Adherence to COVID-19 protocols: A comparative study of public and private hospitals in Ghana

Objective

This study aimed to comparatively examine how public and private hospitals adhered to the COVID-19 safety protocols, and the factors associated with, and barriers to adherence in Ghana.

Study design

A case study design drawing on quantitative and qualitative methods to determine adherence to, and barrier of adherence to the COVID-19 protocols.

Method

A sample of 283 staff participated in the quantitative study, while in-depth interviews were conducted among management staff across the public and private hospitals. Data were analyzed using descriptive statistics, independent t-test to compare differences in adherence and logistic regression model to identify the factors associated with adherence to the COVID-19 protocols.

Results

The regression results showed that adherence to the COVID-19 protocols in public and private hospitals were significantly associated with staff training on adherence in public (OR = 2.08; p < 0.01) and private (OR = 1.44; p < 0.05), and knowledge on adherence in public (OR = 3.12; p < 0.01) and private (OR = 11.45; p < 0.01) hospitals. Adherence to the protocol varied significantly between public and private hospitals (0.001 > p < 0.05), with an effect size ranging from small to large. Clients' behavioural factors and poor stocking of PPEs due to financial challenges were reported as barriers to adherence in both hospital types.

Conclusion

Adherence to the COVID-19 protocols was more pronounced in public hospitals than private hospitals suggesting the need for interventions targeting the latter to promote client and staff safety.

Real-time evaluation and adaptation to facilitate rapid recruitment in a large, prospective cohort study

BACKGROUND

Recruiting large cohorts efficiently can speed the translation of findings into care across a range of scientific disciplines and medical specialties. Recruitment can be hampered by factors such as financial barriers, logistical concerns, and lack of resources for patients and clinicians. These and other challenges can lead to underrepresentation in groups such as rural residents and racial and ethnic minorities. Here we discuss the implementation of various recruitment strategies for enrolling participants into a large, prospective cohort study, assessing the need for adaptations and making them in real-time, while maintaining high adherence to the protocol and high participant satisfaction.

METHODS

While conducting a large, prospective trial of a multi-cancer early detection blood test at Geisinger, an integrated health system in central Pennsylvania, we monitored recruitment progress, adherence to the protocol, and participants' satisfaction. Tracking mechanisms such as paper records, electronic health records, research databases, dashboards, and electronic files were utilized to measure each outcome. We then reviewed study procedures and timelines to list the implementation strategies that were used to address barriers to recruitment, protocol adherence and participant satisfaction.

RESULTS

Adaptations to methods that contributed to achieving the enrollment goal included offering multiple recruitment options, adopting group consenting, improving visit convenience, increasing the use of electronic capture and the tracking of data and source documents, staffing optimization via leveraging resources external to the study team when appropriate, and integrating the disclosure of study results into routine clinical care without adding unfunded work for clinicians. We maintained high protocol adherence and positive participant experience as exhibited by a very low rate of protocol deviations and participant complaints.

CONCLUSION

Recruiting rapidly for large studies - and thereby facilitating clinical translation - requires a nimble, creative approach that marshals available resources and changes course according to data. Planning a rigorous assessment of a study's implementation outcomes prior to study recruitment can further ground study adaptations and facilitate translation into practice. This can be accomplished by proactively and continuously assessing and revising implementation strategies.

Impact of migration on diabetes burden: audit in the metropolitan area of Bologna, Italy

PURPOSE

To investigate the impact of diabetes in immigrants on the Italian healthcare system, as well as their compliance with standard protocols of control and treatment.

METHODS

The prevalence of immigrants with diabetes living in the metropolitan area of Bologna (about 1 million inhabitants) in 2019 was investigated using a database containing all subjects in active follow-up for diabetes, based on antidiabetic drug use, disease-specific copayment exemption, ICD-9 codes, continuous care in diabetes units. Country of origin was derived from fiscal code.

RESULTS

The overall prevalence of diabetes (n = 53,941; 51.8% males, median age 64) was 6.1% in both Italy-born and immigrant cohorts. Immigrant prevalence was 12.4%, moderately higher than that observed in the total population (12.2%). Diabetes risk was increased in the whole immigrant cohort (odds ratio (OR) 1.74; 95% Confidence Interval (CI) 1.69-1.79). Among cases with incident diabetes, the proportion of immigrants (median age, 49 vs. 65 in Italy-born individuals) increased progressively from 11.7% to 26.5% from 2011 to 2019 (males, 8.9-21.0%; females, 14.9-32.8%) in all age groups, particularly in young adults, but also in older subjects. Metabolic control was lower in immigrants, as was adherence to shared diagnostic and therapeutic protocols, without systematic differences in antidiabetic drug use, but much lower use of drugs for comorbid conditions.

CONCLUSIONS

The population with diabetes in the metropolitan area of Bologna is rapidly changing. Quality improvement initiatives are needed to reduce the burden for the universalistic Italian health care system generated by the rapidly-growing high-risk immigrant population.

Quality Review Committee Audit Improves Thoracic Enhanced Recovery After Surgery Protocol Compliance

INTRODUCTION

Compliance with thoracic Enhanced Recovery After Surgery (ERAS) protocols is critical to achieving their maximum benefits. We sought to examine utilization of quality review meetings as a method to improve protocol compliance through identification and resolution of barriers with compliance.

METHODS

A multidisciplinary committee implemented a thoracic ERAS protocol for anatomic lung resections across five hospitals within our health system. Compliance data at one institution were tracked for 4 mo after initiation of the ERAS protocol; a quality review meeting was held at one hospital, and two additional months of compliance data were recorded. Outcomes of interest were compliance changes to five protocol elements. Pathway elements deferred due to "mindful deviation" were excluded. Chi-square and Fisher's exact tests were used to compare compliance differences.

RESULTS

We included 81 patients: 53 patients before the quality review meeting and 28 after. There were 405 compliance opportunities; 68 (17%) were excluded for mindful deviation, leaving 337 (83%) for inclusion. Overall compliance improved from 53% before to 84% after the quality review meeting. Compliance to avoiding intraoperative urinary catheters, placing chest tubes to water seal in postanesthesia care unit, liberal chest tube removal, and postoperative multimodal pain regimen use improved after the quality review meeting (P values <0.05). Use of preoperative pain bundles was not significantly different (87% versus 96%, P = 0.25).

CONCLUSIONS

Conducting a quality review meeting significantly improved ERAS protocol element use at our intervention healthcare region. This methodology should be considered at other institutions implementing surgical protocols.

Assessment of the Relationship Between Protocol Adherence, Study Complexity and Personnel in Surgical Clinical Trials

BACKGROUND

In order to improve quality and efficiency of surgical trials, we assessed protocols complexity and examined whether it influenced the conduct, as measured by the number and types of deviations that occurred during the execution phase. Knowledge of these facts and performance of research team would allow to effectively mitigate the occurrence of deviations.

METHODS

Thirty-five research protocols were rated according to a previously established complexity scoring model. Statistical analyses were performed to examine associations between protocol complexity, number of protocol/informed consent amendments vs. number/types of protocol deviations; as well as correlations with phase of the study, type of investigational product, personnel changes/experience level were assessed.

RESULTS

Assessment of complexity score in Pearson's correlation test with the number of protocol deviations showed weak correlation, suggesting that other factors can influence protocol adherence. There was no correlation observed between number of deviations and type of study by investigational product category. In examining association between protocol deviations and number of subjects enrolled a trend was observed towards increased number of deviations once more subjects have entered the study. The higher number of protocol deviations was associated with increased number of protocol amendments (p = 0.0396), and there was no statistical significance observed between number of deviations and informed consent amendments (p = 0.5083). There was a moderate correlation detected between increased number of protocol deviations and total number of investigators on the study.

CONCLUSION

Protocol adherence can be improved with effective training and retention of research coordinators, investigators and frequent internal auditing to address discrepancies and effectively implement corrective actions. Upfront training of research personnel, with subsequent monitoring of performance metrics throughout the execution phase can reduce the total number of protocol deviations, ensure data integrity and improve quality of research conducted. Engagement of all stakeholders upfront, including clinical site personnel, can help develop well-designed clinical trial protocol, avoid time consuming and costly protocol and informed consent amendments at execution phase and ensure higher quality of research conducted, while allowing to meet objectives of the trial in a more efficient manner.

A data-driven examination of which patients follow trial protocol

Protocol adherence in behavioral intervention clinical trials is critical to trial success. There is increasing interest in understanding which patients are more likely to adhere to trial protocols. The objective of this study was to demonstrate the use of a data-driven approach to explore patient characteristics associated with the lowest and highest rates of adherence in three trials assessing interventions targeting behaviors related to lifestyle and risk for cardiovascular disease. Each trial included a common set of baseline variables. Model-based recursive partitioning (MoB) was applied in each trial to identify participant characteristics of subgroups characterized by these baseline variables with differences in protocol adherence. Bootstrap resampling was conducted to provide optimism-corrected c-statistics of the final solutions. In the three trials, rates of protocol adherence varied from 56.9% to 87.5%. Evaluation of heterogeneity of protocol adherence via MoB in each trial resulted in trees with 2–4 subgroups based on splits of 1–3 variables. In two of the three trials, the first split was based on pain in the past week, and those reporting lower pain were less likely to be adherent. In one of these trials, the second and third splits were based on education and employment, where those with lower education levels and who were employed were less likely to be adherent. In the third trial, the two splits were based on smoking status and then marriage status, where smokers who were married were least likely to be adherent. Optimism-corrected c-statistics ranged from 0.54 to 0.63. Model-based recursive partitioning can be a useful approach to explore heterogeneity in protocol adherence in behavioral intervention trials. An important next step would be to assess whether patterns hold in other similar studies and samples. Identifying subgroups who are less likely to be adherent to an intervention can help inform modifications to the intervention to help tailor the intervention to these subgroups and increase future uptake and impact.

Trial registration

ClinicalTrials.gov identifiers: NCT01828567, NCT02360293, and NCT01838226.

Treatment fidelity in the Tinnitus Retraining Therapy Trial

BACKGROUND

Treatment fidelity, defined as ensuring that the recipient receives the intended intervention, is a critical component for accurate estimation of treatment efficacy. Ensuring fidelity and protocol adherence in behavioral trials requires careful planning during the design phase and implementation during the trial. The Tinnitus Retraining Therapy Trial (TRTT) randomized individuals with severe tinnitus to tinnitus retraining therapy (TRT, comprised of tinnitus-specific educational counseling (TC) and sound therapy (ST) using conventional sound generators (SGs)); Partial TRT (TC and placebo SGs); or standard of care (SOC), using a patient-centered care approach. Study audiologists administered both types of counseling in the TRTT, creating a challenge for managing protocol adherence.

METHODS

We developed methods to enhance treatment fidelity including training, competency assessment, scripts, visual aids, and fidelity monitoring. Protocol monitors identified critical topics and content to be addressed for each type of counseling session, prepared corresponding scripts, and developed training aids and treatment-specific checklists covering those topics. Study audiologists' competency assessment required submission and review by the protocol monitors of an audiotape of one TC and one SOC counseling session. Treatment-specific aids included scripts, a 3-D model of the ear, handouts, and for TC, an illustrated flip-chart with talking points that followed the scripted content. During the trial, audiologists completed treatment-specific checklists during each counseling session, indicating topics covered/discussed and submitted audiotapes of counseling sessions. Protocol monitors reviewed audiotapes using corresponding treatment-specific checklists. Results for individual checklist items were tabulated and proportions calculated.

RESULTS

Twenty-five audiologists were certified for TC and/or SOC counseling and 24 completed at least one counseling session. Adherence to each of 33 critical items on the TC checklist as assessed by the protocol monitor ranged from 70 to 100% across 37 counseling sessions (median 97%), with no difference between adherence for TRT (median, 97%) and partial TRT (median, 100%). Adherence to each of 44 critical items on the SOC checklist across 30 SOC counseling sessions ranged from 42 to 100% (median, 87.5%).

CONCLUSION

The TRTT used multiple methods to address treatment fidelity. The close adherence to each treatment type was critical for evaluating the efficacy of the study interventions in this randomized trial.

TRIAL REGISTRATION

clinicaltrials.gov NCT01177137 . Registered on 5 August 2010.

The implementation and adherence to evidence-based protocols for psychotherapy for depression: the perspective of therapists in Dutch specialized mental healthcare

BACKGROUND

Although psychotherapy is an effective treatment for depression, a large number of patients still do not receive care according to the protocols that are used in clinical trials. Instead, patients often receive a modified version of the original intervention. It is not clear how and when treatment protocols are used or modified in the Dutch specialized mental health care and whether these changes lead to suboptimal adherence to treatment protocols.

METHODS

In the context of an ongoing multicenter trial that investigates whether twice-weekly sessions of protocolized interpersonal psychotherapy (IPT) and cognitive behavioral therapy (CBT) for depression lead to better treatment outcomes compared to once-weekly sessions, two focus groups using semi-structured interviews were organized. Aims were to increase insight in the adherence to and modifications of CBT and IPT protocols in the Dutch specialized mental health care for depression. Participants were fifteen therapists from seven mental health locations part of five mental health organizations. Verbatim transcripts were coded and analyzed using qualitative software.

RESULTS

Three themes emerged: modification as the common practice, professional and patient factors influencing the adherence to protocols and organizational boundaries and flexibility. Treatment modification appeared to happen on a frequent basis, even in the context of a trial. Definitions of treatment modifications were multiple and varied from using intuition to flexible use of the same protocol. Therapist training and supervision, the years of work experience and individual characteristics of the therapist and the patient were mentioned to influence the adherence to protocols. Modifications of the therapists depended very much on the culture within the mental health locations, who differed in terms of the flexibility offered to therapists to choose and modify treatment protocols.

CONCLUSIONS

Not all treatment modifications were in line with existing evidence or guidelines. Regular supervision, team meetings and a shared vision were identified as crucial factors to increase adherence to treatment protocols, whereas additional organizational factors, among which a change of mindset, may facilitate adequate implementation.

Adherence to a procalcitonin-guided antibiotic treatment protocol in patients with severe sepsis and septic shock

Background

In randomised controlled trials, procalcitonin (PCT)-guided antibiotic treatment has been proven to significantly reduce length of antibiotic therapy in intensive care unit (ICU) patients. However, concern was raised on low protocol adherence and high rates of overruling, and thus the value of PCT-guided treatment in real clinical life outside study conditions remains unclear. In this study, adherence to a PCT protocol to guide antibiotic treatment in patients with severe sepsis and septic shock was analysed.

Methods

From 2012 to 2014, surgical ICU patients with severe sepsis or septic shock were retrospectively screened for PCT measurement series appropriate to make treatment decisions on antibiotic therapy. We compared (1) patients with appropriate PCT measurement series to patients without appropriate series; (2) patients who reached the antibiotic stopping advice threshold (PCT < 0.5 ng/mL and/or decrease to 10% of peak level) to patients who did not reach a stopping advice threshold; and (3) patients who were treated adherently to the PCT protocol to non-adherently treated patients. The groups were compared in terms of antibiotic treatment duration, PCT kinetics, and other clinical outcomes.

Results

Of 81 patients with severe sepsis or septic shock, 14 were excluded due to treatment restriction or short course in the ICU. The final analysis was performed on 67 patients. Forty-two patients (62.7%) had appropriate PCT measurement series. In patients with appropriate PCT series, median initial PCT (p = 0.001) and peak PCT levels (p < 0.001) were significantly higher compared to those with non-appropriate series. In 26 patients with appropriate series, PCT levels reached an antibiotic stopping advice. In 8 of 26 patients with stopping advice, antibiotics were discontinued adherently to the PCT protocol (30.8%). Patients with adherently discontinued antibiotics had a shorter antibiotic treatment (7d [IQR 6–9] vs. 12d [IQR 9–16]; p = 0.002). No differences were seen in terms of other clinical outcomes.

Conclusion

In patients with severe sepsis and septic shock, procalcitonin testing was irregular and adherence to a local PCT protocol was low in real clinical life. However, adherently treated patients had a shorter duration of antibiotic treatment without negative clinical outcomes. Procalcitonin peak values and kinetics had a clear impact on the regularity of PCT testing.

Electronic supplementary material

The online version of this article (10.1186/s13613-018-0415-5) contains supplementary material, which is available to authorized users.

Variation in care for surgical patients with colorectal cancer: protocol adherence in 12 European hospitals

PURPOSE

Surgical care for patients with colorectal cancer has become increasingly standardized. The Enhanced Recovery After Surgery (ERAS) protocol is a widely accepted structured care method to improve postoperative outcomes of patients after surgery. Despite growing evidence of effectiveness, adherence to the protocol remains challenging in practice. This study was designed to assess the adherence rate in daily practice and examine the relationship between the importance of interventions and adherence rate.

METHODS

This international observational, cross-sectional multicenter study was performed in 12 hospitals in four European countries. Patients were included from January 1, 2014. Data was retrospectively collected from the patient record by the local study coordinator.

RESULTS

A total of 230 patients were included in the study. Protocol adherence was analyzed for both the individual interventions and on patient level. The interventions with the highest adherence were antibiotic prophylaxis (95%), thromboprophylaxis (87%), and measuring body weight at admission (87%). Interventions with the lowest adherence were early mobilization-walking and sitting (9 and 6%, respectively). The adherence ranged between 16 and 75%, with an average of 44%.

CONCLUSION

Our results show that the average protocol adherence in clinical practice is 44%. The variation on patient and hospital level is considerable. Only in one patient the adherence rate was >70%. In total, 30% of patients received 50% or more of the key interventions. A solid implementation strategy seems to be needed to improve the uptake of the ERAS pathway. The importance-performance matrix can help in prioritizing the areas for improvement.

Implementation and Evaluation of a Clinical Pathway for Pancreaticoduodenectomy Procedures: a Prospective Cohort Study

INTRODUCTION

Medical and nursing protocols in perioperative care for pancreaticoduodenectomy are mainly mono-disciplinary, limiting their integration and transparency in a continuous health care system. The aims of this study were to evaluate adherence to a multidisciplinary clinical pathway for all pancreaticoduodenectomy patients during their entire hospital stay and to determine if the use of this clinical pathway is associated with beneficial effects on clinical end points.

MATERIALS AND METHODS

A prospective cohort study was conducted in 95 pancreaticoduodenectomy patients treated according to a clinical pathway, including a variance report, compared to a historical control group (n = 52) with a traditional treatment regime.

RESULTS

Process evaluation of the clinical pathway group revealed that protocol adherence throughout all units was above 80%. Major complications according to Clavien-Dindo classification grade ≥3 decreased from 27 to 13%; p = 0.02. Hospital length of stay was significantly shorter in the clinical pathway group, median 10 days [IQR 8-15], compared with the control group, median 13 days [IQR 10-18]; p = 0.02.

CONCLUSION

The use of a clinical pathway in pancreaticoduodenectomy patients was associated with high protocol adherence, improved outcome and shorter hospital length of stay. Variance report analysis and protocol adherence with a Prepare-Act-Reflect Cycle are essential in surveillance of outcome.

How bedside feedback improves head-of-bed angle compliance for intubated patients

One clinical defense against ventilator-associated pneumonia is maintaining the head-of-bed angle of ventilated patients above 30°. Most previous studies of head-of-bed angles using electronic monitoring have recorded compliance rates of less than 50%. The purpose of this study was to determine how bedside feedback of the head-of-bed angle affects bed angles set by healthcare workers. Electronic inclinometers were installed on 22 beds in an intensive care for a period of 38 days. Intubated patients were randomly assigned into two cohorts. One cohort received a graphical display of the bed angle adjacent to the in-room computer display. The head-of-bed angle of each intubated patient was continuously recorded, yielding 1,528 h of observation. The mean head-of-bed angle was 28.78° for beds with displays and 25.50° for those without, a significant difference. The most significant effects were for angles near 30°. Beds in the display cohort were three times as likely to be in a compliant position as beds in the no-display cohort. The results suggest that electronic bedside feedback improves head-of-bed angle compliance by raising angles slightly below the compliance threshold into compliance. This result may support studies of how compliant bed-angle protocols affect health outcomes.

Assessing protocol adherence in a clinical trial with ordered treatment regimens: Quantifying the pragmatic, randomized optimal platelet and plasma ratios (PROPPR) trial experience

BACKGROUND

Medication dispensing errors are common in clinical trials, and have a significant impact on the quality and validity of a trial. Therefore, the definition, calculation and evaluation of such errors are important for supporting a trial's conclusions. A variety of medication dispensing errors can occur. In this paper, we focus on errors in trials where the intervention includes multiple therapies that must be given in a pre-specified order that varies across treatment arms and varies in duration.

METHODS

The Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial was a Phase III multi-site, randomized trial to compare the effectiveness and safety of 1:1:1 transfusion ratios of plasma and platelets to red blood cells with a 1:1:2 ratio. In this trial, these three types of blood products were to be transfused in a pre-defined order that differed by treatment arm. In this paper, we present approaches from the PROPPR trial that we used to define and calculate the occurrence of out of order blood transfusion errors. We applied the proposed method to calculate protocol adherence to the specified order of transfusion in each treatment arm.

RESULTS

Using our proposed method, protocol adherence was greater in the 1:1:1 group than in the 1:1:2 group (96% vs 93%) (p<0.0001), although out of order transfusion errors in both groups were low. Final transfusion ratios of plasma to platelets to red blood cells for the 1:1:1 ratio group was 0.93:1.32:1, while the transfusion ratio for the 1:1:2 ratio group was 0.48:0.48:1.

CONCLUSIONS

Overall, PROPPR adherence to blood transfusion order pre-specified in the protocol was high, and the required order of transfusions for the 1:1:2 group was more difficult to achieve. The approaches proposed in this manuscript were useful in evaluating the PROPPR adherence and are potentially useful for other trials where a specific treatment orders with varying durations must be maintained.

Rheumatologists' adherence to a disease activity score steered treatment protocol in early arthritis patients is less if the target is remission

To compare rheumatologists' adherence to treatment protocols for rheumatoid arthritis (RA) targeted at Disease Activity Score (DAS) ≤2.4 or <1.6. The BeSt-study enrolled 508 early RA (1987) patients targeted at DAS ≤2.4. The IMPROVED-study included 479 early RA (2010) and 122 undifferentiated arthritis patients targeted at DAS <1.6. We evaluated rheumatologists' adherence to the protocols and assessed associated opinions and conditions during 5 years. Protocol adherence was higher in BeSt than in IMPROVED (86 and 70 %), with a greater decrease in IMPROVED (from 100 to 48 %) than in BeSt (100 to 72 %). In BeSt, 50 % of non-adherence was against treatment intensification/restart, compared to 63 % in IMPROVED and 50 vs. 37 % were against tapering/discontinuation. In both studies, non-adherence was associated with physicians' disagreement with DAS or with next treatment step and if patient's visual analogue scale (VAS) for general health was ≥20 mm higher than the physician's VAS. In IMPROVED, also discrepancies between swelling, pain, erythrocyte sedimentation rate, and VASgh were associated with non-adherence. Adherence to DAS steered treatment protocols was high but decreased over 5 years, more in a DAS <1.6 steered protocol. Non-adherence was more likely if physicians disagreed with DAS or next treatment step. In the DAS <1.6 steered protocol, non-adherence was also associated with discrepancies between subjective and (semi)objective disease outcomes, and often against required treatment intensification. These results may indicate that adherence to DAS-steered protocols appears to depend in part on the height of the target and on how physicians perceive the DAS reflects RA activity.

Mandatory adherence to diagnostic protocol increases the yield of CTPA for pulmonary embolism

Objectives

To determine if mandatory adherence to a diagnostic protocol increases the rate of computed tomography pulmonary angiographies (CTPAs) positive for pulmonary embolism (PE)—the so-called diagnostic yield. Further, we aim to identify factors associated with this diagnostic yield.

Methods

We included all patients with suspected PE requiring CTPA from 9 January 2014 t0 3 June 2014. The requesting physicians were forced to follow diagnostic workup for PE by calculating a Wells score and, if necessary, determining D-dimer level. The percentage of positive CTPA scans was calculated and compared with our previous cohort (Walen et al. Insights Imaging 2014;5(2):231–236). Odds ratios were calculated as a measure of association between dichotomous variables and CTPA findings.

Results

Of 250 scans, 74 were positive (29.6 % [95 % CI, 24.3-35.5 %]) and 175 were negative (70 %). The percentage positive scans increased with 6.6 % and the percentage negative scans decreased with 3.1 %. This change was statistically significant (p = 0.001). Independent clinical predictors of diagnostic yield were previous deep venous thrombosis (DVT) (OR, 3.22; p = 0.013) and clinical signs of DVT (OR, 2.71; p = 0.012). Chronic obstructive pulmonary disease (COPD) was negatively associated with PE (OR, 0.33; p = 0.045).

Conclusions

This study shows that mandatory adherence to a diagnostic protocol increases the yield of CTPA for PE in our centre.

Main Messages

• Mandatory adherence to diagnostic protocol increases the yield of CTPA for PE

• Previous DVT and signs of DVT were associated with a higher yield

• No patients with a low Wells score and a low D-dimer had PE

How lapse and slip errors influence head-of-bed angle compliance rates as measured by a portable, wireless data collection system

The recommended protocols to prevent ventilator-associated pneumonia include keeping ventilated patients' head and upper body elevated to an angle between 30 and 45 degrees. These recommendations are largely based on a study that has been difficult to replicate, because studies that have attempted to replicate the original conditions have failed to achieve the necessary bed angles consistently. This work suggests the possibility that two specific types of human error, slips and lapses, contribute to non-compliant bed angles. A novel device provided 83,655 samples of bed angles over a period of 1579 hours. The bed angle was out of compliance 64.2% of the time analyzed. Slips, the accident of raising the bed to an angle slightly less than the desired angle, accounted for most of the out-of-compliance measurements, or 55.9% of the time analyzed. It appears that stochastic variation in the bed adjustments results in the bed being out of compliance. Interventions should be investigated such as increasing the target angle and providing feedback at the moment the bed is raised to close to, but less than, the target angle.

Improving maternal health and safety through adherence to postpartum hemorrhage protocol in Latin America

OBJECTIVE

To determine provider compliance with protocols for the prevention of postpartum hemorrhage and provider characteristics associated with adherence and non-adherence.

METHODS

A multicenter descriptive study was conducted involving 78 direct observations of provider-implemented protocols and 52 interviews with Peruvian maternal healthcare providers at 4 Peruvian clinical sites representing the local, regional, and national levels of care. Parturient participants planning a normal vaginal delivery were 17-49 years of age and 34-42 weeks pregnant. Primary outcomes were compared using χ2 testing, while quantitative survey data were evaluated using means, standard deviations, and Student t test or analysis of variance for statistical significance.

RESULTS

There were 3 significant differences between the national, regional, and local levels of care: adherence to all 3 interventions (P<0.001); professional experience (P<0.04); and retention of healthcare providers (P<0.001). There were no differences in provider training (P<0.097), and the retention of experienced healthcare providers was not associated with greater adherence to protocols. There were no significant differences in parturient characteristics.

CONCLUSION

Individual characteristics and institutional beliefs may have more influence than experience or training on adherence to protocols for prevention of postpartum hemorrhage; addressing these biases may improve patient safety in Peru and throughout Latin America.

The effect of adherence to ACLS protocols on survival of event in the setting of in-hospital cardiac arrest

AIM

Advanced Cardiac Life Support (ACLS) algorithms are the default standard of care for in-hospital cardiac arrest (IHCA) management. However, adherence to published guidelines is relatively poor. The records of 149 patients who experienced IHCA were examined to begin to understand the association between overall adherence to ACLS protocols and successful return of spontaneous circulation (ROSC).

METHODS

A retrospective chart review of medical records and code team worksheets was conducted for 75 patients who had ROSC after an IHCA event (SE group) and 74 who did not survive an IHCA event (DNS group). Protocol adherence was assessed using a detailed checklist based on the 2005 ACLS Update protocols. Several additional patient characteristics and circumstances were also examined as potential predictors of ROSC.

RESULTS

In unadjusted analyses, the percentage of correct steps performed was positively correlated with ROSC from an IHCA (p<0.01), and the number of errors of commission and omission were both negatively correlated with ROSC from an IHCA (p<0.01). In multivariable models, the percentage of correct steps performed and the number of errors of commission and omission remained significantly predictive of ROSC (p<0.01 and p<0.0001, respectively) even after accounting for confounders such as the difference in age and location of the IHCAs.

CONCLUSIONS

Our results show that adherence to ACLS protocols throughout an event is correlated with increased ROSC in the setting of cardiac arrest. Furthermore, the results suggest that, in addition to correct actions, both wrong actions and omissions of indicated actions lead to decreased ROSC after IHCA.