Practical quality improvement changes for a low-resourced pediatric unit.

Background: This work describes a sustainable and replicable initiative to optimize multi-disciplinary care and uptake of clinical best practices for patients in a pediatric intensive care unit in Low/Middle Income Countries and to understand the various factors that may play a role in the reduction in child mortality seen after implementation of the Quality Improvement Initiative. Methods: This was a longitudinal assessment of a quality improvement program with the primary outcome of intubated pediatric patient mortality. The program was assessed 36 months following implementation of the quality improvement intervention using a t-test with linear regression to control for co-variates. An Impact Pathway model was developed to describe potential pathways for improvement, and context was added with an exploratory analysis of adoption of the intervention and locally initiated interventions. Results: 147 patients were included in the sustainability cohort. Comparing the initial post-implementation cohort to the sustainability cohort, the overall PICU unexpected extubations per 100 days mechanical ventilation decreased significantly from baseline (6.98) to the first year post intervention (3.52; p < 0.008) but plateaued without further significant decrease in the final cohort (3.0; p = 0.73), whereas the mortality decreased from 22.4 (std 0.42) to 9.5% (std 0.29): p value: 0.002 (confidence intervals: 0.05;0.21). The regression model that examined age, sex, diagnosis and severity of illness (via aggregate Pediatric Risk of Mortality (PRISM) scores between epochs) yielded an adjusted R-squared (adjusting for the number of predictors) value of 0.046, indicating that approximately 4.6% of the variance in mortality was explained by the predictors included in the model. The overall significance of the regression model was supported by an F-statistic of 3.198 (p = 0.00828). age, weight, diagnosis, and severity of illness. 15 new and locally driven quality practices were observed in the PICU compared to the initial post-implementation time period. The Impact Pathway model suggested multiple unique potential pathways connecting the improved patient outcomes with the intervention components. Conclusion: Sustained improvements were seen in the care of intubated pediatric patients. While some of this improvement may be attributable to the intervention, it appears likely that the change is multifactorial, as evidenced by a significant number of new quality improvement projects initiated by the local clinical team. Although currently limited by available data, the use of Driver Diagram and Impact Pathway models demonstrates several proposed causal pathways and holds potential for further elucidating the complex dynamics underlying such improvements.

Sustainable improvement in upstream and downstream outcomes for intubated patients three years after an airway-based educational intervention in a low-resource pediatric intensive care unit.

OBJECTIVE: To determine whether implementation of an education-based intervention can sustainably improve upstream and downstream outcomes in intubated patients in a pediatric intensive care unit (PICU) in a low-resource country. DESIGN: Quality improvement study comparing airway-related morbidity in two previously studied patient cohorts pre-intervention (Epoch 1) and immediately post-intervention (Epoch 2) with a third cohort thirty-six months post-intervention (Epoch 3). SETTING: PICU of the largest public children's hospital in El Salvador. PATIENTS: 147 patients under 18 years requiring intubation and mechanical ventilation (MV) met inclusion criteria in the long-term follow-up period and were consecutively sampled without exclusion (Epoch 3) (compared to 98 previously studied patients in the short-term follow-up period (Epoch 2)). INTERVENTION: A low-cost, education-based intervention to close knowledge gaps, improve communication among PICU doctors, nurses, and respiratory therapists, and optimize patient outcomes. MEASUREMENTS AND MAIN RESULTS: The primary outcome measure was change in unplanned extubation (UE) between Epochs 2 and 3. Other outcomes included use of cuffed endotracheal tubes (ETT), rate of elective ETT change and days of MV. The 17 % decrease in UE previously reported for Epoch 2 was sustained in Epoch 3. There was a statistically significant increase in use of cuffed ETT from 35.7 % in Epoch 2-55.1 % in Epoch 3 (p = 0.003, z-score -2.99). There was also a statistically significant mean difference in rate of elective ETT change per 100 MV days from Epoch 2 to Epoch 3 of 1.7 (p = 0.007; 95 % CI 0.15-0.84). There was no change in MV days from Epoch 2 to Epoch 3 (p-value 0.764; 95 % CI -1.48-2.02). Beyond these quantifiable results, many unanticipated practice changes were observed three years after the initial intervention. CONCLUSIONS: Sustained improvement in upstream and downstream outcomes (UE, cuffed ETT use, elective ETT change) for intubated patients in a low-resource PICU were observed three years after a low-cost, low-touch, education-based intervention.

Geriatric Assessment in Colorectal Surgery: A Systematic Review.

INTRODUCTION: The prevalence of colorectal surgery among older adults is expected to rise due to the aging population. Geriatric conditions (e.g., frailty) are risk factors for poor surgical outcomes. The goal of this systematic review is to examine how current literature describes geriatric assessment interventions in colorectal surgery and associated outcomes. METHODS: Systematic searches of Ovid MEDLINE, Cochrane Library, CINAHL, Embase, and Web of Science were completed. Review was performed according to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines and prospectively registered in PROSPERO, the international prospective register of systematic reviews in health and social care. All cohort studies and randomized trials of adult colorectal surgery patients where geriatric assessment was performed were included. Geriatric assessment with/without management interventions were identified and described. RESULTS: Seven-hundred ninety-three studies were identified. Duplicates (197) were removed. An additional 525 were excluded after title/abstract review. After full-text review, 20 studies met the criteria. Reference list review increased final total to 25 studies. All 25 studies were cohort studies. No randomized clinical trials were identified. Heterogeneous assessments were organized into geriatrics domains (mind, mobility, medications, matters most, and multi-complexity). Incomplete evaluations across geriatric domains were performed with few studies describing the use of assessments to impact management decisions. CONCLUSIONS: There are no randomized trials assessing the impact of geriatric assessment to tailor management strategies and improve outcomes in colorectal surgery. Few studies performed assessments to evaluate the geriatric domain matters most. These findings represent a gap in evidence for the efficacy of geriatric assessment and management strategies in colorectal surgical care.

Perspectives on Perioperative Team-Based Morbidity and Mortality Conferences: A Mixed Methods Study.

BACKGROUND: Morbidity and mortality conferences (MMCs) are quality improvement mechanisms during which adverse events are reviewed, often by physicians within a single discipline. There is a growing desire to include nonphysicians and physicians from other disciplines in team-based morbidity and mortality conferences (TBMMs). This mixed methods study investigates perioperative perspectives on MMCs generally and TBMMs specifically. METHODS: A national survey of perioperative health care professionals, including surgeons, anesthesiologists, and nurses, was used to explore opinions about MMCs and TBMMs. Semistructured qualitative interviews and focus groups were conducted with health care professionals and leaders at a single study site. Quantitative data were compared using a Kruskal-Wallis test. Interview transcripts were inductively analyzed. Data were analyzed using a concurrent mixed methods approach, triangulating both sources of data. RESULTS: Survey respondents (N = 1,466) were generally positive about both MMCs and TBMMs, agreeing that conferences were respectful, affected practice, and were educational. Nurses, compared to surgeons and anesthesiologists, were more likely to find conferences educational (p = 0.004) and were less comfortable speaking up in conferences (p < 0.001). Attendees who had more experience with TBMMs rated conferences as having significantly higher utility in achieving educational and safety goals. Qualitative data from 14 participants identified barriers and facilitators at the micro, meso, and macro level. Barriers include negative personal interactions, unsupportive leadership, and legal and regulatory issues. Facilitators include interpersonal relationships between professionals, buy-in from leadership, and external motivators. CONCLUSION: Perceptions of TBMMs were overall positive, but significant barriers to implementation remain. Team members may be invited to the table, but more effort is needed to make the entire team feel included in the discussion and optimize the value of these conferences. Strategies for overcoming identified barriers remains an open area of research.

A Qualitative Study of the Work Systems and Culture Around End-of-Day Intraoperative Anesthesia Handoffs in a Tertiary Care Center.

BACKGROUND: Intraoperative handoffs have been implicated as a contributing factor in many perioperative adverse events. Despite conflicting data around their impact on perioperative outcomes, they remain a vulnerable point in the perioperative system with significant attention focused on improving them. This study aimed to understand the processes in place surrounding the point of information transfer in intraoperative handoffs. METHODS: We used semistructured interviews with anesthesia clinicians to understand the processes and systems surrounding intraoperative handoffs. Interview data were coded deductively using the Systems Engineering Initiative for Patient Safety model as a framework, with subthemes developed inductively. RESULTS: Clinicians do a significant amount of work before and after the point of information transfer to ensure a smooth handoff and safe patient care. Despite not having standardization of handoffs, most clinicians have a typical handoff organization and largely agree on content that should be included. However, there is variability based on clinician and patient characteristics, including clinician discipline and patient acuity. These handoffs are additionally impacted by the overall culture in the operating room, including the teamwork and hierarchies present among the surgical and anesthesia teams. Finally, the broader operating room logistics, including scheduling practices for surgical cases and anesthesia teams, impact the quality of intraoperative handoffs and the ability of clinicians to prepare for these handoffs. CONCLUSIONS: Handoffs involve processes beyond the point of information transfer and are embedded in the systems and culture of the operating rooms. These considerations are important when seeking to improve the quality of intraoperative handoffs.

Perioperative Team-Based Morbidity and Mortality Conferences: A Systematic Review of the Literature.

Objective: This systematic review aimed to identify key elements of perioperative team-based morbidity and mortality conferences (TBMMs) and their impact on patient safety, education, and quality improvement outcomes. Background: Patient safety in the perioperative period is influenced by system, team, and individual behaviors. However, despite this recognition, single-discipline morbidity and mortality conferences remain a mainstay of educational and quality improvement efforts. Methods: A structured search was conducted in MEDLINE Complete, Embase, Web of Science, ClinicalTrials.gov, Cochrane CENTRAL, and ProQuest Dissertations and Theses Global in July 2022. Search results were screened, and the articles meeting inclusion criteria were abstracted. Results: Seven studies were identified. Key TBMM elements were identified, including activities done before the conference-case selection and case investigation; during the conference-standardized presentation formats and formal moderators; and after the conference-follow-up emails and quality improvement projects. The impacts of TBMMs on educational, safety, and quality improvement outcomes were heterogeneous, and no meta-analysis could be conducted; however, improvement was typically shown in each of these domains where comparisons were made. Conclusions: Recommendations for key TBMM elements can be drawn from the reports of successful perioperative TBMMs. Possible benefits of structured TBMMs over single-discipline conferences were identified for further exploration, including opportunities for rich educational contributions for trainees, improved patient safety, and the potential for system-wide quality improvement. Design and implementation of TBMM should address meticulous preparation of cases, standardized presentation format, and effective facilitation to increase the likelihood of realizing the potential benefits.

A Systems Theoretic Process Analysis of the Medication Use Process in the Operating Room.

BACKGROUND: While 4 to 10% of medications administered in the operating room may involve an error, few investigations have prospectively modeled how these errors might occur. Systems theoretic process analysis is a prospective risk analysis technique that uses systems theory to identify hazards. The purpose of this study was to demonstrate the use of systems theoretic process analysis in a healthcare organization to prospectively identify causal factors for medication errors in the operating room. METHODS: The authors completed a systems theoretic process analysis for the medication use process in the operating room at their institution. First, the authors defined medication-related accidents (adverse medication events) and hazards and created a hierarchical control structure (a schematic representation of the operating room medication use system). Then the authors analyzed this structure for unsafe control actions and causal scenarios that could lead to medication errors, incorporating input from surgeons, anesthesiologists, and pharmacists. The authors studied the entire medication use process, including requesting medications, dispensing, preparing, administering, documenting, and monitoring patients for the effects. Results were reported using descriptive statistics. RESULTS: The hierarchical control structure involved three tiers of controllers: perioperative leadership; management of patient care by the attending anesthesiologist, surgeon, and pharmacist; and execution of patient care by the anesthesia clinician in the operating room. The authors identified 66 unsafe control actions linked to 342 causal scenarios that could lead to medication errors. Eighty-two (24.0%) scenarios came from perioperative leadership, 103 (30.1%) from management of patient care, and 157 (45.9%) from execution of patient care. CONCLUSIONS: In this study, the authors demonstrated the use of systems theoretic process analysis to describe potential causes of errors in the medication use process in the operating room. Causal scenarios were linked to controllers ranging from the frontline providers up to the highest levels of perioperative management. Systems theoretic process analysis is uniquely able to analyze management and leadership impacts on the system, making it useful for guiding quality improvement initiatives.