Reasons for operation cancellations at a teaching hospital: prioritizing areas of improvement.
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ABSTRACT:
SUBMITTER: Abeeleh MA
PROVIDER: S-EPMC5566748 | biostudies-other | 2017 Aug
REPOSITORIES: biostudies-other
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Project description:Objective: In hospitals, physicians-in-training are major contributors to the burden of tests ordered, increasing cost and resource utilization. We implemented an intervention to discourage overutilization of the complete blood count (CBC) and the basic metabolic panel (BMP). Methods: An intervention was designed, comprising education on high-value care and burden of over-testing, encouragement of competition, and use of positive reinforcement. The intervention was monitored by a test index determined by dividing the total number of a specific laboratory test ordered for a patient by the total number of hospital days. Results: Following a 6-month intervention, the mean CBC index decreased from 1.56 ± 0.02 to 1.45 ± 0.03 (p < 0.001), and the BMP index, from 1.35 ± 0.02 to 1.14 ± 0.03 (p < 0.001). There was significant interaction between the intervention and the slope of the BMP index trend (p = 0.03), but not the CBC index trend. The intervention had no impact on hospital length of stay and mortality. Conclusion: This quality improvement intervention is an effective approach to reducing overutilization of laboratory tests.
| S-EPMC6586109 | biostudies-literature
Project description:Background: Despite recommendations, the influenza vaccination coverage rate in healthcare workers (HCWs) in Italy is far from the recommended target. The aim of the study is to analyze the influenza vaccination campaign performed in 2019 in a research and teaching hospital in Milan. Methods: The vaccination strategy included an ad hoc ambulatory, as in the previous years, and an onsite ambulatory, introduced for the first time. Personal data and professional categories were collected and analyzed using univariate logistic regression. HCWs who refused the vaccination were asked to fill in a questionnaire to explain their reasons for dissent. Results: The achieved vaccination coverage rate (VCR) for HCWs was 21.5 %, compared to 17.1% in 2018. The lowest VCR was registered among nurses (11.9%), while physicians had the highest VCR (40.7%). Prevalence ratios show that some professional categories were more frequently vaccinated for the first time than attending physicians (reference category); those with statistically significant confidence intervals were nurses (PR: 2.42; 95% CI: 1.78-3.28), residents (PR: 1.85; 95% CI: 1.36-2.53), and auxiliary staff (PR: 2.33; 95% CI: 1.45-3.74). Conclusions: An onsite vaccination strategy failed in providing a remarkable increase in VCR in 2019, but it is important to point out that the campaign was influenced by several logistic problems.
| S-EPMC7311955 | biostudies-literature
Project description:BackgroundLassa fever is a viral hemorrhagic fever endemic in West Africa. However, none of the hospitals in the endemic areas of Nigeria has the capacity to perform Lassa virus diagnostics. Case identification and management solely relies on non-specific clinical criteria. The Irrua Specialist Teaching Hospital (ISTH) in the central senatorial district of Edo State struggled with this challenge for many years.Methodology/principal findingsA laboratory for molecular diagnosis of Lassa fever, complying with basic standards of diagnostic PCR facilities, was established at ISTH in 2008. During 2009 through 2010, samples of 1,650 suspected cases were processed, of which 198 (12%) tested positive by Lassa virus RT-PCR. No remarkable demographic differences were observed between PCR-positive and negative patients. The case fatality rate for Lassa fever was 31%. Nearly two thirds of confirmed cases attended the emergency departments of ISTH. The time window for therapeutic intervention was extremely short, as 50% of the fatal cases died within 2 days of hospitalization--often before ribavirin treatment could be commenced. Fatal Lassa fever cases were older (p = 0.005), had lower body temperature (p<0.0001), and had higher creatinine (p<0.0001) and blood urea levels (p<0.0001) than survivors. Lassa fever incidence in the hospital followed a seasonal pattern with a peak between November and March. Lassa virus sequences obtained from the patients originating from Edo State formed--within lineage II--a separate clade that could be further subdivided into three clusters.Conclusions/significanceLassa fever case management was improved at a tertiary health institution in Nigeria through establishment of a laboratory for routine diagnostics of Lassa virus. Data collected in two years of operation demonstrate that Lassa fever is a serious public health problem in Edo State and reveal new insights into the disease in hospitalized patients.
| S-EPMC3459880 | biostudies-literature
Project description:BackgroundInstitutional Review Boards (IRBs) have been criticized for inconsistency, delay, and bias, suggesting an opportunity for quality improvement. To aid such quality improvement, this study aimed at determining IRB members' and investigators' priorities regarding IRB review at 10 Veterans Affairs (VA) IRBs.Methods680 anonymous internet surveys were sent to 252 IRB members and staff, and 428 principal investigators and project coordinators at 9 VA Medical Centers and the VA Central IRB. Surveys included 27 statements adapted from Koocher and Kieth-Spiegel's IRB-RAT describing IRB activities or functions (e.g., "An IRB that is open to reversing its earlier decisions"). Respondents indicated how each statement described both their "ideal" and "actual" IRBs. The difference between the ratings of the actual and ideal IRBs was calculated for each item along with estimated 95% confidence intervals. Ratings outside those intervals indicated activities or functions with relatively good or poor performance compared to the ideal IRB.Results390 (57.4%) responses from 165 IRB members and staff (65.5%) and 225 investigators and project coordinators (52.6%) demonstrated that these IRBs were closest to the ideal when protecting human subjects, treating investigators with respect, and taking appropriate action for alleged scientific misconduct. The IRBs were furthest from the ideal regarding duplicative forms, timeliness of review, and provision of complete rationales for decisions. Although IRB members reported near-ideal willingness to reverse earlier decisions, investigators rated this capacity far from ideal. Investigators rated IRB members' knowledge about procedures and policy as nearly ideal, but IRB members themselves rated this aspect far from ideal. Noteworthy site-level differences in the ratings of IRB functions and activities were also identified.ConclusionsAlthough these VA IRBs perform well in some areas, these data support the need for ongoing quality improvement. The described method of administering and analyzing the IRB-RAT may help identify and monitor site- and activity- specific initiatives for quality improvement.
| S-EPMC7409436 | biostudies-literature
Project description:IntroductionAn effective emergency triage system should prioritize both trauma and non-trauma patients according to level of acuity, while also addressing local disease burden and resource availability. In March 2012, an adapted version of the South African Triage Scale was introduced in the emergency centre (EC) of Ayder Comprehensive Specialized Hospital in northern Ethiopia.MethodsThis quality improvement study was conducted to evaluate the implementation of nurse-led emergency triage in a large Ethiopian teaching hospital using the Donabedian model. A 45% random sample was selected from all adult emergency patients during the study period, May 10th to May 25th 2015. Patient charts were collected and retrospectively reviewed. Presence and proper completion of the triage form were appraised. Triage level was abstracted and compared with patient outcome (dichotomized as "admitted to hospital or died" and "discharged alive from emergency centre") to quantify over- and under-triage triage.ResultsFrom 251 randomly selected patients, 107 (42.6%) charts were retrieved. From these, only 45/107 (42.1%) contained the triage form filled within the chart. None of the triage forms were filled out completely. From 13 (28.9%) admitted or deceased patients, the under-triage rate was 30.7% and from 32 (71.1%) patients discharged alive from the EC the over-triage rate was 21.9%.DiscussionThe under-triage rate observed in this study exceeds the recommended threshold of 5% and is a serious patient safety concern. However, under-triage may have been magnified by irregularities in the hospital admission process. Haphazard medical record handling, poor documentation, erroneous triage decisions, and poor rapport between nurses and physicians were the main process-related challenges that must be addressed through intensive training and improved human resource management approaches to enhance the quality of triage in the emergency centre.
| S-EPMC6234140 | biostudies-literature
Project description:Background:Attributes of the clinical learning environment (CLE) are a measure of quality in postgraduate medical education, and assessing the CLE is a component of the New Accreditation System being introduced in Singapore by the Accreditation Council for Graduate Medical Education International. There is a dearth of published studies of CLE quality in Singapore. Objective:Our study had 3 aims: (1) to measure the CLE in 1 Singaporean residency program; (2) to compare trainee perceptions by sex, training level, and experience; and (3) to identify areas for improvement. Methods:Between October and December 2017, we conducted a mixed assessment of the CLE in an internal medicine program in Singapore, using the Postgraduate Hospital Educational Environment Measure (PHEEM) and qualitative exploration using a focus group. Results:Of 153 IM residents, 136 (89%) provided PHEEM responses and 8 participated in the focus group. Total PHEEM scores and scores for the 3 subscales were higher than published data on the use of the PHEEM in international settings. Exploration of selected PHEEM responses via a focus group identified attributes associated with negative perceptions of the CLE: excessive workload, inadequate faculty presence in the CLE, and unmet trainee needs. It also suggested senior residents' clinical workloads, greater responsibilities, and pending examinations may contribute to their less positive perceptions of the CLE. Conclusions:Our analysis using the PHEEM showed overall positive perceptions of the CLE, along with areas for improvement amenable to interventions. Our approach has relevance to an accreditation model with ongoing evaluation of the CLE.
| S-EPMC6697311 | biostudies-literature
Project description:In many parts of the world, the combined effects of habitat fragmentation and altered disturbance regimes pose a significant threat to biodiversity. This is particularly true in Mediterranean-type ecosystems (MTEs), which tend to be fire-prone, species rich, and heavily impacted by human land use. Given the spatial complexity of overlapping threats and species' vulnerability along with limited conservation budgets, methods are needed for prioritizing areas for monitoring and management in these regions. We developed a multi-criteria Pareto ranking methodology for prioritizing spatial units for conservation and applied it to fire threat, habitat fragmentation threat, species richness, and genetic biodiversity criteria in San Diego County, California, USA. We summarized the criteria and Pareto ranking results (from west to east) within the maritime, coastal, transitional, inland climate zones within San Diego County. Fire threat increased from the maritime zone eastward to the transitional zone, then decreased in the mountainous inland climate zone. Number of fires and fire return interval departure were strongly negatively correlated. Fragmentation threats, particularly road density and development density, were highest in the maritime climate zone, declined towards the east, and were positively correlated. Species richness criteria showed distributions among climate zones similar to those of the fire threat variables. When using species richness and fire threat criteria, most lower-ranked (higher conservation priority) units occurred in the coastal and transitional zones. When considering genetic biodiversity, lower-ranked units occurred more often in the mountainous inland zone. With Pareto ranking, there is no need to select criteria weights as part of the decision-making process. However, negative correlations and larger numbers of criteria can result in more units assigned to the same rank. Pareto ranking is broadly applicable and can be used as a standalone decision analysis method or in conjunction with other methods.
| S-EPMC6128460 | biostudies-literature
Project description:Conservation of large carnivores, such as the African lion, requires preservation of extensive core habitat areas, linkages between them, and mitigation of human-wildlife conflict. However, there are few rigorous examples of efforts that prioritized conservation actions for all three of these critical components. We used an empirically optimized resistance surface to calculate resistant kernel and factorial least cost path predictions of population connectivity and conflict risk for lions across the Kavango-Zambezi Transfrontier Conservation Area (KAZA) and surrounding landscape. We mapped and ranked the relative importance of (1) lion dispersal areas outside National Parks, (2) corridors between the key areas, and (3) areas of highest human-lion conflict risk. Spatial prioritization of conservation actions is critical given extensive land use redesignations that are reducing the extent and increasing the fragmentation of lion populations. While our example focuses on lions in southern Africa, it provides a general approach for rigorous, empirically based comprehensive conservation planning based on spatial prioritization.
| S-EPMC6033387 | biostudies-literature
Project description:Advance directives can help guide care in the ICU. As a healthcare quality improvement initiative, we sought to increase the percentage of patients with a healthcare power of attorney and/or practitioner orders for life-sustaining treatment in our ICU and to increase medical resident experience with advance directives through routine screening and documentation of advance directives in the ICU.DesignProspective analysis.SettingUrban U.S. community teaching hospital.PatientsAll patients admitted to the ICU from September 2018 to February 2019.InterventionsInternal medicine residents in the ICU received a lecture about advance directives and instructions to screen their patients for advance directives. For willing and decisional patients, residents facilitated the creation of a healthcare power of attorney and/or practitioner orders for life-sustaining treatment. Residents were anonymously surveyed at the beginning and end of the ICU rotation about their experience and level of comfort with healthcare power of attorney and practitioner orders for life-sustaining treatment completion.Measurements and main resultsThree-hundred seventy-five patients were admitted to the ICU during the study period. Healthcare power of attorney documents were generated by 34% of all ICU patients without a prior healthcare power of attorney, increased from a baseline rate of 10% (p < 0.001). The number of practitioner orders for life-sustaining treatment documents for patients with code status of "no cardiopulmonary resuscitation" did not increase significantly. The percentage of residents who facilitated completion of a healthcare power of attorney document increased significantly from 56% to 100% (p < 0.001), whereas their practitioner orders for life-sustaining treatment experience did not change significantly by the end of their ICU rotation. On a Likert scale of 0-10, mean resident comfort increased significantly both with healthcare power of attorney documentation, rising from 6.14 to 8.84 (p = 0.005) and with practitioner orders for life-sustaining treatment form completion, increasing from 6.00 to 7.84 (p = 0.008).ConclusionsTraining ICU medical residents to routinely screen for and facilitate completion of advance directives significantly increased the percentage of ICU patients with a healthcare power of attorney and significantly improved medical resident comfort with healthcare power of attorney and practitioner orders for life-sustaining treatment form completion.
| S-EPMC8104255 | biostudies-literature
Project description:IntroductionAlthough sustainability is a key component in the evaluation of continuous quality improvement (CQI) projects, medicine resident CQI projects are often evaluated by immediate improvements in targeted areas without addressing sustainability. AIM/SETTING: To assess the sustainability of resident CQI projects in an ambulatory university-based clinic.Program descriptionDuring their ambulatory rotation, all second year internal medicine residents use the American Board of Internal Medicine's Clinical Preventive Services (CPS) Practice Improvement Modules (PIM) to complete chart reviews, patient surveys, and a system survey. The residents then develop a group CQI project and collect early post data. Third year residents return to evaluate their original CQI project during an ambulatory rotation two to six months later and complete four plan-do-study-act (PDSA) cycles on each CQI project.Program evaluationFrom July 2006 to June 2009, 64 (100%) medicine residents completed the CQI curriculum. Residents completed six group projects and examined their success using early (2 to 6 weeks) and late (2 to 6 months) post-intervention data. Three of the projects demonstrated sustainable improvement in the resident continuity clinic.DiscussionWhen residents are taught principles of sustainability and spread and asked to complete multiple PDSA cycles, they are able to identify common themes that may contribute to success of QI projects over time.
| S-EPMC3019318 | biostudies-literature