of Science, and Cochrane databases were systematically searched. The reference lists of included articles and gray literature were also screened. Articles in English, Dutch, and French were included. There were no exclusion criteria for publication age or study design.

STUDY APPRAISAL AND SYNTHESIS METHODS

The included (N = 33) articles were critically reviewed and assessed with the Downs and Black checklist. The selection and summarizing of the articles were performed in a 3-step procedure, in which each step was performed by 2 researchers separately with researcher triangulation afterward.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Interdisciplinary bedside round has potentially a positive influence on patient centeredness, quality of care, and team collaboration, but because of a substantial variability in definitions, design, outcomes, reporting, and a low quality of evidence, definitive results stay uncertain. Perceived barriers to use IBR are time constraints, lack of shared goals, varied responsibilities of different providers, hierarchy, and coordination challenges. Future research should primarily focus on conceptualizing IBRs, in specific the involvement of patients, before more empiric, multicentered, and longitudinal research is conducted.

Principles for Real-World Implementation of Bedside Predictive Analytics Monitoring

A new development in the practice of medicine is Artificial Intelligence-based predictive analytics that forewarn clinicians of future deterioration of their patients. This proactive opportunity, though, is different from the reactive stance that clinicians traditionally take. Implementing these tools requires new ideas about how to educate clinician users to facilitate trust and adoption and to promote sustained use. Our real-world hospital experience implementing a predictive analytics monitoring system that uses electronic health record and continuous monitoring data has taught us principles that we believe to be applicable to the implementation of other such analytics systems within the health care environment. These principles are mentioned below:• To promote trust, the science must be understandable.• To enhance uptake, the workflow should not be impacted greatly.• To maximize buy-in, engagement at all levels is important.• To ensure relevance, the education must be tailored to the clinical role and hospital culture.• To lead to clinical action, the information must integrate into clinical care.• To promote sustainability, there should be periodic support interactions after formal implementation.

Intensive care unit rounding checklists to reduce catheter-associated urinary tract infections

OBJECTIVE

To assess whether the implementation of an intensive care unit (ICU) rounding checklist reduces the number of catheter-associated urinary tract infections (CAUTIs).

DESIGN

Retrospective before-and-after study that took place between March 2013 and February 2017.

SETTING

An academic community hospital 16-bed, mixed surgical, cardiac, medical ICU.

PATIENTS

Participants were all patients admitted to the adult mixed ICU and had a diagnosis of CAUTI.

INTERVENTION

Initiation of an ICU rounding checklist that prompts physicians to address any use of urinary catheters with analysis comparing the preintervention period before roll out of the rounding checklist versus the postintervention periods.

RESULTS

There were 19 CAUTIs and 9,288 urinary catheter days (2.04 CAUTIs per 1,000 catheter days). The catheter utilization ratio increased in the first year after the intervention (0.67 vs 0.60; P = .0079), then decreased in the second year after the intervention (0.53 vs 0.60; P = .0992) and in the third year after the intervention (0.53 vs 0.60; P = .0224). The rate of CAUTI (ie, CAUTI per 1,000 urinary catheter days) decreased from 4.62 before the checklist was implemented to 2.12 in the first year after the intervention (P = .2104). The CAUTI rate was 0.45 in the second year (P = .0275) and 0.96 in the third year (P = .0532).

CONCLUSIONS

Our study suggests that utilization of a daily rounding checklist is associated with a decrease in the rates of CAUTI in ICU patients. Incorporating a rounding checklist is feasible in the ICU.

Teamwork Among Medicine House Staff During Work Rounds: Development of a Direct Observation Tool

OBJECTIVE

Teamwork is integral to effective health care but difficult to evaluate. Few tools have been tested outside of classroom or medical simulation settings. Accordingly, we aimed to develop and pilot test an easy-to-use direct observation instrument for measuring teamwork among medical house staff.

METHODS

We performed direct observations of 18 inpatient medicine house staff teams at a teaching hospital using an instrument constructed from existing teamwork tools, expert panel review, and pilot testing. We examined differences across teams using the Kruskal-Wallis statistic. We examined interrater reliability with the κ statistic, domain scales using Cronbach α, and construct validity using correlation and multivariable regression analyses of quality and utilization metrics. Observers rated team performance before and after providing feedback to 12 of the 18 team leaders and assessed changes in team performance using paired two-tailed t tests.

RESULTS

We found variation in team performance in the situation monitoring, mutual support, and communication domains. The instrument evidenced good interrater reliability among concurrent, independent observers (κ = 0.7, P < 0.001). It had satisfactory face validity based on expert panel review and the assessments of resident team leaders. Construct validity was supported by a positive correlation between team performance and the Hospital Consumer Assessment of Healthcare Providers and Systems physician communication score (r = 0.6, P = 0.03). Providing resident physicians with information about their teams' performance was associated with improved mean performance in follow-up observations (3.6-3.8/4.0, P = 0.001).

CONCLUSIONS

Direct observation of teamwork behaviors by medicine house staff on ward rounds is feasible and feedback may improve performance.

Reducing Caesarean Section Surgical Site Infection (SSI) by 50%: A Collaborative Approach

OBJECTIVE

Caesarean section surgical site infection (SSI) is a surgical wound site infection occurring within 30 days of surgery with a reported incidence of 3-15%. This quality improvement (QI) project aimed to reduce caesarean section SSI by 50% in a tertiary maternity center.

METHODS

Using multidisciplinary team approach, the project was designed with evidence-based interventions. The Royal College of Physicians of Ireland/Royal College of Surgeons in Ireland "Preventing Surgical Site Infections Key Recommendations for Practice" guideline was used as standard perioperative care. A care bundle was designed targeting preoperative personal patient preparation, preoperative prophylactic antibiotics, and strict skin preparation technique, all measured using a patient survey. The rate of SSI was followed for 14 months. The Model for Improvement methodology was used to implement change.

RESULTS

Surgical site infection rate decreased from 6.7% (n = 684 caesarean sections, n = 46 SSI) to 3.45% (n = 3,206 caesarean sections, n = 110 SSI), p = .0006. Reduction occurred in both elective (4.4%-2.7%) and emergency (9.1%-4.1%) caesarean section groups. There was excellent adherence to all three elements of the care bundle. The 50% reduction in caesarean section SSI was sustained over the 14-month period, significantly reducing maternal morbidity.

CONCLUSIONS

The success of this QI project is attributable to frontline ownership and empowerment of patients and staff.

Bundle approach used to achieve zero central line-associated bloodstream infections in an adult coronary intensive care unit

Background

Central venous catheterisation is commonly used in critical patients in intensive care units (ICU). It may cause complications and attribute to increase mortality and morbidity. At coronary ICU (CICU) of cardiac hospital, central line-associated bloodstream infection (CLABSI) rate was 2.82/1000 central line days in 2015 and 3.11/1000 central line days in 2016. Working in collaboration with Institute for Healthcare Improvement (IHI), we implemented evidence-based practices in the form of bundles in with the aim of eliminating CLABSI in CICU.

Methods

In collaboration with IHI, we worked on this initiative as multidisciplinary team and tested several changes. CLABSI prevention bundles were tested and implemented, single kit for line insertion, simulation-based training for line insertions, standardised and real-time bundle monitoring by direct observations are key interventions tested. We used model for improvement and changes were tested using small Plan-Do-Study-Act cycles. Surveillance methods and CLABSI definition used according to National Healthcare Safety Network.

Results

The CLABSI rate per 1000 patient-days dropped from 3.1 per 1000 device-days to 0.4 per 1000 device-days. We achieved 757 days free of CLABSI in the unit till December 2018 when a single case happened. After that we achieved 602 free days till July 2020 and still counting.

Conclusions

Implementation of evidence-based CLABSI prevention bundle and process monitoring by direct observation led to significant and subsequently sustained improvement in reducing CLABSI rate in adult CICU.

Quality improvement initiative to improve pulmonary function in pediatric cystic fibrosis patients

BACKGROUND

Our Cystic Fibrosis (CF) Center initiated a Quality Improvement (QI) project in November 2017 with the goal of improving our patients' forced expiratory volume in 1 second (FEV1) percent predicted (pp) and continued for 1 year. Our specific aim was to increase the relative mean FEV1 pp by 5% in 12 months for CF patients 6 to 21 years old with FEV1 ≤ 80 pp.

METHODS

We identified patients with FEV1 ≤ 80 pp, developed cause and effect diagrams (fishbones) to identify contributing factors to FEV1 ≤ 80 pp, and created flowcharts to address barriers. The barriers to adherence that may result in FEV1 ≤ 80 pp were studied using a fishbone. A standardized approach across providers was implemented to individualize care for each patient. Each discipline developed a flowchart to address barriers to improving FEV1.

RESULTS

Forty patients were identified (43% male). Their mean age was 16.8 years (range 8.2-21.5 years). Mean FEV1 pp at baseline was 58.6 (range 30-80). The fishbone identified needs for continuing education for patients/families, and providing a treatment plan at each clinic visit. After 6 months of implementation, patients had an improvement in mean FEV1 pp by 6.4% (CI, 0.4%-12.9%). At 12 months, mean FEV1 pp had improved by 14% (CI, 6.5%-21.4%), which exceeded our goal of 5%.

CONCLUSION

Through this ongoing project, team members, patients, and families partnered to improve lung function in pediatric CF patients. Flowcharts facilitated a standardized approach across providers to develop individualized treatment plans for patients, which resulted in improved lung function.

Does preventive care bundle have an impact on surgical site infections following spine surgery? An analysis of 9607 patients

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

The purpose was to analyze the effect of care bundle protocol on SSI in our institution. Postoperative surgical site infections (SSI) pose significant health burden. In spite of the use of prophylactic antibiotics, surgical advances and postoperative care, wound infection continues to affect patient outcomes after spine surgery.

METHODS

Retrospective analysis of 9607 consecutive patients who underwent spine procedures from 2014 to 2018 was performed. Preventive care bundle was implemented from January 2017 consisting of (a) preoperative bundle-glycemic control, chlorhexidine gluconate (CHG) bath, (b) intra-operative bundle-time specified antibiotic prophylaxis, CHG+ alcohol-based skin preparation (c) postoperative bundle-five moments of hand hygiene, early mobilization and bundle auditing. Patients operated from January 2017 were included in the post-implementation cohort and prior to that the pre-implementation cohort was formed. Data were drawn from weekly and yearly spine audits from the hospital infection committee software. Infection data were collected based on CDC criteria, further sub classification was done based on procedure, spinal disorders and spine level. Variables were analyzed and level of significance was set as < 0.05.

RESULTS

A total of 7333 patients met the criteria. The overall SSI rate decreased from 3.42% (131/3829) in pre-implementation cohort to 1.22% (43/3504, p = 0.0001) in post-implementation cohort (RR = 2.73, OR = 2.79). Statistically significant reduction was seen in all the groups (a) superficial and deep, (b) early and late and (c) instrumented and uninstrumented groups but was more pronounced in early (p = 0.0001), superficial (p = 0.0001) and instrumented groups (p = 0.0001). On subgroup analysis based on spine level and spinal disorders, significant reduction was seen in lumbar (p = 0.0001) and degenerative group (p = 0.0001).

CONCLUSIONS

Our study revealed significant reduction of SSI secondary to strict bundle adherence and monitored compliance compared to patients who did not receive these interventions.

LEVEL OF EVIDENCE

III.

Impact of an evidence-based intervention on urinary catheter utilization, associated process indicators, and infectious and non-infectious outcomes

BACKGROUND

Multi-centre intervention studies tackling urinary catheterization and its infectious and non-infectious complications are lacking.

AIM

To decrease urinary catheterization and, consequently, catheter-associated urinary tract infections (CAUTIs) and non-infectious complications.

METHODS

Before/after non-randomized multi-centre intervention study in seven hospitals in Switzerland. Intervention bundle consisting of: (1) a concise list of indications for urinary catheterization; (2) daily evaluation of the need for ongoing catheterization; and (3) education on proper insertion and maintenance of urinary catheters. The primary outcome was urinary catheter utilization. Secondary outcomes were CAUTIs, non-infectious complications and process indicators (proportion of indicated catheters and frequency of catheter evaluation).

FINDINGS

In total, 25,880 patients were included in this study [13,171 at baseline (August-October 2016) and 12,709 post intervention (August-October 2017)]. Catheter utilization decreased from 23.7% to 21.0% (P=0.001), and catheter-days per 100 patient-days decreased from 17.4 to 13.5 (P=0.167). CAUTIs remained stable at a low level with 0.02 infections per 100 patient-days (baseline) and 0.02 infections (post intervention) (P=0.98). Measuring infections per 1000 catheter-days, the rate was 1.02 (baseline) and 1.33 (post intervention) (P=0.60). Non-infectious complications decreased significantly, from 0.79 to 0.56 events per 100 patient-days (P<0.001), and from 39.4 to 35.4 events per 1000 catheter-days (P=0.23). Indicated catheters increased from 74.5% to 90.0% (P<0.001). Re-evaluations increased from 168 to 624 per 1000 catheter-days (P<0.001).

CONCLUSION

A straightforward bundle of three evidence-based measures reduced catheter utilization and non-infectious complications, whereas the proportion of indicated urinary catheters and daily evaluations increased. The CAUTI rate remained unchanged, albeit at a very low level.

Promoting the Quality of Ventilator-Associated Pneumonia Control in Intensive Care Units: an Action Research

BACKGROUND

Ventilator-associated pneumonia (VAP) is the most common infection in intensive care units (ICUs), with the highest mortality rate of all hospital-acquired infections. This study aimed to improve the quality of VAP control in the ICU of a university-affiliated teaching hospital in Kouhdasht, Iran.

MATERIALS AND METHODS

This action research was conducted during 2016-2018. The survey data of 18 participants, who were included in the study using the non-probability sampling method, were evaluated. Qualitative data were analyzed using Graneheim and Lundman's qualitative content analysis, and descriptive indices and t-test were measured to analyze quantitative data. Finally, the qualitative and quantitative data were integrated.This research was developed and implemented in four stages, including assessment and identification of priorities for improvement, design of action plans, implementation of action plans, and reassessment. Data were collected by analyzing 540 performance observations, 55 interviews, six focused group discussions, and two steering group discussions.

RESULTS

The mean scores of VAP control before and after implementing the action plans were 259.33±21.64 and 395.16±13.90, respectively (P<0.001). The qualitative findings indicated that the low quality of the personnel's working life and poor organizational culture were the main barriers to the quality improvement of VAP control. Improvement was achieved after implementing the action plans for enhancing the nurses' quality of working life and realization of their professional identity.

CONCLUSION

The results of this study suggested that effective approaches, such as personnel empowerment, improvement of environmental conditions, and provision of facilities and equipment can improve the quality of VAP control in ICUs.

The impact of antimicrobial stewardship program implementation at four tertiary private hospitals: results of a five-years pre-post analysis

Background

Antimicrobial stewardship (AMS) programs have shown to reduce the emergence of antimicrobial resistance (AMR) and health-care-associated infections (HAIs), and save health-care costs associated with an inappropriate antimicrobial use. The primary objective of this study was to compare the consumption and cost of antimicrobial agents using defined daily dose (DDD) and direct cost of antibiotics before and after the AMS program implementation. Secondary objective was to determine the rate of HAIs [Clostridium difficile (C. difficile), ventilator-associated pneumonia (VAP), and central line-associated bloodstream infection (CLABSI) before and after the AMS program implementation.

Methods

This is a pre-post quasi-experimental study. Adult inpatients were enrolled in a prospective fashion under the active AMS arm and compared with historical inpatients who were admitted to the same units before the AMS implementation. Study was conducted at four tertiary private hospitals located in two cities in Saudi Arabia. Adult inpatients were enrolled under the pre- AMS arm and post- AMS arm if they were on any of the ten selected restricted broad-spectrum antibiotics (imipenem/cilastatin, piperacillin/tazobactam, colistin, tigecycline, cefepime, meropenem, ciprofloxacin, moxifloxacin, teicoplanin and linezolid).

Results

A total of 409,403 subjects were recruited, 79,369 in the pre- AMS control and 330,034 in the post- AMS arm. Average DDDs consumption of all targeted broad-spectrum antimicrobials from January 2016 to June 2019 post- AMS launch was lower than the DDDs use of these agents pre- AMS (233 vs 320 DDDs per 1000 patient-days, p = 0.689). Antimicrobial expenditures decreased by 28.45% in the first year of the program and remained relatively stable in subsequent years, with overall cumulative cost savings estimated at S.R. 6,286,929 and negligible expenses of S.R. 505,115 (p = 0.648). Rates of healthcare associated infections involving C. difficile, VAP, and CLABSI all decreased significantly after AMS implementation (incidence of HAIs in 2015 compared to 2019: for C. difficile, 94 vs 13, p = 0.024; for VAP, 24 vs 6, p = 0.001; for CLABSI, 17 vs 1, p = 0.000; respectively).

Conclusion

Implementation of AMS program at HMG healthcare facilities resulted in reduced antimicrobials use and cost, and lowered incidence of healthcare associated infections.

'Adiós Bacteriemias': a multi-country quality improvement collaborative project to reduce the incidence of CLABSI in Latin American ICUs

QUALITY PROBLEM

The incidence of central line-associated bloodstream infections (CLABSI) in Latin America has been estimated at 4.9 episodes per 1000 central line (CL) days, compared to a pooled incidence of 0.9 in the United States. CLABSI usually result from not adhering to standardized health procedures and can be prevented using evidence-based practices.

INITIAL ASSESSMENT

The first phase of the 'Adiós Bacteriemias' Collaborative was implemented in 39 intensive care units (ICUs) from Latin America from September 2012 to September 2013 with a 56% overall reduction in the incidence of CLABSI.

CHOICE OF SOLUTION

Bundles of care for the processes of insertion and maintenance of CLs have proven to be effective in the reduction of CLABSI across different settings.

IMPLEMENTATION

Building on the results of the first phase, we implemented a second phase of the 'Adiós Bacteriemias' Collaborative between June 2014-July 2015. We adapted the Breakthrough Series (BTS) Collaborative model to guide the adoption of bundles of care for CLABSI prevention through virtual learning sessions and continuous feedback.

EVALUATION

Eighty-three ICUs from five Latin American countries actively reported process and outcome measures. The overall reduction in the CLABSI incidence rate was 22% (incidence rate 0.78; 95% CI 0.65, 0.95), from 2.58 episodes per 1000 CL days at baseline to 2.02 episodes per 1000 CL days (P < 0.01) during the intervention period.

LESSONS LEARNED

Adiós Bacteriemias was effective in reducing the incidence of CLABSI and improving the adherence to good practices for CL insertion and maintenance processes in participating ICUs in Latin America.

A Model for Promoting Occupational Safety and Health in Taiwan's Hospitals: An Integrative Approach

Advocating for improving workplace safety and health has gained substantial support in recent years. The medical industry is a high-risk industry and receives considerable public attention. This study used an integrative approach as a starting point and combined the contextual factors of an organization: perceived organizational support, safety climate, social influence, and shared decision making. Subsequently, the effects of these factors on preventive action and safety satisfaction were investigated. This study surveyed employees of two hospitals, one in Northern Taiwan and one in Eastern Taiwan, collecting valid data from 468 respondents. Structural equation modeling (SEM) was used to verify our research framework. The finding indicates that (1) All hypotheses proposed in this study were supported. (2) The overall goodness of fit of the model was excellent, and the explained variance of the outcome variables was high. (3) Safety climate had the strongest total effects on preventive action and safety satisfaction simultaneously, whereas preventive action had the strongest direct effect on safety satisfaction. The objective of this study was to obtain empirical conclusions and make suggestions for academic theory and clinical practice. The findings may serve as a reference for future research and for scholars and practitioners, enabling the creation of healthy workplaces and, thus, a brighter future.

Improving decision making in acute healthcare through implementation of an intensive care unit (ICU) intervention in Australia: a multimethod study

OBJECTIVE

To evaluate the implementation of an intensive care unit (ICU) intervention designed to establish rules for making ICU decisions about postsurgery beds.

DESIGN

Preintervention/postintervention case study using a multimethod approach, involving two phases of staff interviews, process mapping and collection of administrative data.

SETTING

ICU in a 700-bed regional tertiary care hospital in Australia.

PARTICIPANTS

31 interview participants. Phases 1 and 2 participants drawn from three groups of staff: bedside nursing staff in the ICU, ICU specialist doctors and senior management staff involved in oversight of ICU operations. Phase 2 included an additional participant group: staff from surgery and emergency departments.

INTERVENTION

Implementation of an ICU escalation plan and introduction of a multidisciplinary morning meeting to determine ICU bed status in accordance with the plan.

MAIN OUTCOME MEASURES

Interview data consisted of preintervention staff perceptions of ICU workplace cohesiveness with bed pressure, and postintervention staff perceptions of the escalation plan and ICU performance. Administrative data consisted of bed status (red, amber or green), monthly number of planned elective surgeries requiring an ICU bed and monthly number of elective surgeries cancelled due to unavailability of ICU beds.

RESULTS

Improved internal communication, decision making and cohesion within the ICU and better coordination between ICU and other hospital departments. Significant reduction in elective surgeries cancelled due to unavailability of ICU beds, χ²₁=24.9, p<0.0001.

CONCLUSIONS

By establishing rules for decision making around ICU bed allocation, the intervention improved internal professional relationships within the ICU as well as between the ICU and external departments and reduced the number of elective surgeries cancelled.

Is Lean sustainable in today's NHS hospitals? A systematic literature review using the meta-narrative and integrative methods

Purpose

Methodological variance and quality, heterogeneity of value and divergent approaches are reasons for the varied results of Lean interventions in healthcare despite ongoing global popularity. However, there is piecemeal evidence addressing the sustainability of initiatives-the aim of this review is to use an integrative approach to consider Lean's sustainability and the quality of available evidence in today's National Health Service (NHS).

Data sources

A literature review of AMED, CINAHL, Cochrane, JBI, SCOPUS, DelphiS, MEDLINE, EMBASE, MIDIRS, Web of Science and PsycINFO electronic databases was conducted.

Study selection

Peer-reviewed studies in NHS hospitals/trusts that concerned undiluted, service-wide Lean adoption and contained quantitative data were included. Reference lists were consulted for evidence via a snowball approach. Methodological quality was assessed using an adapted critical appraisal tool.

Data extraction

Research design, method of intervention, outcome measures and sustainability were extracted.

Results of data synthesis

Electronic searches identified 12 studies eligible for inclusion. This comprised of five quasi-experimental designs (one mixed-method), three multi-site analyses, one action research, one failure mode and effects analysis, one content analysis of annual reports and one systematic review. Six articles considered sustainability with two of these providing measured successes. Despite diverse and positive outcomes studies lacked scientific rigour, failed to consider confounding issues, were at risk of positive bias and did not demonstrate sustainability with any statistical significance.

Conclusion

Lean has ostensible value but it is difficult to draw a conclusion on efficacy or sustainability. Higher quality scientific research into Lean and the effect of staffing cultures on initiatives are needed to ascertain the extent that Lean can affect healthcare quality and subsequently be sustained.

Improving hand hygiene compliance with patient zone demarcation: More than just lines on the floor

Background

Hand hygiene compliance can be difficult to improve as this prospective activity may not come to mind easily during busy clinical operations. Clinicians are often driven by clinical goals under time pressure, and the sudden recall to clean hands can either be disruptive or too late. Using patient zones as a reference has been known to be helpful. A low-tech solution of taping patient zones on the floor was introduced in a children’s intensive care unit. Coupled with this demarcation is a simplified protocol that uses patient zones for “just-in-time” reminders. Clinicians now clean their hands whenever they cross zone lines, namely “ before patient zone” and “ after patient zone”, along with “ before aseptic procedure” and “ after bodily fluids exposure”.

Methods

The mandatory national quarterly hand hygiene surveillance data for children’s intensive care unit and the entire hospital was tracked. Seven pre-intervention and seven post-intervention quarters were compared for improvement and sustainability.

Results

Overall, children’s intensive care unit hand hygiene compliance rose from an average of 77% to 90%, as well as physicians' hand hygiene compliance rates from 72% to 86%, and these differences are statistically significant. Hand Hygiene Moment 1 as defined by World Health Organization benefited the most from this intervention.

Discussion

Patient zone demarcation, along with more intuitive hand hygiene guidelines, is a cost-effective, operationally sensitive intervention that can improve hand hygiene compliance. The bundled solution taps on human factors science in understanding the cognitive challenges faced by clinicians. The positive effects are most profound in multi-bed cubicles where patient zones and infection control barriers are not clearly visible.

"The multimodal approach for ventilator-associated pneumonia prevention"-requirements for nationwide implementation

The multimodal approach for ventilator-associated pneumonia (VAP) prevention has been shown to be a successful strategy in reducing VAP rates in many intensive care units (ICU) in some countries. The simultaneous application of several measures or "bundles" to reduce VAP rates has achieved a higher impact than the progressive implementation of the individual interventions. The ultimate objective of recommendation bundles is their integration in the culture of routine healthcare of the staff in charge of ventilated patients for accomplished rates to persist over time. The noteworthy elements of this new strategy include the selection of the individual recommendations of the bundle, education of care workers (HCW) in the culture of patient safety, audit of compliance with the recommendations, commitment of the hospital management to support implementation, nomination and empowerment of local leaders of the projects in ICUs, both physicians and nurses, and the continuous collection of VAP episodes. The implementation of this new strategy is not an easy task, as both its inherent strength and important barriers to its application have become evident, which need to be overcome for maximal reduction of VAP rates.

Adverse Events in Hospitalized Pediatric Patients

: media-1vid110.1542/5789657761001PEDS-VA_2017-3360Video Abstract BACKGROUND: Patient safety concerns over the past 2 decades have prompted widespread efforts to reduce adverse events (AEs). It is unclear whether these efforts have resulted in reductions in hospital-wide AE rates. We used a validated safety surveillance tool, the Global Assessment of Pediatric Patient Safety, to measure temporal trends (2007-2012) in AE rates among hospitalized children.

METHODS

We conducted a retrospective surveillance study of randomly selected pediatric inpatient records from 16 teaching and nonteaching hospitals. We constructed Poisson regression models with hospital random intercepts, controlling for patient age, sex, insurance, and chronic conditions, to estimate changes in AE rates over time.

RESULTS

Examining 3790 records, reviewers identified 414 AEs (19.1 AEs per 1000 patient days; 95% confidence interval [CI] 17.2-20.9) and 210 preventable AEs (9.5 AEs per 1000 patient days; 95% CI 8.2-10.8). On average, teaching hospitals had higher AE rates than nonteaching hospitals (26.2 [95% CI 23.7-29.0] vs 5.1 [95% CI 3.7-7.1] AEs per 1000 patient days, P < .001). Chronically ill children had higher AE rates than patients without chronic conditions (33.9 [95% CI 24.5-47.0] vs 14.0 [95% CI 11.8-16.5] AEs per 1000 patient days, P < .001). Multivariate analyses revealed no significant changes in AE rates over time. When stratified by hospital type, neither teaching nor nonteaching hospitals experienced significant temporal AE rate variations.

CONCLUSIONS

AE rates in pediatric inpatients are high and did not improve from 2007 to 2012. Pediatric AE rates were substantially higher in teaching hospitals as well as in patients with more chronic conditions.

Redesigning Rounds in the ICU: Standardizing Key Elements Improves Interdisciplinary Communication

BACKGROUND

Daily multidisciplinary rounds (MDR) in the ICU represent a mechanism by which health care professionals from different disciplines and specialties can meet to synthesize data, think collectively, and form complete patient care plans. It was hypothesized that providing a standardized, structured approach to the daily rounds process would improve communication and collaboration in seven distinct ICUs in a single academic medical center.

METHODS

Lean-inspired methodology and information provided by frontline staff regarding inefficiencies and barriers to optimal team functioning were used in designing a toolkit for standardization of rounds in the ICUs. Staff perceptions about communication were measured, and direct observations of rounds were conducted before and after implementation of the intervention.

RESULTS

After implementation of the intervention, nurse participation during presentation of patient data increased from 17/47 (36.2%) to 56/78 (71.8%) (p < 0.0002) in the surgical ICUs and from 8/23 (34.8%) to 107/107 (100%) (p <0.0001) in the medical ICUs. Nurse participation during generation of the daily plan increased in the surgical ICUs from 24/47 (51.1%) to 63/78 (80.8%) (p = 0.0005) and from 7/23 (30.4%) to 106/107 (99.1%) (p < 0.0001) in the medical ICUs. Miscommunications and errors were corrected in nearly half of the rounding episodes observed.

CONCLUSION

This study demonstrated that the implementation of a simple toolkit that can be incorporated into existing work flow and rounding culture in several different types of ICUs can result in improvements in engagement of nursing staff and in overall communication.

Measuring Medical Housestaff Teamwork Performance Using Multiple Direct Observation Instruments: Comparing Apples and Apples

PURPOSE

To examine the composition and concordance of existing instruments used to assess medical teams' performance.

METHOD

A trained observer joined 20 internal medicine housestaff teams for morning work rounds at Tufts Medical Center, a 415-bed Boston teaching hospital, from October through December 2015. The observer rated each team's performance using nine teamwork observation instruments that examined domains including team structure, leadership, situation monitoring, mutual support, and communication. Observations recorded on paper forms were stored electronically. Scores were normalized from 1 (low) to 5 (high) to account for different rating scales. Overall mean scores were calculated and graphed; weighted scores adjusted for the number of items in each teamwork domain. Teamwork scores were analyzed using t tests, pairwise correlations, and the Kruskal-Wallis statistic, and team performance was compared across instruments by domain.

RESULTS

The nine tools incorporated five major domains, with 5 to 35 items per instrument, for a total of 161 items per observation session. In weighted and unweighted analyses, the overall teamwork performance score for a given team on a given day varied by instrument. While all of the tools identified the same low outlier, high performers on some instruments were low performers on others. Inconsistent scores for a given team across instruments persisted in domain-level analyses.

CONCLUSIONS

There was substantial variation in the rating of individual teams assessed concurrently by a single observer using multiple instruments. Because existing teamwork observation tools do not yield concordant assessments, researchers should create better tools for measuring teamwork performance.

Rethinking Clinical Workflow

The concept of clinical workflow borrows from management and leadership principles outside of medicine. The only way to rethink clinical workflow is to understand the neuroscience principles that underlie attention and vigilance. With any implementation to improve practice, there are human factors that can promote or impede progress. Modulating the environment and working as a team to take care of patients is paramount. Clinicians must continually rethink clinical workflow, evaluate progress, and understand that other industries have something to offer. Then, novel approaches can be implemented to take the best care of patients.

Review of Strategies to Reduce Central Line-Associated Bloodstream Infection (CLABSI) and Catheter-Associated Urinary Tract Infection (CAUTI) in Adult ICUs

Central line-associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) are costly and morbid. Despite evidence-based guidelines, Some intensive care units (ICUs) continue to have elevated infection rates. In October 2015, we performed a systematic search of the peer-reviewed literature within the PubMed and Cochrane databases for interventions to reduce CLABSI and/or CAUTI in adult ICUs and synthesized findings using a narrative review process. The interventions were categorized using a conceptual model, with stages applicable to both CAUTI and CLABSI prevention: (stage 0) avoid catheter if possible, (stage 1) ensure aseptic placement, (stage 2) maintain awareness and proper care of catheters in place, and (stage 3) promptly remove unnecessary catheters. We also looked for effective components that the 5 most successful (by reduction in infection rates) studies of each infection shared. Interventions that addressed multiple stages within the conceptual model were common in these successful studies. Assuring compliance with infection prevention efforts via auditing and timely feedback were also common. Hospitalists with patient safety interests may find this review informative for formulating quality improvement interventions to reduce these infections.

Roles, processes, and outcomes of interprofessional shared decision-making in a neonatal intensive care unit: A qualitative study

Shared decision-making provides an opportunity for the knowledge and skills of care providers to synergistically influence patient care. Little is known about interprofessional shared decision-making processes in critical care settings. The aim of this study was to explore interprofessional team members' perspectives about the nature of interprofessional shared decision-making in a neonatal intensive care unit (NICU) and to determine if there are any differences in perspectives across professional groups. An exploratory qualitative approach was used consisting of semi-structured interviews with 22 members of an interprofessional team working in a tertiary care NICU in Canada. Participants identified four key roles involved in interprofessional shared decision-making: leader, clinical experts, parents, and synthesizer. Participants perceived that interprofessional shared decision-making happens through collaboration, sharing, and weighing the options, the evidence and the credibility of opinions put forward. The process of interprofessional shared decision-making leads to a well-informed decision and participants feeling valued. Findings from this study identified key concepts of interprofessional shared decision-making, increased awareness of differing professional perspectives about this process of shared decision-making, and clarified understanding of the different roles involved in the decision-making process in an NICU.

Patients' involvement in improvement initiatives: a qualitative systematic review

BACKGROUND

Over the last 20 years, quality improvement in health has become an important strategy in health services in many countries. With the emphasis on quality health care, there has been a shift in social paradigms towards including service users in their own health on different levels. There is growing evidence in literature on the positive impact on health outcomes where patients are active participants in their personal care. There is however less information available on the broader influence of users on improvement in systems.

OBJECTIVES

The objective of this review was to identify the barriers and enablers to patients being involved in quality improvement efforts directed towards their own health care.

INCLUSION CRITERIA

This review considered studies that included adults and children of any age experiencing any health problem.The review considered studies that explored patient or user participation in quality improvement and the factors enabling and hindering this processThe qualitative component of this review considered studies that focused on qualitative data, including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research and feminist research. Other texts such as opinion papers and reports were also considered.

SEARCH STRATEGY

The search strategy aimed to find both published and unpublished studies. A three-step search strategy was utilized in this review. The searches using all identified keywords and index terms included the databases PubMed, PsycINFO, Medline, Scopus, EBSCOhost and CINAHL.Qualitative, text and opinion papers were considered for inclusion in this review.Closely related concepts like community involvement, family involvement, patients' involvement in their own care (for example, in the case of shared decision making), and patient centeredness in the context of a consultation were excluded.

METHODOLOGICAL QUALITY

Qualitative and textual papers selected for retrieval were assessed by two independent reviewers for authenticity prior to inclusion in the review using the standardized critical appraisal instruments from the Joanna Briggs Institute.

DATA EXTRACTION

Qualitative and textual data were extracted from papers included in the review using the standardized data extraction tool from the Joanna Briggs Institute.

DATA SYNTHESIS

The above findings were pooled and through the identification of categories, a final meta-synthesis was formulated.

RESULTS

Two synthesized findings were created from the included papers. Firstly, there are barriers to patients' participation in quality improvement in health and in spite of policy support for user involvement in quality improvement, it is a difficult strategy to implement. The second synthesized finding was that there are enablers to patients' involvement in quality improvement: when patients are involved in quality improvement efforts in health care, there are innovative, often unexpected, outcomes at different levels of the process, and sustaining these efforts is possible with ongoing individual or group support.Five categories which supported the synthesized findings were created through the meta-aggregative process.

CONCLUSIONS

There are enablers and barriers to involving patients in quality improvement in health care that need to be considered when planning such interventions.Relationships and roles will need to be very clear from the outset. A developmental approach needs to be considered where support and training is part of the project. Where patients are truly engaged in service improvement, unexpected innovation occurs.There are many more reports and opinion papers published regarding this topic than there are rigorous research studies. This leaves the field open to the development of good methodological studies related to quality improvement and in particular to the participation of patients.

Impact of Empowering Leadership on Antimicrobial Stewardship: A Single Center Study in a Neonatal and Pediatric Intensive Care Unit and a Literature Review

Background: Antimicrobial stewardship (AMS) is an important strategy of quality improvement for every hospital. Leadership is an important factor for implementation of quality improvement and AMS programs. Recent publications show successful AMS programs in children's hospitals, but successful implementation is often difficult to achieve and literature of AMS in neonatal and pediatric intensive care units (NICU/PICU) is scarce. Lack of resources and prescriber opposition are reported barriers. A leadership style focusing on empowering frontline staff to take responsibility is one approach to implement changes in health care institutions. Aim: Literature review regarding empowering leadership and AMS in health care and assessment of the impact of such a leadership style on AMS in a NICU/PICU over 3 years. Methods: Assessment of the impact of a leadership change September 1, 2015 from control-driven to an empowering leadership style on antibiotic use and hospital acquired infections. Prospective analysis and annual comparison of antibiotic use, rate of suspected and confirmed ventilator-associated pneumonia (VAP) and central-line associated blood stream infection (CLABSI) including antibiotic use overall, antibiotic therapy for culture-negative and culture-proven infections including correct initial choice and streamlining of antibiotics in the NICU/PICU of the Children's Hospital of Lucerne between January 1, 2015 and December 31, 2017. Results: Five articles were included in the literature review. All five studies concluded that an empowering leadership style may lead to a higher engagement of physicians. Three out of five studies reported improved AMS as reduced rate in hospital-acquired infections and improved prevention of MRSA infections. From 2015 to 2017, antibiotic days overall and antibiotic days for culture-negative situations (suspected infections and prophylaxis) per 1000 patient days declined significantly from 474.1 to 403.9 and from 418.2 to 309.4 days, respectively. Similar, the use of meropenem and vancomycin declined significantly. Over the 3 years, suspected and proven VAP- and CLABSI-episodes decreased with no confirmed episodes in 2017. Conclusion: An empowering leadership style which focuses on enabling frontline physicians to take direct responsibilities for their patients may be a successful strategy of antimicrobial stewardship allowing to overcome reported barriers of AMS implementation.

Epidemiology of device-associated infections in an intensive care unit of a teaching hospital in Nepal: A prospective surveillance study from a developing country

BACKGROUND

Device-associated health care-acquired infections (DA-HAIs) in intensive care unit patients are a major cause of morbidity, mortality, and increased health care costs.

METHODS

A prospective, structured clinicomicrobiological surveillance was carried out for 3 common DA-HAIs: ventilator-associated pneumonia (VAP), central line-associated bloodstream infection (CLABSI), and catheter-associated urinary tract infection (CAUTI) present in the patients of an intensive care unit of a teaching hospital in Nepal. DA-HAIs were identified using the Centers for Disease Control and Prevention definitions, and their rates were expressed as number of DA-HAIs per 1,000 device-days.

RESULTS

Overall incidence rate of DA-HAIs was 27.3 per 1,000 patient-days occurring in 37.1% of patients. The device utilization ratio for mechanical ventilation, central line catheter, and urinary catheter was 0.83, 0.63, and 0.78, respectively. The rates of VAP, CLABSI, and CAUTI were 21.40, 8.64, and 5.11 per 1,000 device-days, respectively. Acinetobacter spp (32.7%), Klebsiella spp (23.6%), Burkholderia cepacia complex (12.7%), and Escherichia coli (10.9%) were the common bacterial pathogens. Most of the bacterial isolates associated with DA-HAIs were found to be multidrug-resistant.

CONCLUSIONS

Incidence of DA-HAIs in the study intensive care unit was high compared with that of developed countries. Formulation and implementation of standard infection control protocols, active surveillance of DA-HAIs, and antimicrobial stewardship are urgently needed in our country.

Recent Time Trends and Predictors of Heart Dose From Breast Radiation Therapy in a Large Quality Consortium of Radiation Oncology Practices

PURPOSE

Limited data exist regarding the range of heart doses received in routine practice with radiation therapy (RT) for breast cancer in the United States today and the potential effect of the continual assessment of the cardiac dose on practice patterns.

METHODS AND MATERIALS

From 2012 to 2015, 4688 patients with breast cancer treated with whole breast RT at 20 sites participating in a state-wide consortium were enrolled into a registry. The importance of limiting the cardiac dose has been emphasized in the consortium since 2012, and the mean heart dose (MHD) has been reported by each institution since 2014. The effects on the MHD were estimated for both conventional and accelerated fractionation using regression models, with technique (intensity modulated RT [IMRT] vs 3-dimensional conformal RT), deep inspiration breath hold use, patient position (supine vs prone), nodal RT (if delivered), and boost (yes vs no) as covariates.

RESULTS

For left-sided breast cancer treated with conventional fractionation, the median MHD in 2012 was 2.19 Gy versus 1.65 Gy in 2015 (P<.001). The factors that significantly increased the MHD for conventional fractionation were increased separation relative to 22 cm (1.5%/1 cm), supraclavicular or infraclavicular nodal RT (17.1%), internal mammary nodal RT (40.7%), use of a boost (20.9%), treatment year before 2015 (7.7%), and use of IMRT (20.8%). For left-sided BC treated with accelerated fractionation, the median MHD in 2012 was 1.70 Gy versus 1.22 Gy in 2015 (P<.001). The factors that significantly increased the MHD for accelerated fractionation were separation (1.7%/1 cm), use of a boost (20.0%), year before 2015 (8.5%), and use of IMRT (19.2%). The factors for both conventional fractionation and accelerated fractionation that significantly reduced the MHD were the use of deep inspiration breath hold and prone positioning.

CONCLUSIONS

The MHD for left-sided breast cancer decreased during a recent 4-year period, coincident with an increased focus on cardiac sparing in the radiation oncology community in general and a state-wide consortium specifically. These data suggest a positive effect of systematically monitoring the heart dose delivered.

Impact of a Sequential Intervention on Albumin Utilization in Critical Care

OBJECTIVES

Literature generally finds no advantages in mortality risk for albumin over cheaper alternatives in many settings. Few studies have combined financial and nonfinancial strategies to reduce albumin overuse. We evaluated the effect of a sequential multifaceted intervention on decreasing albumin use in ICU and explore the effects of different strategies.

DESIGN

Prospective prepost cohort study.

SETTING

Eight ICUs at two hospitals in an academic healthcare system.

PATIENTS

Adult patients admitted to study ICUs from September 2011 to August 2014 (n = 22,004).

INTERVENTIONS

Over 2 years, providers in study ICUs participated in an intervention to reduce albumin use involving monthly feedback and explicit financial incentives in the first year and internal guidelines and order process changes in the second year.

MEASUREMENTS AND MAIN RESULTS

Outcomes measured were albumin orders per ICU admission, direct albumin costs, and mortality. Mean (SD) utilization decreased 37% from 2.7 orders (6.8) per admission during the baseline to 1.7 orders (4.6) during the intervention (p < 0.001). Regression analysis revealed that the intervention was independently associated with 0.9 fewer orders per admission, a 42% relative decrease. This adjusted effect consisted of an 18% reduction in the probability of using any albumin (p < 0.001) and a 29% reduction in the number of orders per admission among patients receiving any (p < 0.001). Secondary analysis revealed that probability reductions were concurrent with internal guidelines and order process modification while reductions in quantity occurred largely during the financial incentives and feedback period. Estimated cost savings totaled $2.5M during the 2-year intervention. There was no significant difference in ICU or hospital mortality between baseline and intervention.

CONCLUSIONS

A sequential intervention achieved significant reductions in ICU albumin use and cost savings without changes in patient outcomes, supporting the combination of financial and nonfinancial strategies to align providers with evidence-based practices.

How to Become a Smart Patient in the Era of Precision Medicine?

The objective of this paper is to define the definition of smart patients, summarize the existing foundation, and explore the approaches and system participation model of how to become a smart patient. Here a thorough review of the literature was conducted to make theory derivation processes of the smart patient; "data, information, knowledge, and wisdom (DIKW) framework" was performed to construct the model of how smart patients participate in the medical process. The smart patient can take an active role and fully participate in their own health management; DIKW system model provides a theoretical framework and practical model of smart patients; patient education is the key to the realization of smart patients. The conclusion is that the smart patient is attainable and he or she is not merely a patient but more importantly a captain and global manager of one's own health management, a partner of medical practitioner, and also a supervisor of medical behavior. Smart patients can actively participate in their healthcare and assume higher levels of responsibility for their own health and wellness which can facilitate the development of precision medicine and its widespread practice.

Variation in Preventive Care in Children Receiving Chronic Glucocorticoid Therapy

OBJECTIVE

To assess preventive care measure prescribing in children exposed to glucocorticoids and identify prescribing variation according to subspecialty and patient characteristics.

STUDY DESIGN

Retrospective cohort study of children initiating chronic glucocorticoids in the gastroenterology, nephrology, and rheumatology divisions at a pediatric tertiary care center. Outcomes included 25-hydroxyvitamin D (25OHD) and lipid testing, pneumococcal polysaccharide (PPV) and influenza vaccination, and stress dose hydrocortisone prescriptions.

RESULTS

A total of 701 children were followed for a median of 589 days. 25OHD testing was performed in 73%, lipid screening in 29%, and PPV and influenza vaccination in 16% and 78%, respectively. Hydrocortisone was prescribed in 2%. Across specialties, 25OHD, lipid screening, and PPV prescribing varied significantly (all P < .001). Using logistic regression adjusting for specialty, 25OHD testing was associated with older age, female sex, non-Hispanic ethnicity, and lower baseline height and body mass index z-scores (all P < .03). Lipid screening was associated with older age, higher baseline body mass index z-score, and lower baseline height z-score (all P < .01). Vaccinations were associated with lower age (P < .02), and PPV completion was associated with non-White race (P = .04).

CONCLUSIONS

Among children chronically exposed to glucocorticoids, 25OHD testing and influenza vaccination were common, but lipid screening, pneumococcal vaccination, and stress dose hydrocortisone prescribing were infrequent. Except for influenza vaccination, preventive care measure use varied significantly across specialties. Quality improvement efforts are needed to optimize preventive care in this high-risk population.

Implementation of a transfusion bundle reduces inappropriate red blood cell transfusions in intensive care - a before and after study

BACKGROUND

Restrictive red blood cell (RBC) transfusion has been widely described in transfusion guidelines. However, compliance with these guidelines is often poor. Therefore, we developed a care bundle for the transfusion of RBCs in intensive care. We investigated the effect of the application of the transfusion bundle on transfusion practice, hypothesising that the implementation of the transfusion bundle would lead to a reduction of inappropriate RBC transfusions.

STUDY DESIGN AND METHODS

We conducted a before and after study between January and December 2014 in a medical-surgical intensive care unit (ICU) of a university hospital in Amsterdam, the Netherlands. The primary outcome was the percentage of appropriate transfusions, referring to those transfusions that were in accordance to the patients' individual preset haemoglobin threshold.

RESULTS

The mean pre-transfusion haemoglobin level was 7·3 g dL^-1 [standard deviation (SD) = 1·15] during baseline and significantly decreased to 7·1 g dL^-1 (SD = 1·04) after transfusion bundle implementation; 95% confidence interval (CI): 0·009-0·308, P-value = 0·04. The number of inappropriate transfusions significantly decreased from 25% (111/439) during baseline to 15% (42/280) during implementation, a difference of 10%; 95% CI: -0·164 to -0·0416, P-value 0·001. This further decreased to 12% (45/370) in the post-implementation phase. A logistic regression analysis showed that the chance to find an appropriate transfusion is approximately twice as high after transfusion bundle implementation.

CONCLUSIONS

Introduction of a transfusion bundle results in a significant reduction of the number of inappropriate RBC transfusions in the medical-surgical ICU. Our results show that the introduction of a transfusion care bundle helps to improve compliance with transfusion guidelines in daily practice.

Implementing the Use of Pharmacist Progress Notes in a Surgical ICU

BACKGROUND

Critical care pharmacists are established and valuable members of the critical care team, however there is rarely written evidence of their daily involvement in the patient's electronic medical record (EMR). Documentation in the EMR has the advantage of ensuring a seamless pass-off and provides an opportunity to capture the pharmacist's cognitive and clinical impact in a way that traditional systems of tracking "interventions" fail to do. We investigated implementation of pharmacist progress notes in a surgical intensive care unit (ICU) and their utility in measuring pharmacist activity.

METHODS

Daily pharmacist progress notes written in a surgical ICU over a period of 2 months were reviewed. Each pharmacist action identified through progress note review was quantified and scored by an independent reviewer using a newly developed scoring system, the clinical impact score (CIS). This was developed as a way to quantify pharmacist actions and to classify those actions by clinical impact.

RESULTS

Four hundred sixty-two daily pharmacist progress notes were reviewed over a 2-month period. There were 1,055 actions identified that resulted in a therapy change. Four of these actions resulted in the potential avoidance of a sentinel event. Of patients with at least 5 progress notes (n = 44), the majority of pharmacist actions occurred on ICU day 1.

CONCLUSION

The results of this descriptive study demonstrate that the implementation of daily pharmacist progress notes is feasible in an advanced practice setting, and the pharmacist's contribution to patient care may be obtained through review of this documentation in the patient's medical record. The critical care pharmacist's daily involvement in patient care most commonly results in optimization of pharmacotherapy and avoidance of drug misadventure.

Using Coworker Observations to Promote Accountability for Disrespectful and Unsafe Behaviors by Physicians and Advanced Practice Professionals

BACKGROUND

Health care team members are well positioned to observe disrespectful and unsafe conduct-behaviors known to undermine team function. Based on experience in sharing patient complaints with physicians who subsequently achieved decreased complaints and malpractice risk, Vanderbilt University Medical Center developed and assessed the feasibility of the Co-Worker Observation Reporting System(SM) (CORS (SM)) for addressing coworkers' reported concerns.

METHODS

VUMC leaders used a "Project Bundle" readiness assessment, which entailed identification and development of key people, organizational supports, and systems. Methods involved gaining leadership buy-in, recruiting and training key individuals, aligning the project with organizational values and policies, promoting reporting, monitoring reports, and employing a tiered intervention process to address reported coworker concerns.

RESULTS

Peer messengers shared coworker reports with the physicians and advanced practice professionals associated with at least one report 84% of the time. Since CORS inception, 3% of the medical staff was associated with a pattern of CORS reports, and 71% of recipients of pattern-related interventions were not named in any subsequent reports in a one-year follow-up period.

CONCLUSIONS

Systematic monitoring of documented co-worker observations about unprofessional conduct and sharing that information with involved professionals are feasible. Feasibility requires organizationwide implementation; co-workers willing and able to share respectful, nonjudgmental, timely feedback designed initially to encourage self-reflection; and leadership committed to be more directive if needed. Follow-up surveillance indicates that the majority of professionals "self-regulate" after receiving CORS data.

Mortality Among Older Adults Before Versus After Hospital Transition to Intensivist Staffing

BACKGROUND

A large body of research suggests that hospitals with intensive care units staffed by board-certified intensivists have lower mortality rates than those that do not.

OBJECTIVE

To determine whether hospitals can reduce their mortality by adopting an intensivist staffing model.

DESIGN

Retrospective, longitudinal study using 2003-2010 Medicare data and the Leapfrog Group Hospital surveys.

SETTING AND PATIENTS

In total, 2,916,801 Medicare patients at 488 US hospitals.

MEASUREMENTS

We studied 30-day and in-hospital mortality among patients with several common medical and surgical conditions. We first compared risk-adjusted mortality rates of 3 groups of hospitals: those that were intensivist staffed throughout this time period, those that were not intensivist staffed, and those that transitioned to intensivist staffing somewhere during the period. We then examined rates of mortality improvement within each of the 3 groups and used difference-in-differences techniques to assess the independent effect of intensivist staffing among the subset of hospitals that transitioned.

RESULTS

Hospitals with intensivist staffing at the beginning of our study period had lower mortality rates than those without. However, hospitals that adopted intensivist staffing during the study period did not substantially improve their mortality rates. In our difference-in-differences analysis, there was no significant independent improvement in mortality after transitioning to intensivist staffing either overall [relative risk (RR), 0.96; 95% confidence interval (CI), 0.90-1.02] or in the medical (RR, 0.95; 95% CI, 0.89-1.02) or surgical populations (RR, 0.97; 95% CI, 0.84-1.10).

LIMITATIONS

Risk adjustment was based on administrative data. Categorization of exposure was by survey response at the hospital level.

CONCLUSIONS

Adoption of an intensivist staffing model was not associated with improved mortality in Medicare beneficiaries. These findings suggest that the lower mortality rates previously observed at hospitals with intensivist staffing may be attributable to other factors.

Mapping communication spaces: The development and use of a tool for analyzing the impact of EHRs on interprofessional collaborative practice

INTRODUCTION

Members of the healthcare team must access and share patient information to coordinate interprofessional collaborative practice (ICP). Although some evidence suggests that electronic health records (EHRs) contribute to in-team communication breakdowns, EHRs are still widely hailed as tools that support ICP. If EHRs are expected to promote ICP, researchers must be able to longitudinally study the impact of EHRs on ICP across communication types, users, and physical locations.

OBJECTIVE

This paper presents a data collection and analysis tool, named the Map of the Clinical Interprofessional Communication Spaces (MCICS), which supports examining how EHRs impact ICP over time, and across communication types, users, and physical locations.

METHODS

The tool's development evolved during a large prospective longitudinal study conducted at a Canadian pediatric academic tertiary-care hospital. This two-phased study [i.e., pre-implementation (phase 1) and post implementation (phase 2)] of an EHR employed a constructivist grounded theory approach and triangulated data collection strategies (i.e., non-participant observations, interviews, think-alouds, and document analysis). The MCICS was created through a five-step process: (i) preliminary structural development based on the use of the paper-based chart (phase 1); (ii) confirmatory review and modification process (phase 1); (iii) ongoing data collection and analysis facilitated by the map (phase 1); (iv) data collection and modification of map based on impact of EHR (phase 2); and (v) confirmatory review and modification process (phase 2).

RESULTS

Creating and using the MCICS enabled our research team to locate, observe, and analyze the impact of the EHR on ICP, (a) across oral, electronic, and paper communications, (b) through a patient's passage across different units in the hospital, (c) across the duration of the patient's stay in hospital, and (d) across multiple healthcare providers. By using the MCICS, we captured a comprehensive, detailed picture of the clinical milieu in which the EHR was implemented, and of the intended and unintended consequences of the EHR's deployment. The map supported our observations and analysis of ICP communication spaces, and of the role of the patient chart in these spaces.

CONCLUSIONS

If EHRs are expected to help resolve ICP challenges, it is important that researchers be able to longitudinally assess the impact of EHRs on ICP across multiple modes of communication, users, and physical locations. Mapping the clinical communication spaces can help EHR designers, clinicians, educators and researchers understand these spaces, appreciate their complexity, and navigate their way towards effective use of EHRs as means for supporting ICP. We propose that the MCICS can be used "as is" in other academic tertiary-care pediatric hospitals, and can be tailored for use in other healthcare institutions.

Strategies to Prevent Catheter-Associated Urinary Tract Infections in Acute Care Hospitals: 2014 Update

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their catheter-associated urinary tract infection (CAUTI) prevention efforts. This document updates “Strategies to Prevent Catheter-Associated Urinary Tract Infections in Acute Care Hospitals,” published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

Strategies to Prevent Surgical Site Infections in Acute Care Hospitals: 2014 Update

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their surgical site infection (SSI) prevention efforts. This document updates “Strategies to Prevent Surgical Site Infections in Acute Care Hospitals,” published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.