Evidence Review for the American College of Surgeons Quality Verification Part II: Processes for Reliable Quality Improvement

After decades of experience supporting surgical quality and safety by the American College of Surgeons, the American College of Surgeons Quality Verification Program was developed to help hospitals improve surgical quality, safety, and reliability. This review is the second of a 3-part review aiming to synthesize the evidence supporting the main principles of the American College of Surgeons Quality Verification Program. Evidence was systematically reviewed for 5 principles: case review, peer review, credentialing and privileging, data for surveillance, and continuous quality improvement using data. MEDLINE was searched for articles published from inception to January 2019 and 2 reviewers independently screened studies for inclusion in a hierarchical fashion, extracted data, and summarized results in a narrative fashion. A total of 9,098 studies across the 5 principles were identified. After exclusion criteria, a total of 184 studies in systematic reviews and primary studies were included for assessment. The identified literature supports the importance of standardized processes and systems to identify problems and improve quality of care.

Clinical criteria to screen for inpatient diagnostic errors: a scoping review

Diagnostic errors are common and costly, but difficult to detect. "Trigger" tools have promise to facilitate detection, but have not been applied specifically for inpatient diagnostic error. We performed a scoping review to collate all individual "trigger" criteria that have been developed or validated that may indicate that an inpatient diagnostic error has occurred. We searched three databases and screened 8568 titles and abstracts to ultimately include 33 articles. We also developed a conceptual framework of diagnostic error outcomes using real clinical scenarios, and used it to categorize the extracted criteria. Of the multiple criteria we found related to inpatient diagnostic error and amenable to automated detection, the most common were death, transfer to a higher level of care, arrest or "code", and prolonged length of hospital stay. Several others, such as abrupt stoppage of multiple medications or change in procedure, may also be useful. Validation for general adverse event detection was done in 15 studies, but only one performed validation for diagnostic error specifically. Automated detection was used in only two studies. These criteria may be useful for developing diagnostic error detection tools.

Record review to explore the adequacy of post-operative vital signs monitoring using a local modified early warning score (mews) chart to evaluate outcomes

Objectives

1) To explore the adequacy of: vital signs’ recordings (respiratory and heart rate, oxygen saturation, systolic blood pressure (BP), temperature, level of consciousness and urine output) in the first 8 post-operative hours; responses to clinical deterioration. 2) To identify factors associated with death on the ward between transfer from the theatre recovery suite and the seventh day after operation.

Design

Retrospective review of records of 11 patients who died plus four controls for each case.

Participants

We reviewed clinical records of 55 patients who met inclusion criteria (general anaesthetic, age >13, complete records) from six surgical wards in a teaching hospital between 1 May and 31 July 2009.

Methods

In the absence of guidelines for routine post-operative vital signs’ monitoring, nurses’ standard practice graphical plots of recordings were recoded into MEWS formats (0 = normal, 1–3 upper or lower limit) and their responses to clinical deterioration were interpreted using MEWS reporting algorithms.

Results

No patients’ records contained recordings for all seven parameters displayed on the MEWS. There was no evidence of response to: 22/36 (61.1%) abnormal vital signs for patients who died that would have triggered an escalated MEWS reporting algorithm; 81/87 (93.1%) for controls. Death was associated with age, ≥61 years (OR 14.2, 3.0–68.0); ≥2 pre-existing co-morbidities (OR 75.3, 3.7–1527.4); high/low systolic BP on admission (OR 7.2, 1.5–34.2); tachycardia (≥111–129 bpm) (OR 6.6, 1.4–30.0) and low systolic BP (≤81–100 mmHg), as defined by the MEWS (OR 8.0, 1.9–33.1).

Conclusions

Guidelines for post-operative vital signs’ monitoring and reporting need to be established. The MEWS provides a useful scoring system for interpreting clinical deterioration and guiding intervention. Exploration of the ability of the Cape Town MEWS chart plus reporting algorithm to expedite recognition of signs of clinical and physiological deterioration and securing more skilled assistance is essential.