Costs of quality improvement: a survey of four acute care hospitals.

BACKGROUND: In the past few decades, improving quality and safety has become an imperative for hospitals in the United States and elsewhere. Yet, little is known about the total costs of these efforts or what proportion of gross revenues is spent on quality- and safety-related activities. A study was conducted to quantify the total costs of building and maintaining the systemwide infrastructure that supports inpatient quality and safety. METHODS: In 2007, a survey was administered in person to the chief medical officers and associated staff of four urban, nonprofit, acute care teaching hospitals within a health care system in the Northeast. FINDING: Core inpatient quality improvement (QI) activities were composed of eight categories: information systems, patient safety, collecting and reporting quality metrics for local and national organizations, improving patient flow, staff incentives and education, patient satisfaction, leadership efforts focused on QI, and miscellaneous. Total reported costs for inpatient QI ranged from $2 million to $21 million. Relative costs varied from $200 to $400 per discharge (1%-2% of total operating revenue). Hospitals demonstrated great variability in how they allocated funds between specific activities such as patient safety projects ($10 to $80 per discharge), computerized provider order entry ($20 to $140 per discharge), and collecting and reporting quality metrics for national organizations ($30 to $80 per discharge). DISCUSSION: Total QI costs are challenging to define and are still small compared with total hospital operating revenue. The demand for resources for inpatient QI is likely to increase as the proposed number of metrics tracked by multiple regulatory and accreditation agencies continues to grow, coordination between agencies remains limited, and public demands for transparency increase.

Leveraging Quality Improvement Science to Reduce C. difficile Infections in a Community Hospital.

BACKGROUND: The most common infection acquired in US hospitals is Clostridium difficile, which can lead to protracted diarrhea, severe abdominal cramping, and infectious colitis and an attributable mortality of 6.5%. The mortality associated with C. difficile is of major clinical importance. The best strategy to prevent such infections is an open question. METHODS: A multiyear quality improvement initiative was performed in our community hospital to determine where hospitals should focus their resources to achieve sustainable reductions in hospital-acquired C. difficile infection (CDI). Quality improvement methodology was used to evaluate the impact of sequential interventions in environmental cleaning, infection prevention, and antibiotic stewardship over time. RESULTS: After four years, hospital-acquired CDI declined 55.5%, from 12.2 to 5.4 cases/10,000 patient-days (Poisson rate test, p = 0.002). High-risk antibiotic use declined 88.1%, from 63.7 to 7.6 days on treatment/1,000 patient-days (Student's t-test, p < 0.001). The highest-impact intervention was stewardship on diagnostics and high-risk antibiotics using home-grown decision support tools. CONCLUSION: Translating scientific evidence into clinical practice using quality improvement methods led to sustained reductions in C. difficile transmission and identified high-risk antibiotics and diagnostics as key leverage points.

Does electronic stewardship work?

Faced with national requirements to promote antimicrobial stewardship and reduce drug-resistant infections, community hospitals are challenged to make the best use of existing resources. Eighteen months after building antibiotic decision support into our electronic order platform, high-risk antibiotic use decreased by 83% (P < .001) at our community hospital. Hospital-acquired Clostridium difficile infections declined 24% (P = .07).

"Real World" compliance with strategies to prevent early-onset group B streptococcal disease.

OBJECTIVE: To assess the "real-world" compliance with risk- and culture-based strategies to prevent early-onset group B streptococcal disease. STUDY DESIGN: We retrospectively reviewed the medical records of consecutive term pregnancies delivered at three institutions (a subset of practices at an academic hospital using the culture-based strategy, an academic hospital using the risk-based strategy, and a community hospital using both) between January and March 1998. We abstracted demographic data and risk factors for group B streptococcus, group B streptococcal culture information, documentation of intrapartum antibiotic prophylaxis, and adverse drug reactions. We compared intrapartum compliance with the intended strategy. RESULTS: There were a total of 505 women managed with the risk-based strategy. Of those, 79 had a risk factor for group B streptococcal disease and 72/79 (91.1%) received intrapartum antibiotic prophylaxis. There were a total of 428 women managed with the culture-based strategy. Of those, 70 had positive cultures and 67 (95.7%) received intrapartum antibiotic prophylaxis. An additional 39 women in the culture-based group had no documentation that cultures had been done. Of those, eight (20.5%) had risk factors and all eight received intrapartum antibiotic prophylaxis. Compliance with the risk-based strategy was 91.1 versus 96.2% with the culture-based strategy (p=0.3). Among women managed using the risk-based strategy, 5/426 (1.2%) received intrapartum antibiotic prophylaxis without an identifiable risk factor. Among women in the culture-based strategy, 5/359 (1.4%) received intrapartum antibiotic prophylaxis with documented negative group B streptococcal cultures (p=0.5). When examined by site, compliance with the intended strategy was 91.2% at the academic hospital using the risk-based strategy, 100% at the academic hospital using the culture-based strategy, 90.9% at the community practices using the risk-based strategy, and 82.4% at the community practices using the culture-based strategy. CONCLUSION: Overall, intrapartum compliance with the risk-based approach was similar to the culture-based approach. However, there were more cultures not done and cultures done at inappropriate gestations at the community hospital practice.

Triplets after cloacal malformation repair.

BACKGROUND: Patients with cloacal malformations at birth usually require multiple surgical procedures to correct their anatomic defects. In addition, many also have associated Müllerian anomalies. Those who conceive after repairs invariably are considered "high-risk" pregnancies and are considered poor candidates for maintaining multiple gestations. Further, because of the nature of their defects and their repairs, following such patients with multiple gestation presents unique challenges. CASE: A 29-year-old multipara conceived triplets and delivered at 30 weeks with a good maternal and neonatal outcome. CONCLUSIONS: Patients with repaired cloacal abnormalities present unique challenges and risks compared to the general population with regard to the risks of multiple pregnancies.