Healthcare Quality (JHQ)

Leadership Lessons From COVID-19 and the Path Forward No abstract available

Processes for Trauma Care at Six Level I Trauma Centers During the COVID-19 Pandemic Introduction: As the COVID-19 pandemic spread, patient care guidelines were published and elective surgeries postponed. However, trauma admissions are not scheduled and cannot be postponed. There is a paucity of information available on continuing trauma care during the pandemic. The study purpose was to describe multicenter trauma care process changes made during the COVID-19 pandemic. Methods: This descriptive survey summarized the response to the COVID-19 pandemic at six Level I trauma centers. The survey was completed in 05/2020. Questions were asked about personal protective equipment, ventilators, intensive care unit (ICU) beds, and negative pressure rooms. Data were summarized as proportions. Results: The survey took an average of 5 days. Sixty-seven percent reused N-95 respirators; 50% sanitized them with 25% using ultraviolet light. One hospital (17%) had regional resources impacted. Thirty-three percent created ventilator allocation protocols. Most hospitals (83%) designated more beds to the ICU; 50% of hospitals designated an ICU for COVID-19 patients. COVID-19 patients were isolated in negative pressure rooms at all hospitals. Conclusions: In response to the COVID-19 pandemic, Level I trauma centers created processes to provide optimal trauma patient care and still protect providers. Other centers can use the processes described to continue care of trauma patients during the COVID-19 pandemic.

Nurse Burnout Predicts Self-Reported Medication Administration Errors in Acute Care Hospitals Background: Every one out of 10 nurses reported suffering from high levels of burnout worldwide. It is unclear if burnout affects job performance, and in turn, impairs patient safety, including medication safety. The purpose of this study is to determine whether nurse burnout predicts self-reported medication administration errors (MAEs). Methods: A cross-sectional study using electronic surveys was conducted from July 2018 through January 2019, using the Copenhagen Burnout Inventory. Staff registered nurses (N = 928) in acute care Alabama hospitals (N = 42) were included in this study. Descriptive statistics, correlational, and multilevel mixed-modeling analyses were examined. Results: All burnout dimensions (Personal, Work-related, and Client-related Burnout) were significantly correlated with age (r = −0.17 to −0.21), years in nursing (r = −0.10 to −0.17), years of hospital work (r = −0.07 to −0.10), and work environment (r = −0.24 to −0.57). The average number of self-reported MAEs in the last 3 months was 2.13. Each burnout dimension was a statistically significant predictor of self-reported MAEs (p < .05). Conclusions: Nurse burnout is a significant factor in predicting MAEs. This study provides important baseline data for actionable interventions to improve nursing care delivery, and ultimately health care, for Alabamians.

The Effect of Numbered Jerseys on Directed Commands, Teamwork, and Clinical Performance During Simulated Emergencies Communication and teamwork are essential during inpatient emergencies such as cardiac arrest and rapid response (RR) codes. We investigated whether wearing numbered jerseys affect directed commands, teamwork, and performance during simulated codes. Eight teams of 6 residents participated in 64 simulations. Four teams were randomized to the experimental group wearing numbered jerseys, and four to the control group wearing work attire. The experimental group used more directed commands (49% vs. 31%, p < .001) and had higher teamwork score (25 vs. 18, p < .001) compared with control group. There was no difference in time to initiation of chest compression, bag-valve-mask ventilation, and correct medications. Time to defibrillation was longer in the experimental group (190 vs. 140 seconds, p = .035). Using numbered jerseys during simulations was associated with increased use of directed commands and better teamwork. Time to performance of clinical actions was similar except for longer time to defibrillation in the jersey group.

Lean in Healthcare: Time for Evolution or Revolution? Lean has gained recognition in healthcare as a quality improvement tool. The purpose of this research was to examine the extent to which quality improvement projects in healthcare adhered to Lean's eight-step process. We analyzed 605 publications identified through a systematic literature review following PRISMA guidelines. Each publication was coded using a structured coding sheet. The most frequent type of publication reported empirical research (48.6%) and most of these (80.3%) shared the results of the Lean projects. Of the 237 publications reporting Lean projects, more than half (71.3%) used an experimental, one-site, pre/postdesign. The impact of the project was most often measured using a single metric (59.1%) that was operational (e.g., waiting time). Although most Lean project publications reported the use of tools to "break down the problem" (84.4%, Step 2) and "see countermeasures through" (70.0%, Step 6), fewer than half described using tools associated with each of the other steps. Projects completed an average of 2.77 steps and none of the projects completed all steps. Although some may perceive low adherence to the tenets of Lean as a deficiency, it may be that Lean approaches are evolving to better meet the needs of healthcare.

Improving Utilization of Vaccine Two-Dimensional (2D) Barcode Scanning Technology Maximizes Accuracy Benefits Background: Recording vaccine data accurately can be problematic in medical documentation, including blank and inaccurate records. Vaccine two-dimensional (2D) barcode scanning has shown promise, yet scanner use to record vaccine data is limited. We sought to identify strategies to improve scanning rates and assess changes in accuracy. Methods: Between January and June 2017, 27 pilot sites within a large health system were assigned to one of four groups to test strategies to maximize scanner use: training only, commitment card, scanning report, or combination. Seventy-two thousand vaccine records were assessed for completeness, accuracy, and scanning. Results: Significant increases in vaccinator scanning rates found with commitment card and scanning report inclusion (alone and paired) compared with the training-only group. Record completeness and accuracy significantly improved with use of scanning. When manually entered, about 1 in 9 records had a missing or inaccurate expiration date; when scanned, this dropped to 1 in 5,000. Conclusions: Pilot findings indicate 2D scanning has the potential to eliminate most omissions and inaccuracies in vaccine records. Such data are critical during a recall or need to trace specific vaccines or patients. Implications: Consistent use and expanded adoption of 2D scanning can meaningfully improve the quality of vaccine records and clinical practices.

Improving Inpatient Tobacco Treatment Measures: Outcomes Through Standardized Treatment, Care Coordination, and Electronic Health Record Optimization Introduction: The Centers for Disease Control and Prevention states that tobacco use is the largest and most preventable cause of disease and mortality in the United States. The Joint Commission implemented inpatient tobacco treatment measures (TTMs) in 2012 to encourage healthcare systems to create processes that help patients quit tobacco use through evidence-based care. Methods: A tobacco cessation care delivery system was implemented at James A. Haley Veterans' Hospital and Clinics, which included: standardized pathways within the Veterans Health Administration (VHA) electronic health record system to improve nicotine replacement therapy ordering; evidence-based tobacco cessation counseling; and improved care coordination for tobacco cessation treatment through the use of technological innovation. Results: Outcomes were obtained from the VHA quality metric reporting system known as Strategic Analytics for Improvement and Learning (SAIL). TOB-2 and TOB-3 (two Joint Commission inpatient TTMs) equivalent to tob20 and tob40 within SAIL improved by greater than 300% after implementation at James A. Haley Veterans' Hospital and Clinics. Conclusion: Implementation of a tobacco cessation care system at James A. Haley Veterans' Hospital and Clinics enhanced interdisciplinary coordination of tobacco cessation care and resulted in improvements of The Joint Commission inpatient TTMs by greater than threefold.

Continuous Cloud-Based Early Warning Score Surveillance to Improve the Safety of Acutely Ill Hospitalized Patients Introduction: This study sought to evaluate the impact of changes made to the process of continually screening hospitalized patients for decompensation. Methods: Patients admitted to hospital wards were screened using a cloud-based early warning score (modified National Early Warning Score [mNEWS]). Patient with mNEWS ≥7 triggered a structured response. Outcomes of this quality improvement study during the intervention period from February through August 2018 (1741 patients) were compared with a control population (1,610 patients) during the same months of 2017. Results: The intervention group improved the time to the first lactate order within 24 hours of mNEWS ≥7 (p < .001), the primary outcome, compared with the control group. There was no significant improvement in time to intensive care unit (ICU) transfer, ICU length of stay (LOS), or hospital mortality. Among patients with a lactate ordered within 24 hours, there was a 47% reduction of in-hospital mortality (odds ratio 0.53, 95% confidence interval 0.3–0.89, p = .02) and a 4.7 day reduction in hospital LOS (p < .001) for intervention versus control cohorts. Conclusions: Cloud-based electronic surveillance can result in earlier detection of clinical decompensation. This intervention resulted in lower hospital LOS and mortality among patients with early detection of and intervention for clinical decompensation.

Assessing the Efficacy of Certificate of Need Laws Through Total Joint Arthroplasty Lawmakers suggest Certificate of Need (CON) laws' main goals are increasing access to healthcare, increasing quality of healthcare, and decreasing healthcare costs. This retrospective database study aims to evaluate the effectiveness of CON through analysis of total knee, hip, and shoulder arthroplasty (TKA, THA, and TSA, respectively). A review was performed using the Humana Insurance PearlDiver national database from 2007 to 2015. Access to care was approximated by the rates of total joint arthroplasty (TJA) in patients diagnosed with arthritis to the corresponding joint. The quality of care was assessed using complication rates after TJA. The total cost of TJA was approximated from average reimbursement to the healthcare facility per procedure. Patients in states without CON programs received TKA, THA, and TSA more frequently (p < .0001, p = .250, p = .019). No significant difference was found in studied complication rates between CON and non-CON states. Similarly, there was no trend found when comparing the cost of each procedure in CON versus non-CON states. These findings are consistent with other recent studies detailing the impact of CON regulation on THA and TKA. The apparent nonsuperiority of CON states in achieving their purported goals may call into question the effectiveness of additional bureaucracy and regulation, suggesting a need for further examination.

Multi-Level Predictors of Discharges Against Medical Advice: Identifying Contributors to Variation Using an All-Payer Database There is increasing evidence of the role of non–patient-level factors on discharge against medical advice (DAMA), but limited quantitative information regarding the extent of their impact. This study quantifies the contribution of discharge-level and hospital-level factors to the variation in DAMA. We grouped variables from the 2014 National Inpatient Sample data and ran incremental mixed-effects logit models with grouping at the level of the discharge, the hospital, and the census region. We obtained the intraclass correlation coefficients (ICCs), and evaluated the incremental change in ICC. The final sample included 2,687,430 discharges. 12.8% of the identified variation in the probability of DAMA was associated with the hospital, and 1.2% of the variation was associated with the census division in which the hospital was located. The final, fully-adjusted model had 7.3% of variation in DAMA associated with the hospital-level, with the greatest percentage reductions because of the addition of patient demographics. Even after adjusting for measured patient-level characteristics, there was a contribution of non–patient-level factors to DAMA outcomes. The findings identify a role for a multi-level approach to addressing DAMA.

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

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