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Wongtangman K, Semczuk P, Freda J, Smith RV, Pushparaj V, Beckham D, Aasman B, Rudolph MI, Salloum E, Kiyatkin M, Anand P, Ganz-Lord FA, Himes C, Fassbender P, Eikermann M. The effect of a bundle intervention for ambulatory otorhinolaryngology procedures on same-day case cancellation rate and associated costs. Anaesthesia 2024; 79:593-602. [PMID: 38353045 DOI: 10.1111/anae.16247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2024] [Indexed: 05/12/2024]
Abstract
Cancellations within 24 h of planned elective surgical procedures reduce operating theatre efficiency, add unnecessary costs and negatively affect patient experience. We implemented a bundle intervention that aimed to reduce same-day case cancellations. This consisted of communication tools to improve patient engagement and new screening instruments (automated estimation of ASA physical status and case cancellation risk score plus four screening questions) to identify patients in advance (ideally before case booking) who needed comprehensive pre-operative risk stratification. We studied patients scheduled for ambulatory surgery with the otorhinolaryngology service at a single centre from April 2021 to December 2022. Multivariable logistic regression and interrupted time-series analyses were used to analyse the effects of this intervention on case cancellations within 24 h and costs. We analysed 1548 consecutive scheduled cases. Cancellation within 24 h occurred in 114 of 929 (12.3%) cases pre-intervention and 52 of 619 (8.4%) cases post-intervention. The cancellation rate decreased by 2.7% (95%CI 1.6-3.7%, p < 0.01) during the first month, followed by a monthly decrease of 0.2% (95%CI 0.1-0.4%, p < 0.01). This resulted in an estimated $150,200 (£118,755; €138,370) or 35.3% cost saving (p < 0.01). Median (IQR [range]) number of days between case scheduling and day of surgery decreased from 34 (21-61 [0-288]) pre-intervention to 31 (20-51 [1-250]) post-intervention (p < 0.01). Patient engagement via the electronic health record patient portal or text messaging increased from 75.9% at baseline to 90.8% (p < 0.01) post-intervention. The primary reason for case cancellation was patients' missed appointment on the day of surgery, which decreased from 7.2% pre-intervention to 4.5% post-intervention (p = 0.03). An anaesthetist-driven, clinical informatics-based bundle intervention decreases same-day case cancellation rate and associated costs in patients scheduled for ambulatory otorhinolaryngology surgery.
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Affiliation(s)
- K Wongtangman
- Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Department of Anesthesiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - P Semczuk
- Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - J Freda
- Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - R V Smith
- Department of Otorhinolaryngology/Head and Neck Surgery, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - V Pushparaj
- Faculty Practice Operations, Montefiore Health System, Bronx, NY, USA
| | - D Beckham
- Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - B Aasman
- Center for Health Data Innovations, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - M I Rudolph
- Department of Anesthesiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
- Department for Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - E Salloum
- Department of Anesthesiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - M Kiyatkin
- Department of Anesthesiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - P Anand
- Department of Anesthesiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - F A Ganz-Lord
- Network Performance Group, and Staff Physician, Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - C Himes
- Department of Anesthesiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - P Fassbender
- Department of Anesthesiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
- Klinik für Anästhesiologie, Operative Intensivmedizin, Schmerz- und Palliativmedizin, Marien Hospital Herne, Universitätsklinikum der Ruhr-Universität Bochum, Herne, Germany
| | - M Eikermann
- Department of Anesthesiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
- Klinik für Anästhesiologie und Intensivmedizin, Universität Duisburg-Essen, Essen, Germany
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Muñoz-Muñoz F, Leppe J, González-Seguel F, Castro-Ávila A. Daily compliance of the ABCDEF liberation bundle for patients in the intensive care unit: A retrospective descriptive study. Medwave 2024; 24:e2795. [PMID: 38723209 DOI: 10.5867/medwave.2024.04.2795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2024] Open
Abstract
Introduction Implementing the ABCDEF bundle has demonstrated improved outcomes in patients with critical illness. This study aims to describe the daily compliance of the ABCDEF bundle in a Chilean intensive care unit. Methods Retrospective observational study of electronic clinical records of nursing, physiotherapy, and medical professionals who cared for patients over 18 years of age, admitted to an intensive care unit for at least 24 hours, with or without mechanical ventilation. Daily bundle compliance was determined by considering the daily records for each element: Assess pain (element A), both spontaneous awakening trials (element B1) and spontaneous breathing trials (element B2), choice of sedation (element C), delirium assessment (element D), early mobilization (element E), and family engagement (element F). Results 4165 registered bundle elements were obtained from nursing (47%), physiotherapy (44%), and physicians (7%), including 1134 patient/days (from 133 patients). Elements E and C showed 67 and 40% compliance, while D, A, and B2 showed 24, 14 and 11%, respectively. For B1 and F, 0% compliance was achieved. Compliance was higher in patients without mechanical ventilation for A and E, while it was similar for D. Conclusions Early mobilization had the highest compliance, while spontaneous awakening trials and family engagement had absolute non-compliance. Future studies should explore the reasons for the different degrees of compliance per bundle element in clinical practice.
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Affiliation(s)
- Felipe Muñoz-Muñoz
- Exercise and Rehabilitation Sciences Laboratory, School of Physical Therapy, Faculty of Rehabilitation Sciences, Universidad Andrés Bello, Santiago, Chile
| | - Jaime Leppe
- Carrera de Kinesiología, Facultad de Medicina, Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Felipe González-Seguel
- Carrera de Kinesiología, Facultad de Medicina, Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Ana Castro-Ávila
- Carrera de Kinesiología, Facultad de Medicina, Clínica Alemana Universidad del Desarrollo, Santiago, Chile
- Department of Health Sciences University of York Heslington, York YO10 5DD, United Kingdom
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Broome JM, Nordham KD, Piehl M, Tatum D, Caputo S, Belding C, De Maio VJ, Taghavi S, Jackson-Weaver O, Harris C, McGrew P, Smith A, Nichols E, Dransfield T, Rayburn D, Marino M, Avegno J, Duchesne J. Faster refill in an urban emergency medical services system saves lives: A prospective preliminary evaluation of a prehospital advanced resuscitative care bundle. J Trauma Acute Care Surg 2024; 96:702-707. [PMID: 38189675 DOI: 10.1097/ta.0000000000004239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
INTRODUCTION Military experience has demonstrated mortality improvement when advanced resuscitative care (ARC) is provided for trauma patients with severe hemorrhage. The benefits of ARC for trauma in civilian emergency medical services (EMS) systems with short transport intervals are still unknown. We hypothesized that ARC implementation in an urban EMS system would reduce in-hospital mortality. METHODS This was a prospective analysis of ARC bundle administration between 2021 and 2023 in an urban EMS system with 70,000 annual responses. The ARC bundle consisted of calcium, tranexamic acid, and packed red blood cells via a rapid infuser. Advanced resuscitative care patients were compared with trauma registry controls from 2016 to 2019. Included were patients with a penetrating injury and systolic blood pressure ≤90 mm Hg. Excluded were isolated head trauma or prehospital cardiac arrest. In-hospital mortality was the primary outcome of interest. RESULTS A total of 210 patients (ARC, 61; controls, 149) met the criteria. The median age was 32 years, with no difference in demographics, initial systolic blood pressure or heart rate recorded by EMS, or New Injury Severity Score between groups. At hospital arrival, ARC patients had lower median heart rate and shock index than controls ( p ≤ 0.03). Fewer patients in the ARC group required prehospital advanced airway placement ( p < 0.001). Twenty-four-hour and total in-hospital mortality were lower in the ARC group ( p ≤ 0.04). Multivariable regression revealed an independent reduction in in-hospital mortality with ARC (odds ratio, 0.19; 95% confidence interval, 0.05-0.68; p = 0.01). CONCLUSION Early ARC in a fast-paced urban EMS system is achievable and may improve physiologic derangements while decreasing patient mortality. Advanced resuscitative care closer to the point of injury warrants consideration. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
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Affiliation(s)
- Jacob M Broome
- Department of Surgery, MedStar Georgetown Washington Hospital Center, (J.M.B.) Washington DC; Department of Surgery (K.D.N., D.T., S.C., C.B., S.T., O.J.-W., C.H., P.M., J.D.), Tulane University School of Medicine, New Orleans, Louisiana; Department of Pediatrics (M.P.), and Department of Emergency Medicine (V.J.D.M.), University of North Carolina at Chapel Hill, Chapel Hill; WakeMed Health and Hospitals (M.P.), Raleigh, North Carolina; Lousiana State University Health Science Center New Orleans (A.S.); New Orleans Emergency Medical Services (E.N., T.D., D.R., M.M.); and New Orleans Health Department, New Orleans, Louisiana (J.A.)
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Oehlers J, Blayney C, Tate J, Cheng A, Tucker A, Reed MJ, Stewart BT, Arbabi S, O'Connell K, Powelson E, Pham TN. Implementation of a geriatric care bundle for older adults with acute burns. Burns 2024; 50:841-849. [PMID: 38472006 PMCID: PMC11055663 DOI: 10.1016/j.burns.2024.02.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 01/28/2024] [Accepted: 02/26/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND Frailty and comorbidities are important outcome determinants in older patients (age ≥65) with burns. A Geriatric Burn Bundle (Geri-B) was implemented in 2019 at a regional burn center to standardize care for older adults. Components included frailty screening and protocolized geriatric co-management, malnutrition screening with nutritional support, and geriatric-centered pain regimens. METHODS This study aimed to qualitatively evaluate the implementation of Geri-B using the Proctor Framework. From June-August 2022, older burn-injured patients, burn nurses, and medical staff providers (attending physicians and advanced practice providers) were surveyed and interviewed. Transcribed interviews were coded and thematically analyzed. From May 2022 to August 2023, the number of inpatient visits aged 65 + with a documented frailty screening was monitored. RESULTS The study included 23 participants (10 providers, 13 patients). Participants highly rated Geri-B in all implementation domains. Most providers rated geriatric care effectiveness as 'good' or 'excellent' after Geri-B implementation. Providers viewed it as a reminder to tailor geriatric care and a safeguard against substandard geriatric care. Staffing shortages, insufficient protocol training, and learning resources were reported as implementation barriers. Many providers advocated for better bundle integration into the hospital electronic health record (EHR) (e.g., frailty screening tool, automatic admission order sets). Most patients felt comfortable being asked about their functional status with strong patient support for therapy services. The average frailty screening completion rate from May 2022 to August 2023 was 86%. CONCLUSIONS Geri-B was perceived as valuable for the care of older burn patients and may serve as a framework for other burn centers.
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Affiliation(s)
- Julia Oehlers
- John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii, USA.
| | | | - Jo Tate
- UW Medicine Regional Burn Center, Seattle, WA, USA
| | | | | | - May J Reed
- UW Department of Medicine, Seattle, WA, USA
| | - Barclay T Stewart
- UW Medicine Regional Burn Center, Seattle, WA, USA; UW Department of Surgery, Seattle, WA, USA
| | - Saman Arbabi
- UW Medicine Regional Burn Center, Seattle, WA, USA; UW Department of Surgery, Seattle, WA, USA
| | | | | | - Tam N Pham
- UW Medicine Regional Burn Center, Seattle, WA, USA; UW Department of Surgery, Seattle, WA, USA
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Chien YS, Chen HT, Chiang HT, Luo TS, Yeh HI, Sheu JC, Li JY. Effect of Standardized Bundle Care and Bundle Compliance on Reducing Surgical Site Infections: A Pragmatic Retrospective Cohort Study. Med Sci Monit 2024; 30:e943493. [PMID: 38523334 PMCID: PMC10979649 DOI: 10.12659/msm.943493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 02/14/2024] [Indexed: 03/26/2024] Open
Abstract
BACKGROUND Care bundles for infection control consist of a set of evidence-based measures to prevent infections. This retrospective study aimed to compare surgical site infections (SSIs) from a single hospital surveillance system between 2017 and 2020, before and after implementing a standardized care bundle across specialties in 2019. It also aimed to assess whether bundle compliance affects the rate of SSIs. MATERIAL AND METHODS A care bundle consisting of 4 components (peri-operative antibiotics use, peri-operative glycemic control, pre-operative skin preparation, and maintaining intra-operative body temperature) was launched in 2019. We compared the incidence rates of SSIs, standardized infection ratio (SIR), and clinical outcomes of surgical procedures enrolled in the surveillance system before and after introducing the bundle care. The level of bundle compliance, defined as the number of fully implemented bundle components, was evaluated. RESULTS We included 6059 procedures, with 2010 in the pre-bundle group and 4049 in the post-bundle group. Incidence rates of SSIs (1.7% vs 1.0%, P=0.013) and SIR (0.8 vs 1.48, P<0.01) were significantly lower in the post-bundle group. The incidence of SSIs was significantly lower when all bundle components were fully adhered to, compared with when only half of the components were adhered to (0.3% vs 4.0%, P<0.01). CONCLUSIONS SSIs decreased significantly after the application of a standardized care bundle for surgical procedures across specialties. Full adherence to all bundle components was the key to effectively reducing the risk of surgical site infections.
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Affiliation(s)
- Yu-san Chien
- Department of Critical Care, Mackay Memorial Hospital, Taipei City, Taiwan
- Department of Medicine, Mackay Medical College, Taipei City, Taiwan
| | - Hsiang-ting Chen
- Department of Medical Quality, Mackay Memorial Hospital, Taipei City, Taiwan
| | - Hsiu-tzy Chiang
- Infection Control Center, Mackay Memorial Hospital, Taipei City, Taiwan
| | - Tz-shin Luo
- Department of Cardiovascular Surgery, Mackay Memorial Hospital, Taipei City, Taiwan
| | - Hung-i Yeh
- Department of Internal Medicine, Mackay Memorial Hospital, Taipei City, Taiwan
| | - Jin-Cherng Sheu
- Department of Pediatric Surgery, Mackay Memorial Hospital, Taipei City, Taiwan
| | - Jiun-yi Li
- Department of Medicine, Mackay Medical College, Taipei City, Taiwan
- Department of Medical Quality, Mackay Memorial Hospital, Taipei City, Taiwan
- Department of Cardiovascular Surgery, Mackay Memorial Hospital, Taipei City, Taiwan
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Curtis K, McKenzie J, Melville G, Moules P, Wylie C, Tyler A, Mulholland B. Implementation Evaluation of an Early Notification Care Bundle for Patients with Hip Fracture (eHIP). Gerontology 2024; 70:536-543. [PMID: 38452743 DOI: 10.1159/000538182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 03/01/2024] [Indexed: 03/09/2024] Open
Abstract
INTRODUCTION Hip fracture in older adults results in significant mortality and is one of the costliest fall-related injuries. The Australian Commission for Quality and Safety in Health Care hip fracture clinical care standards consolidate the best available evidence for managing this patient group; however, uptake is variable. The aim of this study was to evaluate the implementation and effectiveness of a multidisciplinary early activation mechanism and bundle of care (eHIP) on patient and health service outcomes. METHODS This controlled pre- and post-test study was conducted from June 2019-June 2021 at a large regional hospital in Australia. We hypothesised that eHIP would result in at least 50% of hip fracture patients receiving six or more components of the ACSQHC Hip Fracture Clinical Care Standard. Secondary outcomes include hospital-acquired complication rates and acute treatment costs. RESULTS There were 565 cases included for analysis. After implementation of eHIP (the post-period), 88% of patients received a correct activation of the eHIP pathway, sustained over 12 months. The proportion of patients receiving the primary outcome of six or more components increased from 36% to 49%. Care at presentation (pain and cognitive assessment) increased by 23%, and unrestricted mobilisation within 24 h improved by 10%. Prescription of appropriate analgesia improved 10-fold (5.2-57%), and patients receiving the gold standard fascia iliaca block increased from 68% to 88%. Acute treatment costs did not significantly change. DISCUSSION/CONCLUSION eHIP, a hip fracture care program incorporating evidence-based behaviour change theory, resulted in sustained improvements to patient care as recommended by the ACSQHC Hip Fracture Clinical Care Standard.
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Affiliation(s)
- Kate Curtis
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Illawarra Shoalhaven LHD, Emergency Department, Wollongong, New South Wales, Australia
| | - John McKenzie
- Illawarra Shoalhaven LHD, Department of Geriatric Medicine, Wollongong, New South Wales, Australia
| | - Geoffrey Melville
- Illawarra Shoalhaven LHD, Emergency Department, Wollongong, New South Wales, Australia,
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia,
| | - Peter Moules
- Illawarra Shoalhaven LHD, Emergency Department, Wollongong, New South Wales, Australia
| | - Cayce Wylie
- Illawarra Shoalhaven LHD, Emergency Department, Wollongong, New South Wales, Australia
| | - Alexandra Tyler
- Illawarra Shoalhaven LHD, Wollongong, New South Wales, Australia
| | - Bridie Mulholland
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
- Mersey Community and North West Regional Hospital, Latrobe, Tasmania, Australia
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White C, Kurtz S, Lusk L, Wilson B, Britton V, Hayden K, Hunt S, Hyland J, Kittrell W, Maddox J, Tanner A, Tucker V. Implementation of a Colorectal Surgical Site Infection Prevention Bundle and Checklist: A Quality Improvement Project. AORN J 2023; 118:297-305. [PMID: 37882597 DOI: 10.1002/aorn.14020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 10/10/2022] [Accepted: 11/25/2022] [Indexed: 10/27/2023]
Abstract
After noting an elevated surgical site infection rate in 2019 associated with colorectal surgeries, leaders at two Central Virginia health system hospitals convened an interdisciplinary team to audit current practices and research infection prevention strategies. After identifying a lack of standardization in care processes for colorectal surgery patients and reviewing the literature on colorectal bundles, the team created a bundle focusing on the use of antibiotics, chlorhexidine gluconate wipes or baths, separate closing instrument trays, nasal decolonization, bowel preparation, and maintaining patient normothermia. After synthesis and stakeholder input, the team implemented the colorectal bundle along with a checklist for all users to complete to ensure compliance and standardization of practice and for auditing purposes. Implementation results were positive: the total number of colorectal infections decreased from nine in 2020 to three in 2021. Education was critical to securing staff member engagement for successful implementation of and compliance with the bundle.
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Brockman A, Krupp A, Bach C, Mu J, Vasilevskis EE, Tan A, Mion LC, Balas MC. Clinicians' perceptions on implementation strategies used to facilitate ABCDEF bundle adoption: A multicenter survey. Heart Lung 2023; 62:108-115. [PMID: 37399777 PMCID: PMC10592449 DOI: 10.1016/j.hrtlng.2023.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 06/02/2023] [Accepted: 06/06/2023] [Indexed: 07/05/2023]
Abstract
BACKGROUND Intensive care unit (ICU) clinicians struggle to routinely implement the ICU Liberation bundle (ABCDEF bundle). As a result, critically ill patients experience increased risk of morbidity and mortality. Despite extensive research related to the barriers and facilitators of bundle use, little is known regarding which implementation strategies are used to facilitate its adoption and sustainability. OBJECTIVES To identify implementation strategies used to increase adoption of the ABCDEF bundle and how those strategies are perceived by end-users (i.e., ICU clinicians) related to their helpfulness, acceptability, feasibility, and cost. METHODS We conducted a national, cross-sectional survey of ICU clinicians from the 68 ICU sites that previously participated in the Society of Critical Care Medicine's ICU Liberation Collaborative. The survey was structured using the 73 Expert Recommendations for Implementing Change (ERIC) implementation strategies. Surveys were delivered electronically to site contacts. RESULTS Nineteen ICUs (28%) returned completed surveys. Sites used 63 of the 73 ERIC implementation strategies, with frequent use of strategies that may be readily available to clinicians (e.g., providing educational meetings or ongoing training), but less use of strategies that require changes to well-established organizational systems (e.g., alter incentive allowance structure). Overall, sites described the ERIC strategies used in their implementation process to be moderately helpful (mean score >3<4 on a 5-point Likert scale), somewhat acceptable and feasible (mean score >2<3), and either not-at-all or somewhat costly (mean scores >1<3). CONCLUSIONS Our results show a potential over-reliance on accessible strategies and the possible benefit of unused ERIC strategies related to changing infrastructure and utilizing financial strategies.
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Affiliation(s)
- Audrey Brockman
- The Ohio State University College of Nursing, 1585 Neil Avenue, Columbus, OH. 43210. USA.
| | - Anna Krupp
- The University of Iowa College of Nursing, 50 Newton Rd, CNB 480, Iowa City, IA. 52246. USA
| | - Christina Bach
- University of Nebraska Medical Center College of Nursing, 985330 Nebraska Medical Center, Omaha, NE. 68198-5330. USA
| | - Jinjian Mu
- The Ohio State University College of Nursing, Center for Research and Health Analytics 1585 Neil Avenue, Columbus, OH. 43210. USA
| | - Eduard E Vasilevskis
- Center for Clinical Quality and Implementation Science, Section of Hospital Medicine, Department of Medicine, Vanderbilt University Medical Center, 2525 West End, Suite 450, Nashville, TN 37027. USA
| | - Alai Tan
- The Ohio State University College of Nursing, Center for Research and Health Analytics 1585 Neil Avenue, Columbus, OH. 43210. USA
| | - Lorraine C Mion
- The Ohio State University College of Nursing, 1585 Neil Avenue, Columbus, OH. 43210. USA
| | - Michele C Balas
- University of Nebraska Medical Center College of Nursing, 985330 Nebraska Medical Center, Omaha, NE. 68198-5330. USA
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Yilmazer T, Tuzer H. Effectiveness of a Pressure Injury Prevention Care Bundle; Prospective Interventional Study in Intensive Care Units. J Wound Ostomy Continence Nurs 2022; 49:226-232. [PMID: 35523237 DOI: 10.1097/won.0000000000000875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to assess the effectiveness of a pressure injury prevention care bundle. DESIGN Prospective interventional study. SUBJECTS AND SETTING Participants were 13 nurses and 104 patients cared for in the intensive care unit for at least 24 hours in a university hospital in Ankara, Turkey. METHODS The study was conducted in 2 stages: the pre-care and post-care bundle stages. In the pre-care bundle stage, the pressure injury incidence of the patients was followed by the nurses. At the end of the third month, the researcher held a 1-day training program for the nurses about the care bundle use to promote correct implementation. In the post-care bundle stage, the nurses provided care according to the bundle. Compliance with the care bundle was assessed. Pressure injury incidence rates in the pre- and post-care bundle stages were compared. RESULTS The incidence of stage 1 pressure injury was 15.11 (1000 patient-days) in the pre-care bundle stage and 6.79 (1000 patient-days) in the post-care bundle stage; this reduction was not statistically significant. CONCLUSIONS A pressure injury prevention bundle was implemented in an intensive care unit, resulting in a decline in stage 1 pressure injuries.
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Affiliation(s)
- Tuba Yilmazer
- Tuba Yilmazer, PhD, RN , Department of Nursing, Faculty of Health Sciences, Ankara Yildirim Beyazit University, Ankara, Turkey
- Hilal Tuzer, PhD, RN, Department of Nursing, Faculty of Health Sciences, Ankara Yildirim Beyazit University, Ankara, Turkey
| | - Hilal Tuzer
- Tuba Yilmazer, PhD, RN , Department of Nursing, Faculty of Health Sciences, Ankara Yildirim Beyazit University, Ankara, Turkey
- Hilal Tuzer, PhD, RN, Department of Nursing, Faculty of Health Sciences, Ankara Yildirim Beyazit University, Ankara, Turkey
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Abstract
BACKGROUND Antimicrobial stewardship (AMS) is central to the World Health Organisation Global Action Plan against antimicrobial resistance (AMR). If antibiotics are used without restraint, morbidity and mortality from AMR will continue to increase. In resource-rich settings, AMS can safely reduce antibiotic consumption. However, for children in low- and middle-income countries (LMIC), the impact of different AMS interventions is unknown. AIM To determine the impact of different AMS interventions on antibiotic use and clinical and microbiologic outcomes in children in LMIC. METHODS MEDLINE, Embase and PubMed were searched for studies of AMS interventions in pediatric population in LMIC settings. Controlled trials, controlled before-and-after studies and interrupted time series studies were included. Outcomes assessed were antibiotic use, multidrug-resistant organism (MDRO) rates, clinical outcomes and cost. RESULTS Of 1462 studies, 34 met inclusion criteria including a total population of >5,000,000 in 17 countries. Twenty were in inpatients, 2 in ED, 10 in OPD and 2 in both. Seven studies were randomized controlled trials. All types of interventions reported a positive impact on antibiotic prescribing. AMS bundles with education, and clinical decision tools appeared more effective than guidelines alone. AMS interventions resulted in significantly decreased clinical infections (4/4 studies) and clinical failure (2/2) and reduced MDRO colonization rate (4/4). There was no concomitant increase in mortality (4/4 studies) or length of stay (2/2). CONCLUSION Multiple effective strategies exist to reduce antibiotic consumption in LMIC. However, marked heterogeneity limit conclusions regarding the most effective approach, particularly regarding clinical outcomes. Overall, AMS strategies are important tools in the reduction of MDRO-related morbidity in children in LMIC.
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Affiliation(s)
- Yara-Natalie Abo
- From the Infectious Diseases Unit, Royal Children’s Hospital, Melbourne, Victoria, Australia, Blantyre, Malawi
| | - Bridget Freyne
- Malawi-Liverpool Wellcome Trust Research Programme
- Clinical Infection, Microbiology and Immunology, University of Liverpool, Liverpool, Merseyside, UK
- Department of Paediatrics, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Diana Kululanga
- Malawi-Liverpool Wellcome Trust Research Programme
- Department of Paediatrics, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Penelope A. Bryant
- From the Infectious Diseases Unit, Royal Children’s Hospital, Melbourne, Victoria, Australia, Blantyre, Malawi
- Clinical Paediatrics, Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
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Umemura Y, Abe T, Ogura H, Fujishima S, Kushimoto S, Shiraishi A, Saitoh D, Mayumi T, Otomo Y, Hifumi T, Hagiwara A, Takuma K, Yamakawa K, Shiino Y, Nakada TA, Tarui T, Okamoto K, Kotani J, Sakamoto Y, Sasaki J, Shiraishi SI, Tsuruta R, Masuno T, Takeyama N, Yamashita N, Ikeda H, Ueyama M, Gando S. Hour-1 bundle adherence was associated with reduction of in-hospital mortality among patients with sepsis in Japan. PLoS One 2022; 17:e0263936. [PMID: 35157744 PMCID: PMC8843226 DOI: 10.1371/journal.pone.0263936] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 01/30/2022] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The updated Surviving Sepsis Campaign guidelines recommend a 1-hour window for completion of a sepsis care bundle; however, the effectiveness of the hour-1 bundle has not been fully evaluated. The present study aimed to evaluate the impact of hour-1 bundle completion on clinical outcomes in sepsis patients. METHODS This was a multicenter, prospective, observational study conducted in 17 intensive care units in tertiary hospitals in Japan. We included all adult patients who were diagnosed as having sepsis by Sepsis-3 and admitted to intensive care units from July 2019 to August 2020. Impacts of hour-1 bundle adherence and delay of adherence on risk-adjusted in-hospital mortality were estimated by multivariable logistic regression analyses. RESULTS The final study cohort included 178 patients with sepsis. Among them, 89 received bundle-adherent care. Completion rates of each component (measure lactate level, obtain blood cultures, administer broad-spectrum antibiotics, administer crystalloid, apply vasopressors) within 1 hour were 98.9%, 86.2%, 51.1%, 94.9%, and 69.1%, respectively. Completion rate of all components within 1 hour was 50%. In-hospital mortality was 18.0% in the patients with and 30.3% in the patients without bundle-adherent care (p = 0.054). The adjusted odds ratio of non-bundle-adherent versus bundle-adherent care for in-hospital mortality was 2.32 (95% CI 1.09-4.95) using propensity scoring. Non-adherence to obtaining blood cultures and administering broad-spectrum antibiotics within 1 hour was related to in-hospital mortality (2.65 [95% CI 1.25-5.62] and 4.81 [95% CI 1.38-16.72], respectively). The adjusted odds ratio for 1-hour delay in achieving hour-1 bundle components for in-hospital mortality was 1.28 (95% CI 1.04-1.57) by logistic regression analysis. CONCLUSION Completion of the hour-1 bundle was associated with lower in-hospital mortality. Obtaining blood cultures and administering antibiotics within 1 hour may have been the components most contributing to decreased in-hospital mortality.
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Affiliation(s)
- Yutaka Umemura
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka, Japan
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Toshikazu Abe
- Department of Emergency and Critical Care Medicine, Tsukuba Memorial Hospital, Tsukuba, Japan
- Health Services Research and Development Center, University of Tsukuba, Tsukuba, Japan
- Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Japan
- * E-mail:
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Seitato Fujishima
- Center for General Medicine Education, Keio University School of Medicine, Tokyo, Japan
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | | | - Daizoh Saitoh
- Division of Traumatology, Research Institute, National Defense Medical College, Tokorozawa, Japan
| | - Toshihiko Mayumi
- Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Yasuhiro Otomo
- Trauma and Acute Critical Care Center, Medical Hospital, Tokyo Medical and Dental University, Tokyo, Japan
| | - Toru Hifumi
- Department of Emergency and Critical Care Medicine, St. Luke’s International Hospital, Tokyo, Japan
| | - Akiyoshi Hagiwara
- Center Hospital of the National Center for Global Health and Medicine, Tokyo, Japan
| | - Kiyotsugu Takuma
- Emergency & Critical Care Center, Kawasaki Municipal Kawasaki Hospital, Kawasaki, Japan
| | - Kazuma Yamakawa
- Department of Emergency Medicine, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Yasukazu Shiino
- Department of Acute Medicine, Kawasaki Medical School, Okayama, Japan
| | - Taka-aki Nakada
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Takehiko Tarui
- Department of Emergency Medical Care, Kyorin University Faculty of Health Sciences, Tokyo, Japan
| | - Kohji Okamoto
- Department of Surgery, Center for Gastroenterology and Liver Disease, Kitakyushu City Yahata Hospital, Kitakyushu, Japan
| | - Joji Kotani
- Division of Disaster and Emergency Medicine, Department of Surgery Related, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yuichiro Sakamoto
- Emergency and Critical Care Medicine, Saga University Hospital, Saga, Japan
| | - Junichi Sasaki
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Shin-ichiro Shiraishi
- Department of Emergency and Critical Care Medicine, Aizu Chuo Hospital, Fukushima, Japan
| | - Ryosuke Tsuruta
- Advanced Medical Emergency & Critical Care Center, Yamaguchi University Hospital, Yamaguchi, Japan
| | - Tomohiko Masuno
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Naoshi Takeyama
- Advanced Critical Care Center, Aichi Medical University Hospital, Aichi, Japan
| | - Norio Yamashita
- Advanced Emergency Medical Service Center Kurume University Hospital, Kurume, Japan
| | - Hiroto Ikeda
- Department of Emergency Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Masashi Ueyama
- Department of Trauma, Critical Care Medicine, and Burn Center, Japan Community Healthcare Organization, Chukyo Hospital, Nagoya, Japan
- Community Healthcare Organization, Chukyo Hospital, Nagoya, Japan
| | - Satoshi Gando
- Department of Anesthesiology and Critical Medicine, Hokkaido University Faculty of Medicine, Sapporo, Japan
- Department of Acute and Critical Care Medicine, Sapporo Tokushukai Hospital, Sapporo, Japan
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Lang E, Neuschwander A, Favé G, Abback PS, Esnault P, Geeraerts T, Harrois A, Hanouz JL, Kipnis E, Leone M, Legros V, Mellati N, Pottecher J, Hamada S, Pirracchio R. Clinical decision support for severe trauma patients: Machine learning based definition of a bundle of care for hemorrhagic shock and traumatic brain injury. J Trauma Acute Care Surg 2022; 92:135-143. [PMID: 34554136 DOI: 10.1097/ta.0000000000003401] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Deviation from guidelines is frequent in emergency situations, and this may lead to increased mortality. Probably because of time constraints, 55% is the greatest reported guidelines compliance rate in severe trauma patients. This study aimed to identify among all available recommendations a reasonable bundle of items that should be followed to optimize the outcome of hemorrhagic shocks (HSs) and severe traumatic brain injuries (TBIs). METHODS We first estimated the compliance with French and European guidelines using the data from the French TraumaBase registry. Then, we used a machine learning procedure to reduce the number of recommendations into a minimal set of items to be followed to minimize 7-day mortality. We evaluated the bundles using an external validation cohort. RESULTS This study included 5,924 trauma patients (1,414 HS and 4,955 TBI) between 2011 and August 2019 and studied compliance to 36 recommendation items. Overall compliance rate to recommendation items was 71.6% and 66.9% for HS and TBI, respectively. In HS, compliance was significantly associated with 7-day decreased mortality in univariate analysis but not in multivariate analysis (risk ratio [RR], 0.91; 95% confidence interval [CI], 0.90-1.17; p = 0.06). In TBI, compliance was significantly associated with decreased mortality in univariate and multivariate analysis (RR, 0.85; 95% CI, 0.75-0.92; p = 0.01). For HS, the bundle included 13 recommendation items. In the validation cohort, when this bundle was applied, patients were found to have a lower 7-day mortality rate (RR, 0.46; 95% CI, 0.27-0.63; p = 0.01). In TBI, the bundle included seven items. In the validation cohort, when this bundle was applied, patients had a lower 7-day mortality rate (RR, 0.55; 95% CI, 0.34-0.71; p = 0.02). DISCUSSION Using a machine-learning procedure, we were able to identify a subset of recommendations that minimizes 7-day mortality following traumatic HS and TBI. These two bundles remain to be evaluated in a prospective manner. LEVEL OF EVIDENCE Care Management, level II.
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Affiliation(s)
- Elodie Lang
- From the Department of Anesthesia and Critical Care Medicine, APHP Hopital Européen Georges Pompidou (E.L., A.N., G.F., S.H.); Department of Anesthesia and Critical Care Medicine, Hôpital Beaujon (P.S.A.), Clichy; Department of Anesthesia and Critical Care Medicine, Hia Sainte Anne (P.E.); Department of Anesthesia and Critical Care Medicine, Chu De Toulouse (T.G.), Toulouse; Department of Anesthesia and Critical Care Medicine, Chu De Bicêtre (A.H.), Le Kremlin Bicêtre France; Department of Anesthesia and Critical Care Medicine, Chu De Caen (J.-L.H.), Caen; Department of Anesthesia and Critical Care Medicine, Chu Lille (E.K.), Lille; Department of Anesthesia and Critical Care Medicine, Hopital Nord (M.L.), Marseille; Department of Anesthesia and Critical Care Medicine, Chu De Reims (V.L.), Reims; Department of Anesthesia and Critical Care Medicine, Chr Metz Thionville (N.M.), Metz; Department of Anesthesia and Critical Care Medicine, Chu Strasbourg (J.P.), Strasbourg, France; Department of Anesthesia and Critical Care Medicine, Zuckerberg San Francisco General Hospital and Trauma Center (R.P.), San Francisco, California
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Curtis K, Kourouche S, Asha S, Considine J, Fry M, Middleton S, Mitchell R, Munroe B, Shaban RZ, D’Amato A, Skinner C, Wiseman G, Buckley T. Impact of a care bundle for patients with blunt chest injury (ChIP): A multicentre controlled implementation evaluation. PLoS One 2021; 16:e0256027. [PMID: 34618825 PMCID: PMC8496821 DOI: 10.1371/journal.pone.0256027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 07/28/2021] [Indexed: 12/03/2022] Open
Abstract
Background Blunt chest injury leads to significant morbidity and mortality. The aim of this study was to evaluate the effect of a multidisciplinary chest injury care bundle (ChIP) on patient and health service outcomes. ChIP provides guidance in three key pillars of care for blunt chest injury—respiratory support, analgesia and complication prevention. ChIP was implemented using a multi-faceted implementation plan developed using the Behaviour Change Wheel. Methods This controlled pre-and post-test study (two intervention and two non-intervention sites) was conducted from July 2015 to June 2019. The primary outcome measures were unplanned Intensive Care Unit (ICU) admissions, non-invasive ventilation use and mortality. Results There were 1790 patients included. The intervention sites had a 58% decrease in non-invasive ventilation use in the post- period compared to the pre-period (95% CI 0.18–0.96). ChIP was associated with 90% decreased odds of unplanned ICU admissions (95% CI 0.04–0.29) at the intervention sites compared to the control groups in the post- period. There was no significant change in mortality. There were higher odds of health service team reviews (surgical OR 6.6 (95% CI 4.61–9.45), physiotherapy OR 2.17 (95% CI 1.52–3.11), ICU doctor OR 6.13 (95% CI 3.94–9.55), ICU liaison OR 55.75 (95% CI 17.48–177.75), pain team OR 8.15 (95% CI 5.52 –-12.03), analgesia (e.g. patient controlled analgesia OR 2.6 (95% CI 1.64–3.94) and regional analgesia OR 8.8 (95% CI 3.39–22.79), incentive spirometry OR 8.3 (95% CI 4.49–15.37) and, high flow nasal oxygen OR 22.1 (95% CI 12.43–39.2) in the intervention group compared to the control group in the post- period. Conclusion The implementation of a chest injury care bundle using behaviour change theory was associated with a sustained improvement in evidence-based practice resulting in reduced unplanned ICU admissions and non-invasive ventilation requirement. Trial registration ANZCTR: ACTRN12618001548224, approved 17/09/2018
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Affiliation(s)
- Kate Curtis
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia
- Emergency Services, Illawarra Shoalhaven Local Health District, Wollongong Hospital, Wollongong, NSW, Australia
- Illawarra Health and Medical Research Institute, University of Wollongong, Wollongong, NSW, Australia
- * E-mail:
| | - Sarah Kourouche
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia
| | - Stephen Asha
- Emergency Department, St George Hospital, Kogarah, NSW, Australia
- St George Clinical School, Faculty of Medicine, University of New South Wales, Kogarah, NSW, Australia
| | - Julie Considine
- School of Nursing and Midwifery and Centre for Quality and Patient Safety Experience in the Institute for Health Transformation, Deakin University, Geelong, VIC, Australia
- Centre for Quality and Patient Safety Experience–Eastern Health Partnership, Box Hill, VIC, Australia
| | - Margaret Fry
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia
- Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
- Northern Sydney Local Health District, Hornsby, NSW, Australia
| | - Sandy Middleton
- Nursing Research Institute, St Vincent’s Health Network Sydney, St Vincent’s Hospital Melbourne, Fitzroy, Australia
- Australian Catholic University, Sydney, NSW, Australia
| | - Rebecca Mitchell
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Macquarie Park, NSW, Australia
| | - Belinda Munroe
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia
- Emergency Services, Illawarra Shoalhaven Local Health District, Wollongong Hospital, Wollongong, NSW, Australia
| | - Ramon Z. Shaban
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia
- Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney, Camperdown, NSW, Australia
- Division of Infectious Diseases and Sexual Health, Department of Infection Prevention and Control, Westmead Hospital and Western Sydney Local Health District, Westmead, NSW, Australia
- New South Wales Biocontainment Centre, Western Sydney Local Health District and New South Wales Health, Warwick Farm, NSW, Australia
| | - Alfa D’Amato
- NSW Activity Based Funding Taskforce, NSW Ministry of Health, Sydney, Australia
| | - Clare Skinner
- Emergency Department, Hornsby Ku-ring-ai Hospital, Hornsby, NSW, Australia
| | - Glen Wiseman
- Emergency Services, Canterbury Hospital, Campsie, NSW, Australia
| | - Thomas Buckley
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia
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Botan V, Law GR, Laparidou D, Rowan E, Smith MD, Ridyard C, Brewster A, Spaight R, Spurr K, Mountain P, Dunmore S, James J, Roberts L, Khunti K, Siriwardena AN. The effects of a leaflet-based intervention, 'Hypos can strike twice', on recurrent hypoglycaemic attendances by ambulance services: A non-randomised stepped wedge study. Diabet Med 2021; 38:e14612. [PMID: 34053095 DOI: 10.1111/dme.14612] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 05/24/2021] [Indexed: 12/18/2022]
Abstract
AIMS We aimed to investigate the effect of an intervention in which ambulance personnel provided advice supported by a booklet-'Hypos can strike twice'-issued following a hypoglycaemic event to prevent future ambulance attendances. METHODS We used a non-randomised stepped wedge-controlled design. The intervention was introduced at different times (steps) in different areas (clusters) of operation within East Midlands Ambulance Service NHS Trust (EMAS). During the first step (T0), no clusters were exposed to the intervention, and during the last step (T3), all clusters were exposed. Data were analysed using a general linear mixed model (GLMM) and an interrupted-time series analysis (ITSA). RESULTS The study included 4825 patients (mean age 65.42 years, SD 19.42; 2,166 females) experiencing hypoglycaemic events attended by EMAS. GLMM indicated a reduction in the number of unsuccessful attendances (i.e., attendance followed by a repeat attendance) in the final step of the intervention when compared to the first (odds ratio OR: 0.50, 95%CI: 0.33-0.76, p = 0.001). ITSA indicated a significant decrease in repeat ambulance attendances for hypoglycaemia-relative to the pre-intervention trend (p = 0.008). Furthermore, the hypoglycaemia care bundle was delivered in 66% of attendances during the intervention period, demonstrating a significant level of practice change (p < 0.001). CONCLUSION The 'Hypos can strike twice' intervention had a positive effect on reducing numbers of repeat attendances for hypoglycaemia and in achieving the care bundle. The study supports the use of information booklets by ambulance clinicians to prevent future attendances for recurrent hypoglycaemic events.
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Affiliation(s)
- Vanessa Botan
- Community and Health Research Unit and Lincoln Clinical Trials Unit, School of Health and Social Care, University of Lincoln, Lincoln, UK
| | - Graham R Law
- Community and Health Research Unit and Lincoln Clinical Trials Unit, School of Health and Social Care, University of Lincoln, Lincoln, UK
| | - Despina Laparidou
- Community and Health Research Unit and Lincoln Clinical Trials Unit, School of Health and Social Care, University of Lincoln, Lincoln, UK
| | - Elise Rowan
- Community and Health Research Unit and Lincoln Clinical Trials Unit, School of Health and Social Care, University of Lincoln, Lincoln, UK
| | - Murray D Smith
- Community and Health Research Unit and Lincoln Clinical Trials Unit, School of Health and Social Care, University of Lincoln, Lincoln, UK
| | - Colin Ridyard
- Community and Health Research Unit and Lincoln Clinical Trials Unit, School of Health and Social Care, University of Lincoln, Lincoln, UK
| | | | - Robert Spaight
- Clinical Audit and Research Unit, East Midlands Ambulance Service NHS Trust (EMAS), Nottingham, UK
| | | | | | - Sally Dunmore
- Clinical Audit and Research Unit, East Midlands Ambulance Service NHS Trust (EMAS), Nottingham, UK
| | - June James
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Leon Roberts
- Clinical Audit and Research Unit, East Midlands Ambulance Service NHS Trust (EMAS), Nottingham, UK
| | - Kamlesh Khunti
- Leicester Diabetes Centre, University of Leicester, Leicester, UK
| | - Aloysius N Siriwardena
- Community and Health Research Unit and Lincoln Clinical Trials Unit, School of Health and Social Care, University of Lincoln, Lincoln, UK
- Clinical Audit and Research Unit, East Midlands Ambulance Service NHS Trust (EMAS), Nottingham, UK
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15
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Tolonen M, Lemma A, Vikatmaa P, Peltola E, Mentula P, Björkman P, Leppäniemi A, Sallinen V. The implementation of a pathway and care bundle for the management of acute occlusive arterial mesenteric ischemia reduced mortality. J Trauma Acute Care Surg 2021; 91:480-488. [PMID: 34086659 PMCID: PMC8404963 DOI: 10.1097/ta.0000000000003305] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 05/20/2021] [Accepted: 05/20/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Acute mesenteric ischemia (AMI) is a disease with high mortality and requires a multidisciplinary approach for effective management. A pathway and care bundle were developed and implemented with the objective to reduce mortality. The aim of this retrospective comparative study was to analyze the effects of the pathway on patient management and outcome. METHODS All consecutive patients operated in a secondary and tertiary referral center because of occlusive arterial AMI were identified between 2014 and April 2020. The pathway aimed to increase overall awareness, and hasten and improve diagnostics and management. Patients treated before implementation of the pathway (pregroup, years 2014-2017) were compared with patients treated using the pathway (postgroup, May 2018 to April 2020). Univariate and multivariate analyses were used to compare the groups. RESULTS There were 78 patients in the pregroup and 67 patients in the postgroup with comparable baseline characteristics and disease acuity. The postgroup was more often diagnosed with contrast-enhanced computed tomography (58 [74%] vs. 63 [94%], p = 0.001) and had shorter mean in-hospital delay to operating room (7 hours [interquartile range, 3.5-12.5] vs. 3 hours [interquartile range, 2-11], p = 0.023). Revascularization was done more often in the postgroup (53 [68%] vs. 56 [84%], p = 0.030) especially using endovascular treatment (26 [33%] vs. 43 [64%], p < 0.001). Thirty-day mortality was lower in the postgroup (23 [51%] vs. 17 [25%], p = 0.001). Being managed in the postgroup remained as a protective factor (odds ratio, 0.32; 95% confidence interval, 0.14-0.75; p = 0.008) for 30-day mortality in the multivariate analysis. CONCLUSION Implementing a pathway and care bundle resulted in enhanced regional and in-hospital awareness of AMI, more appropriate computed tomography imaging, shorter in-hospital delays, increased number of revascularizations, and, hence, lower mortality. LEVEL OF EVIDENCE Therapeutic/Care Management, level IV.
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16
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Sleutel MR, Newcomb P, Elling C, Beaverstock L, Peron T. Effect of an Obstetric Hemorrhage Bundle on Clinical Outcomes and Clinician Perceptions. Nurs Womens Health 2021; 25:248-256. [PMID: 34139197 DOI: 10.1016/j.nwh.2021.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 03/16/2021] [Accepted: 04/01/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To examine the effect of an obstetric hemorrhage (OBH) safety bundle on health outcomes and to explore nurses' and physicians' perceptions of using the bundle. DESIGN Descriptive longitudinal study, including review of electronic health records for 79,509 births, and clinician surveys. SETTING Nine hospitals in the southwestern United States. PARTICIPANTS 685 maternity nurses and 210 obstetricians. INTERVENTIONS/MEASUREMENTS Retrospective and prospective data collection over 3.5 years to examine selected health outcomes before and after implementing an OBH bundle. A 10-item questionnaire was used to survey clinicians for their perceptions of bundle use. The Hospital Survey on Patient Safety Culture was used to explore nurses' views of the safety climate before and after bundle implementation. RESULTS Statistically significant decreases in mean documented blood loss were observed with bundle use. Blood loss rates of less than 500 ml and greater than 1,000 ml increased, and blood loss rates of 500 to 1,000 ml decreased. Use of postpartum hemorrhage medications increased. When adjusted for multiple tests, there was no statistically significant difference in the rates of postpartum hysterectomies or ICU admissions or in length of stay. Clinicians' perceptions of bundle use were positive, with scores ranging from 6 to 8 on a scale of 1 to 10. However, Hospital Survey on Patient Safety Culture results indicated a decrease in nurses' perceptions of safety after bundle implementation. CONCLUSION OBH bundles provide tools and guidance to improve perinatal care and outcomes. Our findings of lower mean blood loss, increased use of postpartum hemorrhage medications, and positive perceptions of the bundle differed from findings of previous studies. Nurses' perceptions of safety decreased, yet clinicians reported that care was safer with the OBH bundle. Nurses' commitment and collaboration are vital to the success of bundle implementation.
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Widdows K, Roberts SA, Camacho EM, Heazell AEP. Stillbirth rates, service outcomes and costs of implementing NHS England's Saving Babies' Lives care bundle in maternity units in England: A cohort study. PLoS One 2021; 16:e0250150. [PMID: 33872334 PMCID: PMC8055032 DOI: 10.1371/journal.pone.0250150] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 04/01/2021] [Indexed: 11/30/2022] Open
Abstract
Objective To assess implementation of the Saving Babies Lives (SBL) Care Bundle, a collection of practice recommendations in four key areas, to reduce stillbirth in England. Design A retrospective cohort study of 463,630 births in 19 NHS Trusts in England using routinely collected electronic data supplemented with case note audit (n = 1,658), and surveys of service users (n = 2,085) and health care professionals (n = 1,064). The primary outcome was stillbirth rate. Outcome rates two years before and after the nominal SBL implementation date were derived as a measure of change over the implementation period. Data were collected on secondary outcomes and process outcomes which reflected implementation of the SBL care bundle. Results The total stillbirth rate, declined from 4.2 to 3.4 per 1,000 births between the two time points (adjusted Relative Risk (aRR) 0.80, 95% Confidence Interval (95% CI) 0.70 to 0.91, P<0.001). There was a contemporaneous increase in induction of labour (aRR 1.20 (95%CI 1.18–1.21), p<0.001) and emergency Caesarean section (aRR 1.10 (95%CI 1.07–1.12), p<0.001). The number of ultrasound scans performed (aRR 1.25 (95%CI 1.21–1.28), p<0.001) and the proportion of small for gestational age infants detected (aRR 1.59 (95%CI 1.32–1.92), p<0.001) also increased. Organisations reporting higher levels of implementation had improvements in process measures in all elements of the care bundle. An economic analysis estimated the cost of implementing the care bundle at ~£140 per birth. However, neither the costs nor changes in outcomes could be definitively attributed to implementation of the SBL care bundle. Conclusions Implementation of the SBL care bundle increased over time in the majority of sites. Implementation was associated with improvements in process outcomes. The reduction in stillbirth rates in participating sites exceeded that reported nationally in the same timeframe. The intervention should be refined to identify women who are most likely to benefit and minimise unwarranted intervention. Trial registration The study was registered on (NCT03231007); www.clinicaltrials.gov.
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Affiliation(s)
- Kate Widdows
- Faculty of Biological, Medical and Health, Maternal and Fetal Health Research Centre, School of Medical Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Stephen A. Roberts
- Centre for Biostatistics, School of Health Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Elizabeth M. Camacho
- Manchester Centre for Health Economics, School of Health Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Alexander E. P. Heazell
- Faculty of Biological, Medical and Health, Maternal and Fetal Health Research Centre, School of Medical Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
- St. Mary’s Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
- * E-mail:
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18
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Press VG, Myers LC, Feemster LC. Preventing COPD Readmissions Under the Hospital Readmissions Reduction Program: How Far Have We Come? Chest 2021; 159:996-1006. [PMID: 33065106 PMCID: PMC8501005 DOI: 10.1016/j.chest.2020.10.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 09/10/2020] [Accepted: 10/01/2020] [Indexed: 01/06/2023] Open
Abstract
The Hospital Readmissions Reduction Program (HRRP) was developed and implemented by the Centers for Medicare & Medicaid Services to curb the rate of 30-day hospital readmissions for certain common, high-impact conditions. In October 2014, COPD became a target condition for which hospitals were penalized for excess readmissions. The appropriateness, utility, and potential unintended consequences of the metric have been a topic of debate since it was first enacted. Nevertheless, there is evidence that hospital policies broadly implemented in response to the HRRP may have been responsible for reducing the rate of readmissions following COPD hospitalizations even before it was added as a target condition. Since the addition of the COPD condition to the HRRP, several predictive models have been developed to predict COPD survival and readmissions, with the intention of identifying modifiable risk factors. A number of interventions have also been studied, with mixed results. Bundled care interventions using the electronic health record and patient education interventions for inhaler education have been shown to reduce readmissions, whereas pulmonary rehabilitation, follow-up visits, and self-management programs have not been consistently shown to do the same. Through this program, COPD has become recognized as a public health priority. However, 5 years after COPD became a target condition for HRRP, there continues to be no single intervention that reliably prevents readmissions in this patient population. Further research is needed to understand the long-term effects of the policy, the role of competing risks in measuring quality, the optimal postdischarge care for patients with COPD, and the integrated use of predictive modeling and advanced technologies to prevent COPD readmissions.
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Affiliation(s)
- Valerie G Press
- Section of General Internal Medicine University of Chicago Medicine.
| | - Laura C Myers
- Divisions of Research and Pulmonary/Critical Care Medicine, Kaiser Permanente Northern California
| | - Laura C Feemster
- Division of Pulmonary, Critical Care, and Sleep Medicine, VA Puget Sound Health Care System
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Smith V, Devane D, Nichol A, Roche D. Care bundles for improving outcomes in patients with COVID-19 or related conditions in intensive care - a rapid scoping review. Cochrane Database Syst Rev 2020; 12:CD013819. [PMID: 33348427 PMCID: PMC8078496 DOI: 10.1002/14651858.cd013819] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the strain of coronavirus that causes coronavirus disease 2019 (COVID-19) can cause serious illness in some people resulting in admission to intensive care units (ICU) and frequently, ventilatory support for acute respiratory failure. Evaluating ICU care, and what is effective in improving outcomes for these patients is critical. Care bundles, a small set of evidence-based interventions, delivered together consistently, may improve patient outcomes. To identify the extent of the available evidence on the use of care bundles in patients with COVID-19 in the ICU, the World Health Organization (WHO) commissioned a scoping review to inform WHO guideline discussions. This review does not assess the effectiveness of the findings, assess risk of bias, or assess the certainty of the evidence (GRADE). As this review was commissioned to inform guideline discussions, it was done rapidly over a three-week period from 26 October to 18 November 2020. OBJECTIVES To identify and describe the available evidence on the use of care bundles in the ICU for patients with COVID-19 or related conditions (acute respiratory distress syndrome (ARDS) viral pneumonia or pneumonitis), or both. In carrying out the review the focus was on characterising the evidence base and not evaluating the effectiveness or safety of the care bundles or their component parts. SEARCH METHODS We searched MEDLINE, Embase, the Cochrane Library (CENTRAL and the Cochrane COVID-19 Study Register) and the WHO International Clinical Trials Registry Platform on 26 October 2020. SELECTION CRITERIA Studies of all designs that reported on patients who are critically ill with COVID-19, ARDS, viral pneumonia or pneumonitis, in the ICU setting, where a care bundle was implemented in providing care, were eligible for inclusion. One review author (VS) screened all records on title and abstract. A second review author (DR) checked 20% of excluded and included records; agreement was 99.4% and 100% respectively on exclude/include decisions. Two review authors (VS and DR) independently screened all records at full-text level. VS and DR resolved any disagreements through discussion and consensus, or referral to a third review author (AN) as required. DATA COLLECTION AND ANALYSIS One review author (VS) extracted the data and a second review author (DR) checked 20% of this for accuracy. As the review was not designed to synthesise effectiveness data, assess risk of bias, or characterise the certainty of the evidence (GRADE), we mapped the extracted data and presented them in tabular format based on the patient condition; that is patients with confirmed or suspected COVID-19, patients with ARDS, patients with any influenza or viral pneumonia, patients with severe respiratory failure, and patients with mixed conditions. We have also provided a narrative summary of the findings from the included studies. MAIN RESULTS We included 21 studies and identified three ongoing studies. The studies were of variable designs and included a systematic review of standardised approaches to caring for critically ill patients in ICU, including but not exclusive to care bundles (1 study), a randomised trial (1 study), prospective and retrospective cohort studies (4 studies), before and after studies (7 studies), observational quality improvement reports (4 studies), case series/case reports (3 studies) and audit (1 study). The studies were conducted in eight countries, most commonly China (5 studies) and the USA (4 studies), were published between 1999 and 2020, and involved over 2000 participants in total. Studies categorised participant conditions patients with confirmed or suspected COVID-19 (7 studies), patients with ARDS (7 studies), patients with another influenza or viral pneumonia (5 studies), patients with severe respiratory failure (1 study), and patients with mixed conditions (1 study). The care bundles described in the studies involved multiple diverse practices. Guidance on ventilator settings (10 studies), restrictive fluid management (8 studies), sedation (7 studies) and prone positioning (7 studies) were identified most frequently, while only one study mentioned chest X-ray. None of the included studies reported the prespecified outcomes ICU-acquired weakness (muscle wasting, weight loss) and users' experience adapting care bundles. Of the remaining prespecified outcomes, 14 studies reported death in ICU, nine reported days of ventilation (or ventilator-free days), nine reported length of stay in ICU in days, five reported death in hospital, three reported length of stay in hospital in days, and three reported adherence to the bundle. AUTHORS' CONCLUSIONS This scoping review has identified 21 studies on care bundle use in critically ill patients in ICU with COVID-19, ARDS, viral influenza or pneumonia and severe respiratory failure. The data for patients with COVID-19 specifically are limited, derived mainly from observational quality improvement or clinical experiential accounts. Research is required, urgently, to further assess care bundle use and optimal components of these bundles in this patient cohort. The care bundles described were also varied, with guidance on ventilator settings described in 10 care bundles, while chest X-ray was part mentioned in one care bundle in one study only. None of the studies identified in this scoping review measured users' experience of adapting care bundles. Optimising care bundle implementation requires that the components of the care bundle are collectively and consistently applied. Data on challenges, barriers and facilitators to implementation are needed. A formal synthesis of the outcome data presented in this review and a critical appraisal of the evidence is required by a subsequent effectiveness review. This subsequent review should further explore effect estimates across the included studies.
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Affiliation(s)
- Valerie Smith
- School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland
| | - Declan Devane
- School of Nursing and Midwifery, National University of Ireland Galway, Galway, Ireland
- HRB-Trials Methodology Research Network, National University of Ireland Galway, Galway, Ireland
- Evidence Synthesis Ireland and Cochrane Ireland, Galway, Ireland
| | - Alistair Nichol
- University College Dublin, Dublin, Ireland
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia and The Department of Intensive Care, The Alfred Hospital, Melbourne, Australia
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Jha P, Woodward CS, Gardner H, Pietz C, Husain SA. A Quality Improvement Initiative to Reduce Surgical Site Infections in Patients Undergoing Delayed Sternal Closure After Pediatric Cardiac Surgery. Pediatr Cardiol 2020; 41:1402-1407. [PMID: 32556486 DOI: 10.1007/s00246-020-02396-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 06/12/2020] [Indexed: 11/30/2022]
Abstract
Sternal wound infections (SWI) in delayed sternal closure (DSC) patients are a healthcare burden after congenital heart surgery. There are no guidelines specific for pediatric DSC patients to prevent this costly complication. The hypothesis was that the modifications to a bundled approach for DSC patients would decrease the SWI rate. For this prospective cohort study, DSC patients were postoperatively admitted to a pediatric cardiac care unit from February 2017 to January 2018. Using a modified protocol for prevention of SWI, the infection rates pre- and post-modified protocol were compared. The primary outcome measure was SWI. Secondary outcome measures were compliance with modifications. Retrospective review of cases in pre-protocol modification era from January 1, 2014 to December 31, 2016 showed 377 pediatric cardiopulmonary bypass cases and 39 (10.4%) underwent DSC. During the post-protocol modification era, there were 129 cardiopulmonary bypass cases and 17 (13%) DSC cases. The SWI rate in DSC were 7.7% and 0% for pre-intervention and post-intervention, respectively (p = 0.52). The Bayesian confidence interval with Jeffreys prior gives a 95% confidence interval of 1.5% to 18.3% for pre-intervention and 0 to 13.5% for post-intervention. Compliance with the protocol bundle during the post protocol era was 93-100%. Although preliminary results are not statistically significant due to cohort size, the economic burden and increased LOS for each SWI is clinically significant. The early results of reduced infections for DSC patients using a modified bundle approach appear promising. Continued study and a multicenter project would be beneficial.
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Affiliation(s)
- Prashant Jha
- Division of Critical Care, Department of Pediatrics, Children's Hospital of Nevada, University Medical Center, 1800 W Charleston Blvd, Las Vegas, NV, 89128, USA.
- Department of Pediatrics, University of Nevada at Las Vegas, Las Vegas, NV, USA.
| | - Cathy S Woodward
- Pediatric Services, University Hospital - University Health System, 4502 Medical Dr, San Antonio, TX, 78229, USA
- Division of Pediatric Critical Care, Department of Pediatrics, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Heather Gardner
- Pediatric Services, University Hospital - University Health System, 4502 Medical Dr, San Antonio, TX, 78229, USA
- Division of Pediatric Critical Care, Department of Pediatrics, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Clinton Pietz
- Pediatric Services, University Hospital - University Health System, 4502 Medical Dr, San Antonio, TX, 78229, USA
- Division of Pediatric Critical Care, Department of Pediatrics, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - S Adil Husain
- Division of Pediatric Cardiothoracic Surgery, The University of Utah's School of Medicine, Salt Lake City, UT, USA
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Whitmore KA, Townsend SC, Laupland KB. Management of tracheostomies in the intensive care unit: a scoping review. BMJ Open Respir Res 2020; 7:e000651. [PMID: 32723731 PMCID: PMC7390235 DOI: 10.1136/bmjresp-2020-000651] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 06/20/2020] [Accepted: 06/25/2020] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVES While there is an extensive body of literature surrounding the decision to insert, and methods for inserting, a tracheostomy, the optimal management of tracheostomies within the intensive care unit (ICU) from after insertion until ICU discharge is not well understood. The objective was to identify and map the key concepts relating to, and identify research priorities for, postinsertion management of adult patients with tracheostomies in the ICU. DESIGN Scoping review of the literature. DATA SOURCES PubMed, Embase and Cumulative Index to Nursing and Allied Health Literature were searched from inception to 3 October 2019. Additional sources were searched for published and unpublished literature. ELIGIBILITY CRITERIA We included studies of any methodology that addressed the a priori key questions relating to tracheostomy management in the ICU. No restrictions were placed on language or year of publication. DATA EXTRACTION AND SYNTHESIS Titles and abstracts were screened by two reviewers. Studies that met inclusion criteria were reviewed in full by two reviewers, with discrepancies resolved by a third. Data were extracted for included studies, and results mapped along the prespecified research questions. RESULTS 6132 articles were screened, and 102 articles were included for detailed analysis. Protocolised weaning was found to be successful in liberating patients from the ventilator in several cohort studies. Observational studies showed that strategies that use T-pieces and high-flow oxygen delivery improve weaning success. Several lines of evidence, including one clinical trial, support early cuff deflation as a safe and effective strategy as it results in a reduced time to wean, shorter ICU stays and fewer complications. Early tracheostomy downsizing and/or switching to cuffless tubes was found to be of benefit in one study. A substantial body of evidence supports the use of speaking valves to facilitate communication. While this does not influence time to wean or incidence of complications, it is associated with a major benefit in patient satisfaction and experience. Use of care bundles and multidisciplinary team approaches have been associated with reduced complications and improved outcomes in several observational studies. CONCLUSIONS The limited body of evidence supports use of weaning protocols, early cuff deflation, use of speaking valves and multidisciplinary approaches. Clinical trials examining post-tracheostomy management strategies in ICUs are a priority.
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Affiliation(s)
- Kirsty A Whitmore
- Department of Intensive Care Services, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Saint Lucia, Queensland, Australia
| | - Shane C Townsend
- Department of Intensive Care Services, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Kevin B Laupland
- Department of Intensive Care Services, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
- Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
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Davidson C, Enns J, Dempster C, Lundeen S, Eppes C. Impact of a surgical site infection bundle on cesarean delivery infection rates. Am J Infect Control 2020; 48:555-559. [PMID: 31706549 DOI: 10.1016/j.ajic.2019.09.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 09/05/2019] [Accepted: 09/06/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND This study investigated cesarean delivery surgical site infection (SSI) rates before and after implementation of a SSI care bundle. METHODS A SSI bundle for cesareans was introduced in our hospital in April 2014 to reduce the SSI rate. The practices were divided into bundle elements that reflected preoperative, intraoperative, and postoperative care. We conducted a retrospective cohort study to evaluate implementation of the SSI care bundle. Women were included if they had a gestational age of at least 23 0/7 weeks and delivered a liveborn neonate(s) between 2012 and 2015. They were then divided into 2 study groups: pre-bundle and post-bundle. The primary study outcome was SSI rate. Secondary outcomes included comorbidities, perioperative factors, and SSI classification. RESULTS The overall incidence of cesarean SSIs during the study time period was 1.89 (76 SSIs in 4014 cesarean deliveries). The pre-bundle mean was 2.44 and decreased to 1.1 following implementation of the SSI bundle (P = .013). This represents a 221% reduction in the SSI rate. Patient demographics and pre-existing medical conditions were similar pre- and post-bundle. Compliance with bundle elements was high. CONCLUSIONS A significant reduction in SSI rate in cesarean deliveries was seen following implementation of an infection prevention bundle.
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Affiliation(s)
- Christina Davidson
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Baylor College of Medicine, Houston, Texas.
| | - Jordan Enns
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Baylor College of Medicine, Houston, Texas
| | - Carrie Dempster
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Baylor College of Medicine, Houston, Texas
| | | | - Catherine Eppes
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Baylor College of Medicine, Houston, Texas
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Stollings JL, Devlin JW, Lin JC, Pun BT, Byrum D, Barr J. Best Practices for Conducting Interprofessional Team Rounds to Facilitate Performance of the ICU Liberation (ABCDEF) Bundle. Crit Care Med 2020; 48:562-570. [PMID: 32205603 DOI: 10.1097/ccm.0000000000004197] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Daily ICU interprofessional team rounds, which incorporate the ICU Liberation ("A" for Assessment, Prevention, and Manage Pain; "B" for Both Spontaneous Awakening Trials and Spontaneous Breathing Trials; "C" for Choice of Analgesia and Sedation; "D" for Delirium Assess, Prevent, and Manage; "E" for Early Mobility and Exercise; "F" for Family Engagement and Empowerment [ABCDEF]) Bundle, support both the care coordination and regular provider communication necessary for Bundle execution. This article describes evidence-based practices for conducting effective interprofessional team rounds in the ICU to improve Bundle performance. DESIGN Best practice synthesis. METHODS The authors, each extensively involved in the Society of Critical Care Medicine's ICU Liberation Campaign, reviewed the pertinent literature to identify how ICU interprofessional team rounds can be optimized to increase ICU Liberation adherence. RESULTS Daily ICU interprofessional team rounds that foster ICU Liberation Bundle use support both care coordination and regular provider communication within and between teams. Evidence-based best practices for conducting effective interprofessional team rounds in the ICU include the optimal structure for ICU interprofessional team rounds; the importance of conducting rounds at patients' bedside; essential participants in rounds; the inclusion of ICU patients and their families in rounds-based discussions; and incorporation of the Bundle into the Electronic Health Record. Interprofessional team rounds in the ICU ideally employ communication strategies to foster inclusive and supportive behaviors consistent with interprofessional collaboration in the ICU. Patient care discussions during interprofessional team rounds benefit from being patient-centered and goal-oriented. Documentation of ICU Liberation Bundle elements in the Electronic Health Record may help facilitate team communication and decision-making. CONCLUSIONS Conducting high-quality interprofessional team rounds in the ICU is a key strategy to support ICU Liberation Bundle use.
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Affiliation(s)
- Joanna L Stollings
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN
- Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN
| | - John W Devlin
- School of Pharmacy, Northeastern University, Boston, MA
- Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, MA
| | - John C Lin
- Division of Pediatrics and Critical Care Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Brenda T Pun
- Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN
- Department of Medicine, Pulmonary and Critical Care, Vanderbilt University Medical Center, Nashville, TN
| | - Diane Byrum
- Innovative Solutions for Healthcare Education, LLC, Charlotte, NC
| | - Juliana Barr
- Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, Palo Alto, CA
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA
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Eissa A, Al Rifai H, Abdelmaaboud M, Eldakrouri A, Santos J, Pastoral G, Furigay J, Girish S. Use of extubation bundle including modified spontaneous breathing trial (SBT) to reduce the rate of reintubation, among preterm neonates ≤ 30 weeks. J Neonatal Perinatal Med 2020; 13:359-366. [PMID: 31744023 DOI: 10.3233/npm-190236] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND Respiratory support in the form of mechanical ventilation is a crucial intervention in premature neonates, with respiratory problems. However, prolonged mechanical ventilation and endotracheal intubation may be associated with major adverse effects. The ideal time for extubation is based on clinical and laboratory parameters assessed at the time of planned extubation. However, such parameters are not very objective, which makes extubation in NICUs a trial-and-error approach. OBJECTIVE This work was done to assess the use of extubation bundle including modified spontaneous breathing trial (SBT) (10 minutes) to reduce the rate of reintubation, among preterm neonates≤30 weeks who were mechanically ventilated and extubated to non-invasive ventilation in the NICU, Women's Wellness and Research Center (WWRC), Hamad Medical Corporation (HMC), Doha, Qatar. METHODS A prospective study based on the collection of data regarding preterm neonates≤30 weeks gestation admitted to the NICU, Women's Wellness and Research Center (WWRC), from January, 2015 to December, 2017, who were subjected to mechanical ventilation (MV) and extubation. When the clinical team decides a newborn is ready for extubation based on the extubation bundle, a modified SBT (10 min) is used. RESULTS This study included 465 premature babies from 24-≤30 weeks recruited in the NICU, Women's Wellness and Research Center (WWRC). Extubation bundle with modified SBT was able to predict success of extubation with 95% sensitivity and 90.4% Positive Predictive Value (PPV) in the gestational age (GA) group 24 -≤27 weeks (245) and 95.3% sensitivity and 90% PPV in the GA group > 27 -≤30 weeks (220). As expected, successfully extubated babies had a higher GA and weighed more at extubation, compared to babies who required re-intubation. CONCLUSION We recommend the extubation bundle with modified SBT prior to elective extubation to be used in predicting successful extubation in premature babies. Guidelines for extubation among premature babies are needed in order to reduce unnecessary exposure to adverse effects of mechanical ventilation.
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Affiliation(s)
- A Eissa
- Neonatal Intensive Care Unit, Women's Wellness and Research Center (WWRC), Hamad Medical Corporation (HMC), Doha, Qatar
| | - H Al Rifai
- Neonatal Intensive Care Unit, Women's Wellness and Research Center (WWRC), Hamad Medical Corporation (HMC), Doha, Qatar
| | - M Abdelmaaboud
- Neonatal Intensive Care Unit, Women's Wellness and Research Center (WWRC), Hamad Medical Corporation (HMC), Doha, Qatar
| | - A Eldakrouri
- Neonatal Intensive Care Unit, Women's Wellness and Research Center (WWRC), Hamad Medical Corporation (HMC), Doha, Qatar
| | - J Santos
- Neonatal Intensive Care Unit, Women's Wellness and Research Center (WWRC), Hamad Medical Corporation (HMC), Doha, Qatar
| | - G Pastoral
- Neonatal Intensive Care Unit, Women's Wellness and Research Center (WWRC), Hamad Medical Corporation (HMC), Doha, Qatar
| | - J Furigay
- Neonatal Intensive Care Unit, Women's Wellness and Research Center (WWRC), Hamad Medical Corporation (HMC), Doha, Qatar
| | - S Girish
- Neonatal Intensive Care Unit, Women's Wellness and Research Center (WWRC), Hamad Medical Corporation (HMC), Doha, Qatar
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Abstract
To date, efforts to reduce hospital readmissions have centered largely on hospitals. In a recently published environmental scan, we examined the literature focusing on primary care-based efforts to reduce readmissions. While rigorous studies on interventions arising from primary care are limited, we found that multi-component care transitions programs that are initiated early in the hospitalization and are part of broader primary care practice transformation appear most promising. However, policy changes are necessary to spur innovation and support effective primary care-led transitions interventions. Though more rigorous research is needed, our findings suggest that primary care can and should lead future efforts for reducing hospital readmissions.
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Affiliation(s)
- Sonali Saluja
- The Gehr Family Center for Health Systems Science & Innovation, Keck Medicine of USC, 2020 Zonal Avenue, 323 IRD, Los Angeles, CA, 90033, USA.
| | - Michael Hochman
- The Gehr Family Center for Health Systems Science & Innovation, Keck Medicine of USC, 2020 Zonal Avenue, 323 IRD, Los Angeles, CA, 90033, USA
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Green S, Smith MTD, Kong VY, Skinner DL, Bruce JL, Laing GL, Brysiewicz P, Clarke DL. Compliance with the Surviving Sepsis Campaign guidelines for early resuscitation does not translate into improved outcomes in patients with surgical sepsis in South Africa. S AFR J SURG 2019; 57:8-12. [PMID: 31773925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
INTRODUCTION This project set out to audit our compliance with the 3-hour bundles of care for surgical sepsis and to interrogate how compliance or non-compliance impacts on the outcome of surgical sepsis in our institution. METHODS All emergency surgical patients over the age of fifteen years were reviewed. All patients who fulfilled the ACCP/SCCM criteria for sepsis or septic shock, with a documented surgical source of infection, were identified for review. RESULTS A total of 677 septic patients with a documented surgical source of sepsis were included. Of the 677 patients, 53% (360/677) had intra-abdominal sepsis, 17% (116/677) had diabetic-related limb sepsis and the remaining 30% (201) had soft tissue infections. A total of 585 operative procedures were performed. Compliance with all components of the 3-hour bundle metrics was achieved in 379/677 patients (56%), and not achieved in 298/677 patients (44%). The only significant difference between the compliant and the non-compliant groups was respiratory rate greater than 22 breaths/minute (131 vs 71, p = 0.002) in the compliant cohort. Amongst the compliant cohort 77/379 patients (20%) required admission to ICU, whilst 41/298 patients (14%) in the non-compliant cohort required admission to ICU. This difference was statistically different (p = 0.026). There was no difference in the median length of hospital stay (6 days) between the two groups. Fifty-five patients in the compliant cohort died (15%), whilst 31 (10%) of the patients in the non-compliant cohort died. This difference was not statistically different (p = 0.111). CONCLUSION Compliance with the SCC 3-hour bundle did not seem to improve mortality outcomes in our setting. This observation cannot be adequately explained with our current data and further work looking at management of surgical sepsis in our setting is required. Time to surgical source control is probably the single most important determinant of outcome in patients with surgical sepsis and other aspects of the care bundle are of secondary importance.
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Affiliation(s)
- S Green
- Department of Anaesthesia, Critical Care and Pain Management, University of KwaZulu-Natal, Durban, South Africa
| | - M T D Smith
- Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - V Y Kong
- Department of Surgery, University of KwaZulu-Natal, Durban, South Africa and Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
| | - D L Skinner
- Department of Anaesthesia, Critical Care and Pain Management, University of KwaZulu-Natal, Durban, South Africa
| | - J L Bruce
- Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - G L Laing
- Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - P Brysiewicz
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - D L Clarke
- Department of Surgery, University of KwaZulu-Natal, Durban, South Africa and Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
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Croke L. Preventing surgical site infections after gynecologic procedures. AORN J 2019; 110:P8-P10. [PMID: 31355428 DOI: 10.1002/aorn.12790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Morton K, MacNeill S, Sanderson E, Dixon P, King A, Jenkins S, Metcalfe C, Shaw A, Chalder M, Benger J, Hollingworth W, Calvert J, Purdy S. Evaluation of 'care bundles' for patients with chronic obstructive pulmonary disease (COPD): a multisite study in the UK. BMJ Open Respir Res 2019; 6:e000425. [PMID: 31258918 PMCID: PMC6561386 DOI: 10.1136/bmjresp-2019-000425] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 04/05/2019] [Accepted: 05/08/2019] [Indexed: 11/21/2022] Open
Abstract
Background Chronic obstructive pulmonary disease (COPD) accounts for 10% of emergency hospital admissions in the UK annually. Nearly 33% of patients are readmitted within 28 days of discharge. We evaluated the effectiveness of implementing standardised packages of care called 'care bundles' on COPD readmission, emergency department (ED) attendance, mortality, costs and process of care. Methods This is a mixed-methods, controlled before-and-after study with nested case studies. 31 acute hospitals in England and Wales which introduced COPD care bundles (implementation sites) or provided usual care (comparator sites) were recruited and provided monthly aggregate data. 14 sites provided additional individual patient data. Participants were adults admitted with an acute exacerbation of COPD. Results There was no evidence that care bundles reduced 28-day COPD readmission rates: OR=1.02 (95% CI 0.83 to 1.26). However, the rate of ED attendance was reduced in implementation sites over and above that in comparator sites (implementation: IRR=0.63 (95% CI 0.56 to 0.71); comparator: IRR=1.12 (95% CI 1.02 to 1.24); group-time interaction p<0.001). At implementation sites, delivery of all bundle elements was higher but was only achieved in 2.2% (admissions bundle) and 7.6% (discharge bundle) of cases. There was no evidence of cost-effectiveness. Staff viewed bundles positively, believing they help standardise practice and facilitate communication between clinicians. However, they lacked skills in change management, leading to inconsistent implementation. Discussion COPD care bundles were not effectively implemented in this study. They were associated with a reduced number of subsequent ED attendances, but not with change in readmissions, mortality or reduced costs. This is unsurprising given the low level of bundle uptake in implementation sites, and it remains to be determined if COPD care bundles affect patient care and outcomes when they are effectively implemented. Trial registration number ISRCTN13022442.
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Affiliation(s)
- Katherine Morton
- Population Health Sciences, University of Bristol Faculty of Health Sciences, Bristol, UK
| | | | | | - Padraig Dixon
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Anna King
- Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Chris Metcalfe
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Ali Shaw
- Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Jonathan Benger
- Faculty of Health and Life Sciences, University of the West of England, Bristol, UK
- University of the West of England, Bristol, UK
| | | | - James Calvert
- Respiratory Medicine, North Bristol NHS Trust, Bristol, UK
| | - Sarah Purdy
- Bristol Medical School, University of Bristol, Bristol, UK
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Tilmazer T, Tuzer H. Pressure Ulcer Prevention Care Bundle: A Cross-sectional, Content Validation Study. Wound Manag Prev 2019; 65:33-39. [PMID: 31364993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
UNLABELLED A care bundle is an organized set of interventions that encourages compliance with guidelines designed to improve quality of care. PURPOSE This study was conducted to determine the content validity of a previously developed pressure ulcer prevention care bundle. METHODS A cross-sectional study was performed in a university hospital in Turkey among 95 nurses employed in 8 intensive care units (ICUs) who were invited to use and assess a care bundle based on pressure ulcer guidelines found in the literature and developed by researchers. The care bundle included 48 statements divided into 8 categories. Participants in the care bundle content validation completed 3 paper-and-pencil instruments: a nurse demographic information tool, an item-by-item content validation of the care bundle rated on a 4-point Likert scale, and an evaluation of the care bundle's pressure ulcer prevention capabilities using I agree, I do not agree responses to statements regarding comprehensiveness, ability to prevent pressure ulcers, feasibility, implementation, and complexity. Data were collected to a paper form and analyzed using descriptive statistics, mean scores, and the content validity index (CVI). RESULTS Of a total of 95 potential nurse participants, 68 completed the survey instruments (62 [91.2%] women, overall average age 29.9 ± 5.7 years), for a response rate of 71.6%; 57 (83.8%) had bachelors degrees, 36 (52.9%) had between 5 and 10 years of experience, 24 (35.3%) had participated in a pressure ulcer education program, and 41 (69.3%) cared for patients with 1 to 2 pressure ulcers per week. The care bundle's overall mean content validation score was 3.9 ± 0.1; this was deemed valid and appropriate after minor wording modifications on 2 items. Nurses rated the care bundle as comprehensive, feasible, necessary, and helpful for making clinical decisions; 12 participants had concerns regarding its complexity and implementation. CONCLUSION The care bundle may help nurses develop appropriate interventions for patients. Future research should include assessment using larger groups of nurses and construct validation studies.
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Affiliation(s)
- Tuba Tilmazer
- Ankara Yildirim Beyazit University Faculty of Health Sciences, Department of Nursing, Ankara, Turkey
| | - Hilal Tuzer
- Ankara Yildirim Beyazit University Faculty of Health Sciences, Department of Nursing, Ankara, Turkey
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Santos Malavé C, Diggs D, Sampayo EM. Spanish-Speaking Caregivers' Experience with an Emergency Department Pediatric Asthma-Care Bundle Quality Initiative. J Racial Ethn Health Disparities 2019; 6:660-667. [PMID: 30725382 DOI: 10.1007/s40615-019-00564-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 01/19/2019] [Accepted: 01/23/2019] [Indexed: 11/26/2022]
Abstract
Most pediatric emergency departments' (ED) quality improvement (QI) initiatives for asthma aim to standardize care based on the priorities of healthcare providers. Perceptions and priorities of the caregiver rarely are addressed, especially in families with limited English-language proficiency. We explored Spanish-speaking caregivers' perceptions, understandings, and barriers with the care they received for asthma, after exposure to an ED asthma-care bundle. This qualitative study was part of a larger QI initiative on Spanish-speaking caregivers of patients presenting to a children's hospital ED with an asthma exacerbation. Patients were exposed to an asthma-care bundle, which included timely administration of medication, home dose of medications, an educational intervention, asthma action plans (AAPs), and discharge instructions. Through semi-structured interviews and qualitative analyses, we assessed the perceptions, understandings, and barriers caregivers reported during their ED experience. From January 2015 to October 2016, 492 patients received AAPs in the ED. Of 128 families that preferred Spanish, 88 (69%) received a Spanish AAP, 41 (32%) received Spanish discharge instructions, and 34 (27%) received discharge materials in both languages. Thirteen families were interviewed. Three themes emerged regarding the caregivers' perceived barriers: (1) need for improved accessibility to medication, primary care, and insurance; (2) communication barriers, such as timeliness, availability of interpreters, and need for resources in their preferred language; and (3) uncertainty about the child's diagnosis and acuity. Incorporating the caregivers' perspectives into QI projects may yield valuable information when developing new interventions. In the ED, improving accessibility to interpreters and providing discharge materials in their preferred language, as well as addressing misconceptions about asthma, may enhance caregivers' satisfaction.
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Affiliation(s)
- Claritsa Santos Malavé
- Baylor College of Medicine, Texas Children's Hospital, 6621 Fannin St., Houston, TX, 77030, USA.
| | - Dominique Diggs
- Baylor College of Medicine, Texas Children's Hospital, 6621 Fannin St., Houston, TX, 77030, USA
| | - Esther M Sampayo
- Baylor College of Medicine, Texas Children's Hospital, 6621 Fannin St., Houston, TX, 77030, USA
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Abstract
In order to shift US health care towards greater value, the Centers for Medicare & Medicaid Services (CMS) is exploring outpatient episode-based cost measures under the new Quality Payment Program and planning a bundled payment program that will introduce the first ever outpatient episodes of care. One novel approach to capitalize on this paradigm shift and extend bundled payment policies is to engage primary care physicians and specialists by bundling outpatient imaging studies and associated procedures-central tools in disease screening and diagnosis, but also tools that are expensive and susceptible to increasing health care costs and patient harm. For example, both breast and lung cancer screening represent target areas ripe for bundled payment given high associated costs and variation in management strategies and suboptimal care coordination between responsible clinicians. Benefits to imaging-based screening episodes include stronger alignment between providers (primary care physicians, radiologists, and other clinicians), reduction in unwarranted variation, creation of appropriateness standards, and ability to overcome barriers to cancer screening adherence. Implementation considerations include safeguarding against providers inappropriately withholding care as well as ensuring that accountability and financial risk are distributed appropriately among responsible clinicians.
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Affiliation(s)
- Joshua M Liao
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA.
- Leonard Davis Institute of Health Economics, Wharton School, University of Pennsylvania, Philadelphia, PA, USA.
- UW Medicine Value and Systems Science Lab, Seattle, WA, USA.
| | - Anirban Basu
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, School of Pharmacy, University of Washington School of Medicine, Seattle, WA, USA
| | - Christoph I Lee
- Department of Radiology, University of Washington School of Medicine, Seattle, WA, USA
- Fred Hutchinson Cancer Research Center, Hutchinson Institute for Cancer Outcomes Research, Seattle, WA, USA
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Jansson MM, Syrjälä HP, Talman K, Meriläinen MH, Ala-Kokko TI. Critical care nurses' knowledge of, adherence to, and barriers toward institution-specific ventilator bundle. Am J Infect Control 2018; 46:1051-1056. [PMID: 29573832 DOI: 10.1016/j.ajic.2018.02.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Revised: 02/05/2018] [Accepted: 02/05/2018] [Indexed: 12/01/2022]
Abstract
BACKGROUND Although evidence-based practices are known to improve the quality of care, making it cost-efficient and improving clinical results, barriers to transferring research into clinical practice have hindered this process. AIMS To evaluate critical care nurses' knowledge of, adherence to, and barriers toward institution-specific ventilator bundle. MATERIAL AND METHODS In 2015, we conducted an institution-specific, cross-sectional study in a 26-bed adult mixed medical-surgical intensive care unit (ICU) in Finland using quantitative survey of knowledge and self-reported adherence with qualitative gathering of barrier data. A pre-validated multiple-choice Ventilator Bundle Questionnaire was distributed to all registered nurses who were direct care providers (n = 155). RESULTS The final response rate was 55.5% (n = 86), and 47.2% (n = 34) of respondents had more than 10 years of ICU experience. The levels of knowledge and self-reported adherence were 71.1% and 65.8% of the total score, respectively. The level of knowledge was higher among respondents who had received in-service education about ventilator bundle compared with respondents who had not received in-service education (27.0 vs 24.0 [P = .012]). Less experienced nurses reported significantly higher adherence than nurses with more ICU experience (29.0 vs 25.0 [P = .034]). The correlation between knowledge and adherence scores was low (ρ 0.48 [P <.001]). The most well-known and adhered-to guidelines described patient positioning, daily chlorhexidine-based oral care, and strict hand hygiene. The least-known guidelines and those least adhered to described respiratory equipment, management of sedation and analgesia, and practices prior to and during endotracheal suctioning. The main barriers were related to the nurse respondents (e.g., lack of education [25.9%]), environment (e.g., role ambiguities [36.4%] and inadequate resources [21.1%]), and patients (e.g., patient discomfort [4.8%] and fear of adverse effects [4.6%]). CONCLUSIONS Self-reported adherence did not correlate with knowledge and was not related to work experience. Most of the barriers toward evidence-based guidelines indicated a need for changes that are beyond the control of individual nurses.
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Affiliation(s)
- Miia M Jansson
- Division of Intensive Care, Department of Anesthesiology, Oulu University Hospital, Research Group of Surgery, Anesthesiology and Intensive Care, Medical Research Center Oulu, Oulu, Finland.
| | - Hannu P Syrjälä
- Department of Infection Control, Oulu University Hospital, Oulu, Finland
| | - Kirsi Talman
- Department of Nursing Science, University of Turku, Turku, Finland
| | - Merja H Meriläinen
- Division of Intensive Care, Department of Anesthesiology, Oulu University Hospital, Research Group of Surgery, Anesthesiology and Intensive Care, Medical Research Center Oulu, Oulu, Finland
| | - Tero I Ala-Kokko
- Division of Intensive Care, Department of Anesthesiology, Oulu University Hospital, Research Group of Surgery, Anesthesiology and Intensive Care, Medical Research Center Oulu, Oulu, Finland
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Wyler D, Esterlis M, Dennis BB, Ng A, Lele A. Challenges of pain management in neurologically injured patients: systematic review protocol of analgesia and sedation strategies for early recovery from neurointensive care. Syst Rev 2018; 7:104. [PMID: 30041695 PMCID: PMC6058380 DOI: 10.1186/s13643-018-0756-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 06/13/2018] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND A recent paradigm shift within the intensive care discipline has led to implementation of protocols to drive early recovery from the intensive care unit (ICU). These protocols belong to a large knowledge, translation and quality improvement initiative lead by the Society of Critical Care Medicine, aiming to "liberate" patients from the ICU. They "bundle" evidence-based elements shown to lower ICU stay and mortality and optimize pain management. The bundled elements focus on Assessing, preventing and managing pain; Both spontaneous awakening trials and spontaneous breathing trials; Choice of analgesia and sedation; assessment, prevention, and management of Delirium; Early mobility and exercise; and Family engagement and empowerment (ABCDEF). It is evident that analgesia and sedation protocols either directly relate to or influence most of the bundle elements. A paucity of literature exists for neurologically injured patients, who create unique challenges to bundle implementation and often have limited external validity in existent studies. We will systematically search the literature, present the unique challenges of neurointensive care patients, conduct a stratified analysis of subgroups of interest, and disseminate the evidence of analgesia and sedation protocols in the neurointensive care unit (NICU). We hope the relevant stakeholders can adapt this information through knowledge translation-to make formal recommendations in clinical practice guidelines or a position statement. METHODS/DESIGN The authors will search MEDLINE (PubMed), EMBASE, Cochrane Library, Cochrane Clinical Trials Registry, World Health Organization International Clinical Trials Registry Platform Search Portal, and the National Institutes for Health Clinical Trials Registry. The title, abstract, and full-text screening will be completed in duplicate, and a Cohen's Kappa coefficient of agreement will be reported. Provided the data retrieved from studies is suitable, results will be combined statistically using meta-analysis. We aim to evaluate the impact of ABCDEF bundle components on multiple endpoints of NICU recovery. Our primary outcomes will be time to successful discontinuation of mechanical ventilation and time to early mobility. The authors will guide the methodological design of the study using the PRISMA-statement and the checklist compliance will be available. DISCUSSION Using the evidence from this systematic review, we anticipate disseminating knowledge of analgesia and sedation protocols in the NICU. The results of this systematic review are imperative to close the knowledge gap in a patient population that is often excluded from studies, and to add to the body of literature aiming to enhance early recovery from the NICU and mitigate iatrogenic harm. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42017078909.
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Affiliation(s)
- David Wyler
- Department of Anesthesiology and Pain Medicine, Thomas Jefferson University, 111 South 11th Street Suite 8490 Gibbon, Philadelphia, PA 19107 USA
- Department of Critical Care Medicine and Neurological Surgery, Thomas Jefferson University, 111 South 11th Street Suite 8490 Gibbon, Philadelphia, PA 19107 USA
| | - Michael Esterlis
- Department of Anesthesia, University of Toronto, Toronto, Canada
- St George’s University of London Medical School, London, UK
| | | | - Andrew Ng
- Department of Anesthesiology and Pain Medicine, Thomas Jefferson University, 111 South 11th Street Suite 8490 Gibbon, Philadelphia, PA 19107 USA
| | - Abhijit Lele
- Department of Anesthesiology and Pain Medicine, University of Washington, Harborview Medical Center, Seattle, USA
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Lee KH, Cho NH, Jeong SJ, Kim MN, Han SH, Song YG. Effect of Central Line Bundle Compliance on Central Line-Associated Bloodstream Infections. Yonsei Med J 2018; 59:376-382. [PMID: 29611399 PMCID: PMC5889989 DOI: 10.3349/ymj.2018.59.3.376] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 02/06/2018] [Accepted: 02/06/2018] [Indexed: 01/07/2023] Open
Abstract
PURPOSE The present study aimed to evaluate the effect of central line (CL) bundle compliance on central line-associated bloodstream infections (CLABSIs) in different departments of the same hospital, including the intensive care unit (ICU) and other departments. MATERIALS AND METHODS The four components of the CL bundle were hand hygiene, use of maximal sterile barrier precautions, chlorhexidine use, and selection of an appropriate site for venous access. Compliance of the CL bundle and CLABSIs were measured for every department [emergency room (ER), ICU, general ward (GW), and operating room (OR)]. A total of 1672 patients were included over 3 years (August 2013 through July 2016). RESULTS A total of 29 CLABSI episodes (1.73%) were identified, and only 53.7% of the patients completed CL bundles. The performance rates of all components of the CL bundle were 22.3%, 28.5%, 36.5%, and 84.6% for the ER, ICU, GW, and OR, respectively. The highest CLABSI rate was observed in patients of the ICU, for whom all components were not performed perfectly. Conversely, the lowest CLABSI rate was observed for patients of GWs, for whom all components were performed. Among individual components, femoral insertion site [relative risk (RR), 2.26; 95% confidence interval (CI), 1.09-4.68], not using a full body drape (RR, 3.55; 95% CI, 1.44-8.71), and not performing all CL bundle components (RR, 2.79; 95% CI, 1.19-6.54) were significant variables associated with CLABSIs. CONCLUSION This study provides direct evidence that completing all CL bundle components perfectly is essential for preventing CLABSIs. Customized education should be provided, according to specific weaknesses of bundle performance.
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Affiliation(s)
- Kyoung Hwa Lee
- Division of Infectious Diseases, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
- Department of Infection Control, Gangnam Severance Hospital, Seoul, Korea
| | - Nan Hyoung Cho
- Department of Infection Control, Gangnam Severance Hospital, Seoul, Korea
| | - Su Jin Jeong
- Division of Infectious Diseases, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
- Department of Infection Control, Gangnam Severance Hospital, Seoul, Korea
| | - Mi Na Kim
- Department of Infection Control, Gangnam Severance Hospital, Seoul, Korea
| | - Sang Hoon Han
- Division of Infectious Diseases, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
- Department of Infection Control, Gangnam Severance Hospital, Seoul, Korea
| | - Young Goo Song
- Division of Infectious Diseases, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
- Department of Infection Control, Gangnam Severance Hospital, Seoul, Korea.
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Wallace SK, Halverson JW, Jankowski CJ, DeJong SR, Weaver AL, Weinhold MR, Borah BJ, Moriarty JP, Cliby WA, Kor DJ, Higgins AA, Otto HA, Dowdy SC, Bakkum-Gamez JN. Optimizing Blood Transfusion Practices Through Bundled Intervention Implementation in Patients With Gynecologic Cancer Undergoing Laparotomy. Obstet Gynecol 2018; 131:891-898. [PMID: 29630007 PMCID: PMC5912961 DOI: 10.1097/aog.0000000000002463] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To examine blood transfusion practices and develop a standardized bundle of interventions to address the high rate of perioperative red blood cell transfusion among patients with ovarian and endometrial cancer. METHODS This was a retrospective cohort study. Our primary aim was to determine whether an implemented bundled intervention was associated with a reduction in perioperative red blood cell transfusions among cases of laparotomy for cancer. Secondary aims included comparing perioperative demographic, surgical, complication, and cost data. Interventions included blood transfusion practice standardization using American Society of Anesthesiologists guidelines, an intraoperative hemostasis checklist, standardized intraoperative fluid status communication, and evidence-based use of tranexamic acid. Prospective data from women undergoing laparotomy for ovarian or endometrial cancer from September 28, 2015, to May 31, 2016, defined the study cohort and were compared with historical controls (September 1, 2014, to September 25, 2015). Outcomes were compared in the full unadjusted cohorts and in propensity-matched cohorts. RESULTS In the intervention and historical cohorts, respectively, 89 and 184 women underwent laparotomy for ovarian cancer (n=74 and 152) or advanced endometrial cancer (n=15 and 32). Tranexamic acid was administered in 54 (60.7%) patients. The perioperative transfusion rate was lower for the intervention group compared with historical controls (18.0% [16/89] vs 41.3% [76/184], P<.001), a 56.4% reduction. This improvement in the intervention group remained significant after propensity matching (16.2% [13/80] vs 36.2% [29/80], P=.004). The hospital readmission rate was also lower for the intervention group compared with historical controls (1.1% [1/89] vs 12.5% [23/184], P=.002); however, this improvement did not attain statistical significance after propensity matching (1.2% [1/80] vs 7.5% [6/80], P=.12). Cost analysis demonstrated that this intervention was cost-neutral during index hospitalization plus 30-day follow-up. CONCLUSION Application of a standardized bundle of evidence-based interventions was associated with reduced blood use in our gynecologic oncology practice.
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Affiliation(s)
- Sumer K. Wallace
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Mayo Clinic, Rochester, Minnesota
| | - Jessica W. Halverson
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | | | - Stephanie R. DeJong
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Mayo Clinic, Rochester, Minnesota
| | - Amy L. Weaver
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Megan R. Weinhold
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Mayo Clinic, Rochester, Minnesota
| | - Bijan J. Borah
- Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester MN
| | - James P. Moriarty
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester MN
| | - William A. Cliby
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Mayo Clinic, Rochester, Minnesota
| | - Daryl J. Kor
- Department of Anesthesiology and Perioperative Medicine, Blood Management Program, Mayo Clinic, Rochester, MN
| | - Andrew A. Higgins
- Department of Anesthesiology and Perioperative Medicine, Blood Management Program, Mayo Clinic, Rochester, MN
| | - Hilary A. Otto
- Department of Surgery, Division of Surgical Services, Mayo Clinic, Rochester, MN
| | - Sean C. Dowdy
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Mayo Clinic, Rochester, Minnesota
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester MN
| | - Jamie N. Bakkum-Gamez
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Mayo Clinic, Rochester, Minnesota
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Kaatz S, Coleman CI, Bookhart B, Laliberté F, Nelson WW, Brown K, Martin S, Schein J, Lefebvre P. Implications of stroke and bleeding risk scores and comorbidities on episode-based bundled payments for patients with nonvalvular atrial fibrillation. Curr Med Res Opin 2018; 34:275-284. [PMID: 29164990 DOI: 10.1080/03007995.2017.1409200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Due to the high cost of nonvalvular atrial fibrillation (NVAF), this condition may be a suitable candidate for condition-specific bundled payments. This paper evaluates the healthcare cost of NVAF and uses common bleeding and stroke risk scores (HAS-BLED and CHA2DS2-VASc) to explore the risk-based healthcare cost differences among NVAF patients. METHODS MarketScan claims of NVAF patients (ICD-9-CM code 427.31) were analyzed from January 2010 to April 2015. These claims feature more than 196 million covered lives and more than 300 contributing employers and 25 contributing health plans. A retrospective cohort design was used to assess episodes of care costs among patients with NVAF. Previously and newly diagnosed NVAF patients were selected from adult patients with ≥2 diagnoses of NVAF, and without valvular disease. Total all-cause healthcare costs at 1 year were stratified by stroke (CHA2DS2-VASc) and bleeding (HAS-BLED) risk scores. Study data was extracted in the MarketScan Commercial Claims and Encounters Database (Commercial Database) and the MarketScan Medicare Supplemental and Coordination of Benefits Database (Medicare Supplemental Database). RESULTS Mean all-cause 1 year cost of care based on stroke risk (CHA2DS2-VASc) varied from $15,703 to $59,163 for previously diagnosed and $25,992 to $62,458 for newly diagnosed NVAF. Similarly, mean cost varied base on bleeding risk (HAS-BLED) for previously and newly diagnosed NVAF from $17,950 to $57,029 and $26,356 to $67,104 respectively. CONCLUSION NVAF patients accrue variable healthcare costs. Stroke and bleeding risk should be taken into account during the creation of NVAF payment bundles.
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Affiliation(s)
| | - Craig I Coleman
- b Hartford Hospital , Hartford , CT , USA
- c University of Connecticut School of Pharmacy , Storrs , CT , USA
| | | | | | | | - Kip Brown
- e Groupe d'analyse Ltée , Montréal , QC , Canada
| | - Silas Martin
- f Johnson & Johnson Health Care Systems , Raritan , NJ , USA
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Schwarzkopf D, Rüddel H, Gründling M, Putensen C, Reinhart K. The German Quality Network Sepsis: study protocol for the evaluation of a quality collaborative on decreasing sepsis-related mortality in a quasi-experimental difference-in-differences design. Implement Sci 2018; 13:15. [PMID: 29347952 PMCID: PMC5774030 DOI: 10.1186/s13012-017-0706-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 12/29/2017] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND While sepsis-related mortality decreased substantially in other developed countries, mortality of severe sepsis remained as high as 44% in Germany. A recent German cluster randomized trial was not able to improve guideline adherence and decrease sepsis-related mortality within the participating hospitals, partly based on lacking support by hospital management and lacking resources for documentation of prospective data. Thus, more pragmatic approaches are needed to improve quality of sepsis care in Germany. The primary objective of the study is to decrease sepsis-related hospital mortality within a quality collaborative relying on claims data. METHOD The German Quality Network Sepsis (GQNS) is a quality collaborative involving 75 hospitals. This study protocol describes the conduction and evaluation of the start-up period of the GQNS running from March 2016 to August 2018. Democratic structures assure participatory action, a study coordination bureau provides central support and resources, and local interdisciplinary quality improvement teams implement changes within the participating hospitals. Quarterly quality reports focusing on risk-adjusted hospital mortality in cases with sepsis based on claims data are provided. Hospitals committed to publish their individual risk-adjusted mortality compared to the German average. A complex risk-model is used to control for differences in patient-related risk factors. Hospitals are encouraged to implement a bundle of interventions, e.g., interdisciplinary case analyses, external peer-reviews, hospital-wide staff education, and implementation of rapid response teams. The effectiveness of the GQNS is evaluated in a quasi-experimental difference-in-differences design by comparing the change of hospital mortality of cases with sepsis with organ dysfunction from a retrospective baseline period (January 2014 to December 2015) and the intervention period (April 2016 to March 2018) between the participating hospitals and all other German hospitals. Structural and process quality indicators of sepsis care as well as efforts for quality improvement are monitored regularly. DISCUSSION The GQNS is a large-scale quality collaborative using a pragmatic approach based on claims data. A complex risk-adjustment model allows valid quality comparisons between hospitals and with the German average. If this study finds the approach to be useful for improving quality of sepsis care, it may also be applied to other diseases. TRIAL REGISTRATION ClinicalTrials.gov NCT02820675.
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Affiliation(s)
- Daniel Schwarzkopf
- Integrated Research and Treatment Center for Sepsis Control and Care (CSCC), Jena University Hospital, Am Klinikum 1, 07747 Jena, Germany
- Department for Anesthesiology and Intensive Care Medicine, Jena University Hospital, Am Klinikum 1, 07747 Jena, Germany
| | - Hendrik Rüddel
- Integrated Research and Treatment Center for Sepsis Control and Care (CSCC), Jena University Hospital, Am Klinikum 1, 07747 Jena, Germany
- Department for Anesthesiology and Intensive Care Medicine, Jena University Hospital, Am Klinikum 1, 07747 Jena, Germany
| | - Matthias Gründling
- Department of Anesthesiology and Intensive Care Medicine, Ernst-Moritz-Arndt-University, Sauerbruchstraße, 17475 Greifswald, Germany
| | - Christian Putensen
- Department of Anesthesiology and Intensive Care Medicine, University of Bonn, Sigmund-Freud-Str. 25, 53105 Bonn, Germany
| | - Konrad Reinhart
- Integrated Research and Treatment Center for Sepsis Control and Care (CSCC), Jena University Hospital, Am Klinikum 1, 07747 Jena, Germany
- Department for Anesthesiology and Intensive Care Medicine, Jena University Hospital, Am Klinikum 1, 07747 Jena, Germany
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Lavallée JF, Gray TA, Dumville J, Russell W, Cullum N. The effects of care bundles on patient outcomes: a systematic review and meta-analysis. Implement Sci 2017; 12:142. [PMID: 29187217 PMCID: PMC5707820 DOI: 10.1186/s13012-017-0670-0] [Citation(s) in RCA: 111] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 11/13/2017] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Care bundles are a set of three to five evidence-informed practices performed collectively and reliably to improve the quality of care. Care bundles are used widely across healthcare settings with the aim of preventing and managing different health conditions. This is the first systematic review designed to determine the effects of care bundles on patient outcomes and the behaviour of healthcare workers in relation to fidelity with care bundles. METHODS This systematic review is reported in line with the PRISMA statement for reporting systematic reviews and meta-analyses. A total of 5796 abstracts were retrieved through a systematic search for articles published between January 1, 2001, to February 4, 2017, in the Cochrane Central Register for Controlled Trials, MEDLINE, EMBASE, British Nursing Index, CINAHL, PsychInfo, British Library, Conference Proceeding Citation Index, OpenGrey trials (including cluster-randomised trials) and non-randomised studies (comprising controlled before-after studies, interrupted time series, cohort studies) of care bundles for any health condition and any healthcare settings were considered. Following the removal of duplicated studies, two reviewers independently screen 3134 records. Three authors performed data extraction independently. We compared the care bundles with usual care to evaluate the effects of care bundles on the risk of negative patient outcomes. Random-effect models were used to further explore the effects of subgroups. RESULTS In total, 37 studies (6 randomised trials, 31 controlled before-after studies) were eligible for inclusion. The effect of care bundles on patient outcomes is uncertain. For randomised trial data, the pooled relative risk of negative effects between care bundle and control groups was 0.97 [95% CI 0.71 to 1.34; 2049 participants]. The relative risk of negative patient outcomes from controlled before-after studies favoured the care bundle treated groups (0.66 [95% CI 0.59 to 0.75; 119,178 participants]). However, using GRADE, we assessed the certainty of all of the evidence to be very low (downgraded for risk of bias, inconsistency, indirectness). CONCLUSIONS Very low quality evidence from controlled before-after studies suggests that care bundles may reduce the risk of negative outcomes when compared with usual care. By contrast, the better quality evidence from six randomised trials is more uncertain. TRIAL REGISTRATION PROSPERO, CRD42016033175.
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Affiliation(s)
- Jacqueline F Lavallée
- Division of Nursing, Midwifery and Social Work, University of Manchester, Manchester Academic Health Science Centre, Room 3.331, Jean McFarlane Building, Oxford Road, Manchester, M13 9PL, England.
- Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Greater Manchester, Manchester, England.
- Manchester Centre for Health Psychology, University of Manchester, Manchester, England.
| | - Trish A Gray
- Division of Nursing, Midwifery and Social Work, University of Manchester, Manchester Academic Health Science Centre, Room 3.331, Jean McFarlane Building, Oxford Road, Manchester, M13 9PL, England
- Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Greater Manchester, Manchester, England
| | - Jo Dumville
- Division of Nursing, Midwifery and Social Work, University of Manchester, Manchester Academic Health Science Centre, Room 3.331, Jean McFarlane Building, Oxford Road, Manchester, M13 9PL, England
- Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Greater Manchester, Manchester, England
| | - Wanda Russell
- Primary Care & Research Services, Keele University, Newcastle-under-Lyme, England
| | - Nicky Cullum
- Division of Nursing, Midwifery and Social Work, University of Manchester, Manchester Academic Health Science Centre, Room 3.331, Jean McFarlane Building, Oxford Road, Manchester, M13 9PL, England
- Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Greater Manchester, Manchester, England
- Research and Innovation Division, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, England
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Abstract
Caring for people with dementia in acute settings is challenging and confounded by multiple comorbidities and difficulties transitioning between community and acute care. Recently, there has been an increase in the development and use of integrated care pathways (ICPs) and care bundles for defined illnesses and medical procedures, and these are now being promoted for use in dementia care in acute settings. We present a review of the literature on ICPs and/or care bundles for dementia care in the acute sector. This includes a literature overview including "gray literature" such as relevant websites, reports, and government publications. Taken together, there is clearly a growing interest in and clinical use of ICPs and care bundles for dementia. However, there is currently insufficient evidence to support the effectiveness of ICPs for dementia care in acute settings and limited evidence for care bundles for dementia in this setting.
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Affiliation(s)
- Dawn O. Sullivan
- Centre for Gerontology and Rehabilitation, School of Medicine, University College Cork, St Finbarr’s Hospital, Cork, Ireland
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Barker A, Ngam C, Musuuza J, Vaughn VM, Safdar N. Reducing Clostridium difficile in the Inpatient Setting: A Systematic Review of the Adherence to and Effectiveness of C. difficile Prevention Bundles. Infect Control Hosp Epidemiol 2017; 38:639-650. [PMID: 28343455 PMCID: PMC5654380 DOI: 10.1017/ice.2017.7] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Clostridium difficile infection (CDI) is the most common infectious cause of nosocomial diarrhea, and its prevention is an urgent public health priority. However, reduction of CDI is challenging because of its complex pathogenesis, large reservoirs of colonized patients, and the persistence of infectious spores. The literature lacks high-quality evidence for evaluating interventions, and many hospitals have implemented bundled interventions to reduce CDI with variable results. Thus, we conducted a systematic review to examine the components of CDI bundles, their implementation processes, and their impact on CDI rates. METHODS We conducted a comprehensive literature search of multiple computerized databases from their date of inception through April 30, 2016. The protocol was registered in PROSPERO, an international prospective register of systematic reviews. Bundle effectiveness, adherence, and study quality were assessed for each study meeting our criteria for inclusion. RESULTS In the 26 studies that met the inclusion criteria for this review, implementation and adherence factors to interventions were variably and incompletely reported, making study reproducibility and replicability challenging. Despite contextual differences and the variety of bundle components utilized, all 26 studies reported an improvement in CDI rates. However, given the lack of randomized controlled trials in the literature, assessing a causal relationship between bundled interventions and CDI rates is currently impossible. CONCLUSION Cluster randomized trials that include a rigorous assessment of the implementation of bundled interventions are urgently needed to causally test the effect of intervention bundles on CDI rates. Infect Control Hosp Epidemiol 2017;38:639-650.
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Affiliation(s)
- Anna Barker
- Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Caitlyn Ngam
- Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Jackson Musuuza
- Institute of Clinical and Translational Research, University of Wisconsin, Madison, WI, USA
| | - Valerie M. Vaughn
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- The Patient Safety Enhancement Program, University of Michigan and VA Ann Arbor Health System, Ann Arbor, MI, USA
| | - Nasia Safdar
- William S. Middleton Memorial Veterans Affairs Hospital, Madison, WI, USA
- Division of Infectious Diseases, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
- Department of Infection Control, University of Wisconsin Hospital and Clinics, Madison, WI, USA
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DeLuca LA, Walsh P, Davidson DD, Stoneking LR, Yang LM, Grall KJH, Gonzaga MJ, Larson WJ, Stolz U, Sabb DM, Denninghoff KR. Impact and feasibility of an emergency department-based ventilator-associated pneumonia bundle for patients intubated in an academic emergency department. Am J Infect Control 2017; 45:151-157. [PMID: 27665031 DOI: 10.1016/j.ajic.2016.05.037] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 05/31/2016] [Accepted: 05/31/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) has been linked to emergency department (ED) intubation and length of stay (LOS). We assessed VAP prevalence in ED intubated patients, feasibility of ED VAP prevention, and effect on VAP rates. METHODS This was a quality improvement initiative using a pre/post design. Phase 1 (PRE1) comprised patients before intensive care unit (ICU) bundle deployment. Phase 2 (PRE2) occurred after ICU but before ED deployment. Phase 3 (POST) included patients received VAP prevention starting at ED intubation. Log-rank test for equality and Cox regression using a Breslow method for ties were performed. Bundle compliance was reported as percentages. Number needed to treat (NNT) was calculated by ventilator day. RESULTS PRE1, PRE2, and POST groups were composed of 195, 192, and 153 patients, respectively, with VAP rates of 22 (11.3%), 11 (5.7%), and 6 (3.9%). Log-rank test showed significant reduction in VAP (χ2 = 9.16, P = .0103). The Cox regression hazard ratio was 1.38 for the Clinical Pulmonary Infection Score (P = .001), and the hazard ratio was 0.26 for the VAP bundle (P = .005). Bundle compliance >50% for head-of-bed elevation, oral care, subglottic suctioning, and titrated sedation improved significantly with introduction of a registered nurse champion. NNT varied from 7 to 11. CONCLUSIONS VAP was common for ED intubated patients. ED-based VAP prevention is feasible. We demonstrate significant reduction in VAP rates, which should be replicated in a multicenter study.
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Affiliation(s)
- Lawrence A DeLuca
- Arizona Emergency Medicine Research Center, Department of Emergency Medicine, University of Arizona, Tucson, AZ.
| | - Paul Walsh
- Department of Emergency Medicine, Sutter Medical Center Sacramento, Sacramento, CA
| | - Donald D Davidson
- Arizona Emergency Medicine Research Center, Department of Emergency Medicine, University of Arizona, Tucson, AZ
| | - Lisa R Stoneking
- Arizona Emergency Medicine Research Center, Department of Emergency Medicine, University of Arizona, Tucson, AZ
| | - Laurel M Yang
- Department of Emergency Medicine, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Kristi J H Grall
- Department of Emergency Medicine, Partners Healthcare, Regions Hospital, St Paul, MN
| | | | - Wanda J Larson
- Arizona Emergency Medicine Research Center, Department of Emergency Medicine, University of Arizona, Tucson, AZ
| | - Uwe Stolz
- Arizona Emergency Medicine Research Center, Department of Emergency Medicine, University of Arizona, Tucson, AZ
| | - Dylan M Sabb
- Arizona Emergency Medicine Research Center, Department of Emergency Medicine, University of Arizona, Tucson, AZ
| | - Kurt R Denninghoff
- Arizona Emergency Medicine Research Center, Department of Emergency Medicine, University of Arizona, Tucson, AZ
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Abstract
Over the past 20 years, critical care has matured in a myriad of ways resulting in dramatically higher survival rates for our sickest patients. For millions of new survivors comes de novo suffering and disability called "the postintensive care syndrome." Patients with postintensive care syndrome are robbed of their normal cognitive, emotional, and physical capacity and cannot resume their previous life. The ICU Liberation Collaborative is a real-world quality improvement initiative being implemented across 76 ICUs designed to engage strategically the ABCDEF bundle through team- and evidence-based care. This article explains the science and philosophy of liberating ICU patients and families from harm that is both inherent to critical illness and iatrogenic. ICU liberation is an extensive program designed to facilitate the implementation of the pain, agitation, and delirium guidelines using the evidence-based ABCDEF bundle. Participating ICU teams adapt data from hundreds of peer-reviewed studies to operationalize a systematic and reliable methodology that shifts ICU culture from the harmful inertia of sedation and restraints to an animated ICU filled with patients who are awake, cognitively engaged, and mobile with family members engaged as partners with the ICU team at the bedside. In doing so, patients are "liberated" from iatrogenic aspects of care that threaten his or her sense of self-worth and human dignity. The goal of this 2017 plenary lecture at the 47th Society of Critical Care Medicine Congress is to provide clinical ICU teams a synthesis of the literature that led to the creation of ICU liberation philosophy and to explain how this patient- and family-centered, quality improvement program is novel, generalizable, and practice changing.
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Affiliation(s)
- E Wesley Ely
- Department of Medicine, Tennessee Valley Veteran's Affairs Geriatric Research Education Clinical Center (GRECC), Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN
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Parisi M, Gerovasili V, Dimopoulos S, Kampisiouli E, Goga C, Perivolioti E, Argyropoulou A, Routsi C, Tsiodras S, Nanas S. Use of Ventilator Bundle and Staff Education to Decrease Ventilator-Associated Pneumonia in Intensive Care Patients. Crit Care Nurse 2016; 36:e1-e7. [PMID: 27694363 DOI: 10.4037/ccn2016520] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Ventilator-associated pneumonia (VAP), one of the most common hospital-acquired infections, has a high mortality rate. OBJECTIVES To evaluate the incidence of VAP in a multidisciplinary intensive care unit and to examine the effects of the implementation of ventilator bundles and staff education on its incidence. METHODS A 24-month-long before/after study was conducted, divided into baseline, intervention, and postintervention periods. VAP incidence and rate, the microbiological profile, duration of mechanical ventilation, and length of stay in the intensive care unit were recorded and compared between the periods. RESULTS Of 1097 patients evaluated, 362 met the inclusion criteria. The baseline VAP rate was 21.6 per 1000 ventilator days. During the postintervention period, it decreased to 11.6 per 1000 ventilator days (P = .01). Length of stay in the intensive care unit decreased from 36 to 27 days (P = .04), and duration of mechanical ventilation decreased from 26 to 21 days (P = .06). CONCLUSIONS VAP incidence was high in a general intensive care unit in a Greek hospital. However, implementation of a ventilator bundle and staff education has decreased both VAP incidence and length of stay in the unit.
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Affiliation(s)
- Maria Parisi
- Maria Parisi is a high-dependency unit nurse, Vasiliki Gerovasili is a pulmonologist, Efstathia Kampisiouli is a nursing specialization manager and surgical nurse specialist, Christina Goga is a pulmonologist, Christina Routsi is an associate professor of intensive care medicine, and Serafeim Nanas is a professor of intensive care medicine, First Department of Critical Care, National and Kapodistrian University of Athens, Evangelismos Hospital, Athens, Greece.Stavros Dimopoulos is an internal medicine-intensive care medicine specialist, John Farman Intensive Care Unit, Addenbrookes Cambridge University Hospital, Cambridge, United Kingdom.Efstathia Perivolioti is a consultant and Athina Argyropoulou is a consultant and director, Department of Clinical Microbiology, Evangelismos Hospital, Athens, Greece.Sotirios Tsiodras is an associate professor of medicine and infectious diseases, University of Athens Medical School, 4th Department of Internal Medicine, Attikon University Hospital, Athens, Greece
| | - Vasiliki Gerovasili
- Maria Parisi is a high-dependency unit nurse, Vasiliki Gerovasili is a pulmonologist, Efstathia Kampisiouli is a nursing specialization manager and surgical nurse specialist, Christina Goga is a pulmonologist, Christina Routsi is an associate professor of intensive care medicine, and Serafeim Nanas is a professor of intensive care medicine, First Department of Critical Care, National and Kapodistrian University of Athens, Evangelismos Hospital, Athens, Greece.Stavros Dimopoulos is an internal medicine-intensive care medicine specialist, John Farman Intensive Care Unit, Addenbrookes Cambridge University Hospital, Cambridge, United Kingdom.Efstathia Perivolioti is a consultant and Athina Argyropoulou is a consultant and director, Department of Clinical Microbiology, Evangelismos Hospital, Athens, Greece.Sotirios Tsiodras is an associate professor of medicine and infectious diseases, University of Athens Medical School, 4th Department of Internal Medicine, Attikon University Hospital, Athens, Greece.
| | - Stavros Dimopoulos
- Maria Parisi is a high-dependency unit nurse, Vasiliki Gerovasili is a pulmonologist, Efstathia Kampisiouli is a nursing specialization manager and surgical nurse specialist, Christina Goga is a pulmonologist, Christina Routsi is an associate professor of intensive care medicine, and Serafeim Nanas is a professor of intensive care medicine, First Department of Critical Care, National and Kapodistrian University of Athens, Evangelismos Hospital, Athens, Greece.Stavros Dimopoulos is an internal medicine-intensive care medicine specialist, John Farman Intensive Care Unit, Addenbrookes Cambridge University Hospital, Cambridge, United Kingdom.Efstathia Perivolioti is a consultant and Athina Argyropoulou is a consultant and director, Department of Clinical Microbiology, Evangelismos Hospital, Athens, Greece.Sotirios Tsiodras is an associate professor of medicine and infectious diseases, University of Athens Medical School, 4th Department of Internal Medicine, Attikon University Hospital, Athens, Greece
| | - Efstathia Kampisiouli
- Maria Parisi is a high-dependency unit nurse, Vasiliki Gerovasili is a pulmonologist, Efstathia Kampisiouli is a nursing specialization manager and surgical nurse specialist, Christina Goga is a pulmonologist, Christina Routsi is an associate professor of intensive care medicine, and Serafeim Nanas is a professor of intensive care medicine, First Department of Critical Care, National and Kapodistrian University of Athens, Evangelismos Hospital, Athens, Greece.Stavros Dimopoulos is an internal medicine-intensive care medicine specialist, John Farman Intensive Care Unit, Addenbrookes Cambridge University Hospital, Cambridge, United Kingdom.Efstathia Perivolioti is a consultant and Athina Argyropoulou is a consultant and director, Department of Clinical Microbiology, Evangelismos Hospital, Athens, Greece.Sotirios Tsiodras is an associate professor of medicine and infectious diseases, University of Athens Medical School, 4th Department of Internal Medicine, Attikon University Hospital, Athens, Greece
| | - Christina Goga
- Maria Parisi is a high-dependency unit nurse, Vasiliki Gerovasili is a pulmonologist, Efstathia Kampisiouli is a nursing specialization manager and surgical nurse specialist, Christina Goga is a pulmonologist, Christina Routsi is an associate professor of intensive care medicine, and Serafeim Nanas is a professor of intensive care medicine, First Department of Critical Care, National and Kapodistrian University of Athens, Evangelismos Hospital, Athens, Greece.Stavros Dimopoulos is an internal medicine-intensive care medicine specialist, John Farman Intensive Care Unit, Addenbrookes Cambridge University Hospital, Cambridge, United Kingdom.Efstathia Perivolioti is a consultant and Athina Argyropoulou is a consultant and director, Department of Clinical Microbiology, Evangelismos Hospital, Athens, Greece.Sotirios Tsiodras is an associate professor of medicine and infectious diseases, University of Athens Medical School, 4th Department of Internal Medicine, Attikon University Hospital, Athens, Greece
| | - Efstathia Perivolioti
- Maria Parisi is a high-dependency unit nurse, Vasiliki Gerovasili is a pulmonologist, Efstathia Kampisiouli is a nursing specialization manager and surgical nurse specialist, Christina Goga is a pulmonologist, Christina Routsi is an associate professor of intensive care medicine, and Serafeim Nanas is a professor of intensive care medicine, First Department of Critical Care, National and Kapodistrian University of Athens, Evangelismos Hospital, Athens, Greece.Stavros Dimopoulos is an internal medicine-intensive care medicine specialist, John Farman Intensive Care Unit, Addenbrookes Cambridge University Hospital, Cambridge, United Kingdom.Efstathia Perivolioti is a consultant and Athina Argyropoulou is a consultant and director, Department of Clinical Microbiology, Evangelismos Hospital, Athens, Greece.Sotirios Tsiodras is an associate professor of medicine and infectious diseases, University of Athens Medical School, 4th Department of Internal Medicine, Attikon University Hospital, Athens, Greece
| | - Athina Argyropoulou
- Maria Parisi is a high-dependency unit nurse, Vasiliki Gerovasili is a pulmonologist, Efstathia Kampisiouli is a nursing specialization manager and surgical nurse specialist, Christina Goga is a pulmonologist, Christina Routsi is an associate professor of intensive care medicine, and Serafeim Nanas is a professor of intensive care medicine, First Department of Critical Care, National and Kapodistrian University of Athens, Evangelismos Hospital, Athens, Greece.Stavros Dimopoulos is an internal medicine-intensive care medicine specialist, John Farman Intensive Care Unit, Addenbrookes Cambridge University Hospital, Cambridge, United Kingdom.Efstathia Perivolioti is a consultant and Athina Argyropoulou is a consultant and director, Department of Clinical Microbiology, Evangelismos Hospital, Athens, Greece.Sotirios Tsiodras is an associate professor of medicine and infectious diseases, University of Athens Medical School, 4th Department of Internal Medicine, Attikon University Hospital, Athens, Greece
| | - Christina Routsi
- Maria Parisi is a high-dependency unit nurse, Vasiliki Gerovasili is a pulmonologist, Efstathia Kampisiouli is a nursing specialization manager and surgical nurse specialist, Christina Goga is a pulmonologist, Christina Routsi is an associate professor of intensive care medicine, and Serafeim Nanas is a professor of intensive care medicine, First Department of Critical Care, National and Kapodistrian University of Athens, Evangelismos Hospital, Athens, Greece.Stavros Dimopoulos is an internal medicine-intensive care medicine specialist, John Farman Intensive Care Unit, Addenbrookes Cambridge University Hospital, Cambridge, United Kingdom.Efstathia Perivolioti is a consultant and Athina Argyropoulou is a consultant and director, Department of Clinical Microbiology, Evangelismos Hospital, Athens, Greece.Sotirios Tsiodras is an associate professor of medicine and infectious diseases, University of Athens Medical School, 4th Department of Internal Medicine, Attikon University Hospital, Athens, Greece
| | - Sotirios Tsiodras
- Maria Parisi is a high-dependency unit nurse, Vasiliki Gerovasili is a pulmonologist, Efstathia Kampisiouli is a nursing specialization manager and surgical nurse specialist, Christina Goga is a pulmonologist, Christina Routsi is an associate professor of intensive care medicine, and Serafeim Nanas is a professor of intensive care medicine, First Department of Critical Care, National and Kapodistrian University of Athens, Evangelismos Hospital, Athens, Greece.Stavros Dimopoulos is an internal medicine-intensive care medicine specialist, John Farman Intensive Care Unit, Addenbrookes Cambridge University Hospital, Cambridge, United Kingdom.Efstathia Perivolioti is a consultant and Athina Argyropoulou is a consultant and director, Department of Clinical Microbiology, Evangelismos Hospital, Athens, Greece.Sotirios Tsiodras is an associate professor of medicine and infectious diseases, University of Athens Medical School, 4th Department of Internal Medicine, Attikon University Hospital, Athens, Greece
| | - Serafeim Nanas
- Maria Parisi is a high-dependency unit nurse, Vasiliki Gerovasili is a pulmonologist, Efstathia Kampisiouli is a nursing specialization manager and surgical nurse specialist, Christina Goga is a pulmonologist, Christina Routsi is an associate professor of intensive care medicine, and Serafeim Nanas is a professor of intensive care medicine, First Department of Critical Care, National and Kapodistrian University of Athens, Evangelismos Hospital, Athens, Greece.Stavros Dimopoulos is an internal medicine-intensive care medicine specialist, John Farman Intensive Care Unit, Addenbrookes Cambridge University Hospital, Cambridge, United Kingdom.Efstathia Perivolioti is a consultant and Athina Argyropoulou is a consultant and director, Department of Clinical Microbiology, Evangelismos Hospital, Athens, Greece.Sotirios Tsiodras is an associate professor of medicine and infectious diseases, University of Athens Medical School, 4th Department of Internal Medicine, Attikon University Hospital, Athens, Greece
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Staveski S, Abrajano C, Casazza M, Bair E, Quan H, Dong E, Petty A, Felix K, Roth SJ. Silver-Impregnated Dressings for Sternotomy Incisions to Prevent Surgical Site Infections in Children. Am J Crit Care 2016; 25:402-8. [PMID: 27587419 DOI: 10.4037/ajcc2016843] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND The consequences of surgical site infections can be severe and range from short-term delays in discharge from the hospital to life-threatening infections such as mediastinitis. OBJECTIVES To evaluate the effectiveness of silver-impregnated dressings in decreasing surgical site infections in children after cardiac surgery. METHODS A randomized, controlled trial was used to compare silver-impregnated dressings (59 participants) with standard dressings (58 participants). The study team supervised all dressing changes after a sternotomy and ensured adherence with the hospital's bundle for reduction of surgical site infections. The ASEPSIS tool was used to evaluate sternal wounds for evidence of infection. RESULTS The 2 groups had comparable Risk Adjustment for Congenital Heart Surgery scores, age, sex, weight, height, operating room characteristics, and number of chest tubes and/or pacemaker wires. No surgical site infections occurred in any study participant. Infections did occur, however, during the same period, in cardiac surgical patients who were not enrolled in the study. CONCLUSIONS The evidence did not support the superiority of silver-impregnated dressings for prevention of surgical site infections in children after cardiac surgery. Adherence to a bundle for prevention of surgical site infections may have decreased the incidence of such infections in the study population during the study period.
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Affiliation(s)
- Sandra Staveski
- Sandra Staveski is an assistant professor, Research in Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio. Claire Abrajano, May Casazza, and Ellen Bair are nurse practitioners and Hanson Quan, Emily Dong, Amy Petty, and Katie Felix are cardiovascular surgery physician assistants, Lucile Packard Children's Hospital Stanford, Stanford University Medical Center, Palo Alto, California. Stephen J. Roth is a professor, Department of Pediatrics, and chief, Division of Pediatric Cardiology, at the Stanford University School of Medicine. He is a pediatric cardiac intensivist and director, Children's Heart Center, at Lucile Packard Children's Hospital Stanford.
| | - Claire Abrajano
- Sandra Staveski is an assistant professor, Research in Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio. Claire Abrajano, May Casazza, and Ellen Bair are nurse practitioners and Hanson Quan, Emily Dong, Amy Petty, and Katie Felix are cardiovascular surgery physician assistants, Lucile Packard Children's Hospital Stanford, Stanford University Medical Center, Palo Alto, California. Stephen J. Roth is a professor, Department of Pediatrics, and chief, Division of Pediatric Cardiology, at the Stanford University School of Medicine. He is a pediatric cardiac intensivist and director, Children's Heart Center, at Lucile Packard Children's Hospital Stanford
| | - May Casazza
- Sandra Staveski is an assistant professor, Research in Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio. Claire Abrajano, May Casazza, and Ellen Bair are nurse practitioners and Hanson Quan, Emily Dong, Amy Petty, and Katie Felix are cardiovascular surgery physician assistants, Lucile Packard Children's Hospital Stanford, Stanford University Medical Center, Palo Alto, California. Stephen J. Roth is a professor, Department of Pediatrics, and chief, Division of Pediatric Cardiology, at the Stanford University School of Medicine. He is a pediatric cardiac intensivist and director, Children's Heart Center, at Lucile Packard Children's Hospital Stanford
| | - Ellen Bair
- Sandra Staveski is an assistant professor, Research in Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio. Claire Abrajano, May Casazza, and Ellen Bair are nurse practitioners and Hanson Quan, Emily Dong, Amy Petty, and Katie Felix are cardiovascular surgery physician assistants, Lucile Packard Children's Hospital Stanford, Stanford University Medical Center, Palo Alto, California. Stephen J. Roth is a professor, Department of Pediatrics, and chief, Division of Pediatric Cardiology, at the Stanford University School of Medicine. He is a pediatric cardiac intensivist and director, Children's Heart Center, at Lucile Packard Children's Hospital Stanford
| | - Hanson Quan
- Sandra Staveski is an assistant professor, Research in Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio. Claire Abrajano, May Casazza, and Ellen Bair are nurse practitioners and Hanson Quan, Emily Dong, Amy Petty, and Katie Felix are cardiovascular surgery physician assistants, Lucile Packard Children's Hospital Stanford, Stanford University Medical Center, Palo Alto, California. Stephen J. Roth is a professor, Department of Pediatrics, and chief, Division of Pediatric Cardiology, at the Stanford University School of Medicine. He is a pediatric cardiac intensivist and director, Children's Heart Center, at Lucile Packard Children's Hospital Stanford
| | - Emily Dong
- Sandra Staveski is an assistant professor, Research in Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio. Claire Abrajano, May Casazza, and Ellen Bair are nurse practitioners and Hanson Quan, Emily Dong, Amy Petty, and Katie Felix are cardiovascular surgery physician assistants, Lucile Packard Children's Hospital Stanford, Stanford University Medical Center, Palo Alto, California. Stephen J. Roth is a professor, Department of Pediatrics, and chief, Division of Pediatric Cardiology, at the Stanford University School of Medicine. He is a pediatric cardiac intensivist and director, Children's Heart Center, at Lucile Packard Children's Hospital Stanford
| | - Amy Petty
- Sandra Staveski is an assistant professor, Research in Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio. Claire Abrajano, May Casazza, and Ellen Bair are nurse practitioners and Hanson Quan, Emily Dong, Amy Petty, and Katie Felix are cardiovascular surgery physician assistants, Lucile Packard Children's Hospital Stanford, Stanford University Medical Center, Palo Alto, California. Stephen J. Roth is a professor, Department of Pediatrics, and chief, Division of Pediatric Cardiology, at the Stanford University School of Medicine. He is a pediatric cardiac intensivist and director, Children's Heart Center, at Lucile Packard Children's Hospital Stanford
| | - Katie Felix
- Sandra Staveski is an assistant professor, Research in Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio. Claire Abrajano, May Casazza, and Ellen Bair are nurse practitioners and Hanson Quan, Emily Dong, Amy Petty, and Katie Felix are cardiovascular surgery physician assistants, Lucile Packard Children's Hospital Stanford, Stanford University Medical Center, Palo Alto, California. Stephen J. Roth is a professor, Department of Pediatrics, and chief, Division of Pediatric Cardiology, at the Stanford University School of Medicine. He is a pediatric cardiac intensivist and director, Children's Heart Center, at Lucile Packard Children's Hospital Stanford
| | - Stephen J Roth
- Sandra Staveski is an assistant professor, Research in Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio. Claire Abrajano, May Casazza, and Ellen Bair are nurse practitioners and Hanson Quan, Emily Dong, Amy Petty, and Katie Felix are cardiovascular surgery physician assistants, Lucile Packard Children's Hospital Stanford, Stanford University Medical Center, Palo Alto, California. Stephen J. Roth is a professor, Department of Pediatrics, and chief, Division of Pediatric Cardiology, at the Stanford University School of Medicine. He is a pediatric cardiac intensivist and director, Children's Heart Center, at Lucile Packard Children's Hospital Stanford
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Triamvisit S, Maneewan C, Bunturat P, Wongprasert W, Limpassatan K, Kasatpibal N, Euathrongchit J. Results of an Evidence-Based Care Bundle for Reducing Ventilator-Associated Pneumonia (VAP) in Neurosurgical Patients. J Med Assoc Thai 2016; 99:1014-1019. [PMID: 29927205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) is the most common intensive care unit-acquired infection, resulting in increased morbidity and mortality as well as increased hospital costs. OBJECTIVE To determine the VAP rate before and after using the care bundle. MATERIAL AND METHOD A pre- and intervention study was conducted in the Neurosurgical Critical Care Unit (NCCU) at a university hospital between April 2012 and February 2013. This was compared with the twelve-month period before intervention. The six-element VAP prevention bundle called Suandok Model was implemented. It included 30-degree head elevation, bedside hand hygiene, oral chlorhexidine mouth care, inflating of the cuff of the endotracheal tube maintaining 20 to 25 mmHg, checking residual gastric content before feeding, and implementing a weaning protocol. RESULTS The samples before and after interventions were 66 and 68 cases, respectively. There were no significant differences between sex, age, GCS, diagnosis, and operation. The incidence rates of VAP in the intervention period showed a significant decrease (p = 0.001, 39.55 per 1,000 ventilator days vs. 13.30 per 1,000 ventilator days). CONCLUSION The Suandok Model reduced VAP in NCCU patients.
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Wright EB, Henriques S, Houghton C, Clarke B, Keavney B, Venetucci L. Definition and delivery of an aortopathy bundle of care (ABC): a tool for improving diagnosis and management of Marfan syndrome and related conditions. Clin Med (Lond) 2016; 16 Suppl 3:s30. [PMID: 27252334 PMCID: PMC4989949 DOI: 10.7861/clinmedicine.16-3-s30] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Emma Burkitt Wright
- Manchester Centre for Genomic Medicine, Manchester, UK University of Manchester, Manchester, UK
| | | | | | - Bernard Clarke
- University of Manchester, Manchester, UK Manchester Heart Centre, Manchester, UK
| | - Bernard Keavney
- University of Manchester, Manchester, UK Manchester Heart Centre, Manchester, UK
| | - Luigi Venetucci
- University of Manchester, Manchester, UK Manchester Heart Centre, Manchester, UK
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Speck K, Rawat N, Weiner NC, Tujuba HG, Farley D, Berenholtz S. A systematic approach for developing a ventilator-associated pneumonia prevention bundle. Am J Infect Control 2016; 44:652-6. [PMID: 26874407 DOI: 10.1016/j.ajic.2015.12.020] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Revised: 12/07/2015] [Accepted: 12/09/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) is among the most common type of health care-associated infection in the intensive care unit and is associated with significant morbidity and mortality. Existing VAP prevention intervention bundles vary widely on the interventions included and in the approaches used to develop these bundles. The objective of this study was to develop a new VAP prevention bundle using a systematic approach that elicits clinician perceptions on which interventions are most important and feasible to implement. METHODS We identified potential interventions to include through a review of current guidelines and literature. We implemented a 2-step modified Delphi method to gain consensus on the final list of interventions. An interdisciplinary group of clinical experts participated in the Delphi process, which was guided by a technical expert panel. RESULTS We identified 65 possible interventions. Through the Delphi method, we narrowed that list to 19 interventions that included 5 process and 14 structural measures. CONCLUSIONS We described a structured approach for developing a new VAP prevention bundle. Obtaining clinician input on what interventions to include increases the likelihood that providers will adhere to the bundle.
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Affiliation(s)
- Kathleen Speck
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Anesthesia and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Nishi Rawat
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Anesthesia and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Johns Hopkins Community Physicians, Baltimore, MD
| | - Noah C Weiner
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Anesthesia and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Haddis G Tujuba
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Anesthesia and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Donna Farley
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sean Berenholtz
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Anesthesia and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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Nakibuuka J, Sajatovic M, Nankabirwa J, Ssendikadiwa C, Kalema N, Kwizera A, Byakika-Tusiime J, Furlan AJ, Kayima J, Ddumba E, Katabira E. Effect of a 72 Hour Stroke Care Bundle on Early Outcomes after Acute Stroke: A Non Randomised Controlled Study. PLoS One 2016; 11:e0154333. [PMID: 27145035 PMCID: PMC4856379 DOI: 10.1371/journal.pone.0154333] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Accepted: 04/11/2016] [Indexed: 12/31/2022] Open
Abstract
Background Integrated care pathways (ICP) in stroke management are increasingly being implemented to improve outcomes of acute stroke patients. We evaluated the effect of implementing a 72 hour stroke care bundle on early outcomes among patients admitted within seven days post stroke to the national referral hospital in Uganda. Methods In a one year non-randomised controlled study, 127 stroke patients who had ‘usual care’ (control group) were compared to 127 stroke patients who received selected elements from an ICP (intervention group). Patients were consecutively enrolled (controls first, intervention group second) into each group over 5 month periods and followed to 30-days post stroke. Incidence outcomes (mortality and functional ability) were compared using chi square test and adjusted for potential confounders. Kaplan Meier survival estimates and log rank test for comparison were used for time to death analysis for all strokes and by stroke severity categories. Secondary outcomes were in-hospital mortality, median survival time and median length of hospital stay. Results Mortality within 7 days was higher in the intervention group compared to controls (RR 13.1, 95% CI 3.3–52.9). There was no difference in 30-day mortality between the two groups (RR 1.2, 95% CI 0.5–2.6). There was better 30-day survival in patients with severe stroke in the intervention group compared to controls (P = 0.018). The median survival time was 30 days (IQR 29–30 days) in the control group and 30 days (IQR 7–30 days) in the intervention group. In the intervention group, 41patients (32.3%) died in hospital compared to 23 (18.1%) in controls (P < 0.001). The median length of hospital stay was 8 days (IQR 5–12 days) in the controls and 4 days (IQR 2–7 days) in the intervention group. There was no difference in functional outcomes between the groups (RR 0.9, 95% CI 0.4–2.2). Conclusions While implementing elements of a stroke-focused ICP in a Ugandan national referral hospital appeared to have little overall benefit in mortality and functioning, patients with severe stroke may benefit on selected outcomes. More research is needed to better understand how and when stroke protocols should be implemented in sub-Saharan African settings. Trial Registration Pan African Clinical Trials Registry PACTR201510001272347
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Affiliation(s)
- Jane Nakibuuka
- Department of Medicine, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
- Department of Medicine, Mulago National referral hospital, Kampala, Uganda
- * E-mail:
| | - Martha Sajatovic
- Neurological and Behavioral Outcomes Center, University Hospitals Case Medical Center, Cleveland, Ohio, United States of America
| | - Joaniter Nankabirwa
- Department of Medicine, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | | | - Nelson Kalema
- Department of Medicine, Mulago National referral hospital, Kampala, Uganda
| | - Arthur Kwizera
- Department of Anaesthesia and critical care, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Jayne Byakika-Tusiime
- Department of Epidemiology and Biostatistics, School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Anthony J. Furlan
- University Hospitals Case Medical Center, Neurological Institute, Case Western Reserve University, Cleveland, Ohio, United States of America
| | - James Kayima
- Department of Medicine, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Edward Ddumba
- Department of Medicine, St Raphael of St Francis Nsambya Hospital, Nkozi University, Kampala, Uganda
| | - Elly Katabira
- Department of Medicine, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
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Baig MA, Shahzad H, Jamil B, Hussain E. Sepsis management: An evidence-based approach. J PAK MED ASSOC 2016; 66:337-338. [PMID: 26968289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
The Surviving Sepsis Campaign (SSC) guidelines have outlined an early goal directed therapy (EGDT) which demonstrates a standardized approach to ensure prompt and effective management of sepsis. Having said that, there are barriers associated with the application of evidence-based practice, which often lead to an overall poorer adherence to guidelines. Considering the global burden of disease, data from low- to middle-income countries is scarce. Asia is the largest continent but most Asian countries do not have a well-developed healthcare system and compliance rates to resuscitation and management bundles are as low as 7.6% and 3.5%, respectively. Intensive care units are not adequately equipped and financial concerns limit implementation of expensive treatment strategies. Healthcare policy-makers should be notified in order to alleviate financial restrictions and ensure delivery of standard care to septic patients.
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Affiliation(s)
- Muhammad Akbar Baig
- Postgraduate Year IV, Department of Emergency Medicine, Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - Hira Shahzad
- Section of Pulmonology & Critical Care Services, Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - Bushra Jamil
- Section of Adult Infectious Diseases, Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan.. )
| | - Erfan Hussain
- Adult Critical Care Services, Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
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50
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Chalder MJE, Wright CL, Morton KJP, Dixon P, Daykin AR, Jenkins S, Benger J, Calvert J, Shaw A, Metcalfe C, Hollingworth W, Purdy S. Study protocol for an evaluation of the effectiveness of 'care bundles' as a means of improving hospital care and reducing hospital readmission for patients with chronic obstructive pulmonary disease (COPD). BMC Pulm Med 2016; 16:35. [PMID: 26916196 PMCID: PMC4766609 DOI: 10.1186/s12890-016-0197-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 02/15/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chronic Obstructive Pulmonary Disease is one of the commonest respiratory diseases in the United Kingdom, accounting for 10% of unplanned hospital admissions each year. Nearly a third of these admitted patients are re-admitted to hospital within 28 days of discharge. Whilst there is a move within the NHS to ensure that people with long-term conditions receive more co-ordinated care, there is little research evidence to support an optimum approach to this in COPD. This study aims to evaluate the effectiveness of introducing standardised packages of care i.e. care bundles, for patients with acute exacerbations of COPD as a means of improving hospital care and reducing re-admissions. METHODS / DESIGN This mixed-methods evaluation will use a controlled before-and-after design to examine the effect of, and costs associated with, implementing care bundles for patients admitted to hospital with an acute exacerbation of COPD, compared with usual care. It will quantitatively measure a range of patient and organisational outcomes for two groups of hospitals - those who deliver care using COPD care bundles, and those who deliver care without the use of COPD care bundles. These care bundles may be provided for patients with COPD following admission, prior to discharge or at both points in the care pathway. The primary outcome will be re-admission to hospital within 28 days of discharge, although the study will additionally investigate a number of secondary outcomes including length of stay, total bed days, in-hospital mortality, costs of care and patient / carer experience. A series of nested qualitative case studies will explore in detail the context and process of care as well as the impact of COPD bundles on staff, patients and carers. DISCUSSION The results of the study will provide information about the effectiveness of care bundles as a way of managing in-hospital care for patients with an acute exacerbation of COPD. Given the number of unplanned hospital admissions for this patient group and their rate of subsequent re-admission, it is hoped that this evaluation will make a timely contribution to the evidence on care provision, to the benefit of patients, clinicians, managers and policy-makers. TRIAL REGISTRATION International Standard Randomised Controlled Trials - ISRCTN13022442 - 11 February 2015.
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Affiliation(s)
- M J E Chalder
- School of Social and Community Medicine, University of Bristol, Bristol, UK.
| | - C L Wright
- School of Social and Community Medicine, University of Bristol, Bristol, UK.
| | - K J P Morton
- School of Social and Community Medicine, University of Bristol, Bristol, UK.
| | - P Dixon
- School of Social and Community Medicine, University of Bristol, Bristol, UK.
| | - A R Daykin
- School of Social and Community Medicine, University of Bristol, Bristol, UK.
| | - S Jenkins
- Sue Jenkins Consulting, Taunton, UK.
| | - J Benger
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK.
| | - J Calvert
- Southmead Hospital, North Bristol NHS Trust, Bristol, UK.
| | - A Shaw
- School of Social and Community Medicine, University of Bristol, Bristol, UK.
| | - C Metcalfe
- School of Social and Community Medicine, University of Bristol, Bristol, UK.
- Bristol Randomised Trials Collaboration, University of Bristol, Bristol, UK.
| | - W Hollingworth
- School of Social and Community Medicine, University of Bristol, Bristol, UK.
| | - S Purdy
- School of Social and Community Medicine, University of Bristol, Bristol, UK.
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