Systematic review of the factors and the key indicators that identify doctors at risk of complaints, malpractice claims or impaired performance.

OBJECTIVE: To identify the risk factors associated with complaints, malpractice claims and impaired performance in medical practitioners. DESIGN: Systematic review. DATA SOURCES: Ovid-Medline, Ovid Embase, Scopus and Cochrane Central Register of Controlled Trials were searched from 2011 until March 2020. Reference lists and Google were also handsearched. RESULTS: Sixty-seven peer-reviewed papers and three grey literature publications from 2011 to March 2020 were reviewed by pairs of independent reviewers. Twenty-three key factors identified, which were categorised as demographic or workplace related. Gender, age, years spent in practice and greater number of patient lists were associated with higher risk of malpractice claim or complaint. Risk factors associated with physician impaired performance included substance abuse and burn-out. CONCLUSIONS: It is likely that risk factors are interdependent with no single factor as a strong predictor of a doctor's risk to the public. Risk factors for malpractice claim or complaint are likely to be country specific due to differences in governance structures, processes and funding. Risk factors for impaired performance are likely to be specialty specific due to differences in work culture and access to substances. New ways of supporting doctors might be developed, using risk factor data to reduce adverse events and patient harm. PROSPERO REGISTRATION NUMBER: PROSPERO registration number: CRD42020182045.

Between the flags: implementing a safety-net system at scale to recognise and manage deteriorating patients in the New South Wales Public Health System.

QUALITY PROBLEM: In 2005, the Clinical Excellence Commission (CEC) found that unrecognised patient deterioration remained an important problem in New South Wales (NSW) public hospitals. INITIAL ASSESSMENT: The challenge was to design and implement an effective and sustainable safety-net system in all 225 NSW public hospitals. DESIGNING A SOLUTION: The CEC's system was designed in collaboration with a broad coalition of partners, including clinicians, managers, system administrators and collaborating agencies. A five-element system comprising governance, standard calling criteria in standard observation charts, two-level clinical emergency response systems (CERS) in each facility, an education programme and evaluation, was designed for state-wide implementation. This system was called 'Between the Flags' (BTF). IMPLEMENTATION: Implementation was led by the CEC on behalf of a NSW coalition, and commenced in January 2010 with the implementation of the Standard Adult General Observation Chart, awareness training for all staff and a CERS in each facility. EVALUATION: Since the introduction of BTF, the cardiac arrest rate has declined by 42% (P < 0.05) and the Rapid Response rate has increased by 135.9% (P < 0.05) in NSW. The strength of staff support for BTF has grown with the proportion of respondents strongly agreeing that BTF has benefitted patient safety more than doubling from 21% to 44%, and overall agreement rising from 68% to 82% between 2010 and 2012. LESSONS LEARNED: Key success factors are a focus on governance, standardisation of observation charts and striking the right balance between a rule-based approach and individual clinical judgement.

Aseptic insertion of central venous lines to reduce bacteraemia.

OBJECTIVE: To reduce the rate of central line-associated bacteraemia (CLAB). DESIGN: A collaborative quality improvement project in intensive care units (ICUs) to promote aseptic insertion of central venous lines (CVLs). A checklist was used to record compliance with all aspects of aseptic CVL insertion, with maximal sterile barrier precautions for clinicians ("clinician bundle") and patients ("patient bundle"). CLAB was identified and reported using a standard surveillance definition. PARTICIPANTS AND SETTING: Patients and clinicians in 37 ICUs in New South Wales, July 2007-December 2008. MAIN OUTCOME MEASURES: Compliance with aseptic CVL insertion; rates of CLAB. RESULTS: 10 890 CVL checklists were reviewed for compliance with the clinician and patient bundles: compliance with aseptic CVL insertion improved significantly (P < 0.001). The CLAB rate dropped from 3.0 to 1.2 per 1000 line-days (P < 0.001). Regardless of CVL type, the relative risk (RR) of CLAB in patients with CVLs inserted by clinicians not compliant with the clinician bundle was 1.62 times greater (95% CI, 1.1-2.4; P = 0.018) than the RR with CVLs inserted by clinicians compliant with both bundles. Compliance with both the bundles was associated with a 50% reduction in risk of CLAB (RR, 0.5; 95% CI, 0.4-0.8; P = 0.004). CONCLUSIONS: Compliance with all aspects of aseptic CVL insertion significantly reduces the risk of CLAB. A difficulty we experienced was that most ICUs lacked the organisation and staff to support quality improvement and audit.

Culture change for hand hygiene: clean hands save lives, part II.

OBJECTIVE: To present the results of surveys of staff, patients and visitors about their perceptions of hand hygiene behaviour before and after implementation of the Clean hands save lives campaign in New South Wales public hospitals. DESIGN AND SETTING: Pre- and post-campaign questionnaires, disseminated through project officers in each health authority, were completed by selected staff and patients/visitors in all 208 public hospitals in NSW. Combined, de-identified results for each health authority were forwarded to the NSW Clinical Excellence Commission for analysis. MAIN OUTCOME MEASURES: Awareness of campaign material; staff perceptions about their ability to maintain a high level of hand hygiene compliance before and after contact with patients; compliance self-reported by staff compared with compliance perceived by patients/visitors and compliance assessed by overt observation. RESULTS: Most staff and patients/visitors were aware of campaign materials. Eighty-six per cent of staff respondents (495/578) believed that placement of alcohol-based hand rub (AHR) close to the point of patient care had improved hand hygiene compliance, and 76% (510/671) believed they could sustain their level of compliance. Only 1 in 4 patients or visitors (106/397) were willing to question health care workers who appeared not to be complying with hand hygiene practices. CONCLUSION: As the first coordinated statewide campaign to modify hand hygiene culture, the Clean hands save lives campaign successfully engendered positive attitudes and dispelled negative perceptions about the onerous nature of before- and after-patient-contact hand hygiene compliance.

Improvements in hand hygiene across New South Wales public hospitals: clean hands save lives, part III.

OBJECTIVE: To describe improvements in hand hygiene compliance after a statewide hand hygiene campaign conducted in New South Wales public hospitals. DESIGN AND SETTING: The campaign was conducted in all area health services in NSW (covering all 208 public hospitals). Alcohol-based hand rub (AHR) was introduced into all hospitals between March and June 2006. In each hospital, five overt observation surveys of hand hygiene compliance by health care workers (HCWs) were conducted: one pre-implementation survey and four post-implementation surveys (in August 2006, November 2006, February 2007 and July 2008). MAIN OUTCOME MEASURES: Overtly observed hand hygiene compliance rates by HCWs, stratified by before- and after-patient contact, Fulkerson's contact risk categories, and four health care professional groupings. RESULTS: The overall hand hygiene compliance rate improved from 47% before the intervention to an average of 61% over the last three observation periods (P < 0.001). All professional groups sustained improved compliance rates except medical staff, whose practices reverted to pre-intervention rates. Nursing staff maintained significantly improved compliance, with an average rate of 67% after the intervention. Overall hand hygiene compliance before patient contact improved from 39% (pre-campaign) to 52% (July 2008) (P < 0.001). Overall compliance after patient contact improved from 57% to 64% (P < 0.001) over the same period. Compliance associated with medium-risk contacts increased from an average of 51% in the first two observation periods to an average of 62% over the last three observation periods (P < 0.001). The corresponding compliance rates associated with low-risk contacts were 35% and 56%, respectively (P < 0.001). CONCLUSION: An overall improvement in hand hygiene rates was achieved with the introduction of AHR. Increased adherence to before-patient contact compliance, especially by nursing staff, contributed to the progress made, but an acceptable overall level of hand hygiene practice is yet to be achieved. It is now time to focus on a long-term behavioural change program directed specifically at medical staff.

More than hand hygiene is needed to affect methicillin-resistant Staphylococcus aureus clinical indicator rates: clean hands save lives, part IV.

OBJECTIVE: To examine whether improved hand hygiene compliance in health care workers after a statewide hand hygiene campaign in New South Wales hospitals was associated with a fall in rates of infection with multiresistant organisms. DESIGN AND SETTING: Data on rates of new methicillin-resistant Staphylococcus aureus (MRSA) infections (expressed as four clinical indicators) are reported by some Australian hospitals to the Australian Council on Healthcare Standards (ACHS) for accreditation purposes and are mandatorily reported by all NSW hospitals to the NSW Department of Health. Infections are classified according to whether they are acquired in the intensive care unit (ICU) or other wards and whether they are from sterile sites (blood cultures) or non-sterile sites. The clinical indicators reflect four different site categories (ICU sterile site, ICU non-sterile site, non-ICU sterile site and non-ICU non-sterile site) and are expressed as the number of new health care-associated infections per 10,000 acute care bed-days. Clinical indicator rates were examined for any decline between the pre-campaign period (July-December 2005) and post-campaign period (January-July 2007), and were compared with trends over a similar period in states without a hand hygiene campaign. MAIN OUTCOME MEASURES: Pre-campaign and post-campaign rates for four MRSA clinical indicators. RESULTS: Between the pre- and post-campaign periods, there was a 25% fall in MRSA non-ICU sterile site infections, from 0.60/10,000 bed-days to 0.45/10,000 bed-days (P = 0.027), and a 16% fall in ICU non-sterile site infections, from 36.36/10,000 bed-days to 30.43/10,000 bed-days (P = 0.037). The pre- and post-campaign rates of MRSA infection from ICU sterile sites (5.28/10,000 bed-days v 4.80/10,000 bed-days; P = 0.664) and non-ICU non-sterile sites (5.92/10,000 bed-days v 5.66/10,000 bed-days; P = 0.207) remained stable. Australia-wide MRSA data reported to the ACHS showed a 45% decline in infections from ICU non-sterile sites, from 25.89/10,000 bed-days to 14.30/10,000 bed-days (P < 0.001), and a 46% decline in infections from non-ICU non-sterile sites, from 3.70/10,000 bed-days to 1.99/10,000 bed-days (P < 0.001) over the period 2005-2006. CONCLUSION: Two out of four clinical indicators of MRSA infection remained unchanged despite significant improvements in hand hygiene compliance in NSW hospitals. The reduction in MRSA infections from ICU non-sterile sites in NSW hospitals was mirrored in ACHS data for other Australian states and cannot be assumed to be the result of improved hand hygiene compliance. Concurrent clinical and infection control practices possibly influence MRSA infection rates and may modify the effects of hand hygiene compliance. More sensitive measurements of hand hygiene compliance are needed.

A statewide approach to systematising hand hygiene behaviour in hospitals: clean hands save lives, part I.

OBJECTIVE: To describe the planning and execution of a statewide campaign aimed at improving compliance with hand hygiene practices in New South Wales public hospitals. DESIGN AND SETTING: The campaign was conducted in all area health services (AHSs) in NSW (covering 208 public hospitals) between February 2006 and February 2007. Clinical practice improvement methods and campaign strategies were used to improve the availability and use of alcohol-based hand rub (AHR) at the point of patient care, using staff champions and local leaders, engaging patients and families, and measuring compliance. Staff were given regular feedback on their performance. Project officers funded by the Clinical Excellence Commission (CEC) provided local project management support and implemented the campaign in a standardised format orchestrated by the CEC. MAIN OUTCOME MEASURES: Proportion of available beds with secured and unsecured AHR containers nearby; amount of AHR used (based on purchasing patterns). RESULTS: Hospital visits before the campaign identified a lack of appropriately placed AHR at the point of care. The number of AHR containers per available bed in near-patient locations increased to 13 280/18 951 (70%) after the campaign. The quantity of AHR purchased per month across NSW public hospitals increased from 1477 L to 5568 L (a 377% increase). CONCLUSION: The CEC was successful in systematising the placement of AHR in all NSW public hospitals at the point of patient care. Although the use of AHR increased substantially, some staff were resistant to changing their hand hygiene practices.