Establishing and maintaining a remote vascular surgery aortic program: A single-center 5-year experience at the Veterans Affairs.

OBJECTIVE: We sought to detail the process of establishing a surgical aortic telehealth program and report the outcomes of a 5-year experience. METHODS: A telehealth program was established between two regional Veterans Affairs hospitals, one of which was without a comprehensive aortic surgical program, until such a program was established at the referring institution. A retrospective review was performed of all patients who underwent aortic surgery from 2014 to 2019. The operative data, demographics, perioperative complications, and follow-up data were reviewed. RESULTS: From 2014 to 2019, 109 patients underwent aortic surgery for occlusive and aneurysmal disease. Preoperative evaluation and postoperative follow-up were done remotely via telehealth. The median age of the patients was 68 years, 107 were men (98.2%), 28 (25.7%) underwent open aortic repair, and 81 (74.3%) underwent endovascular repair. Of the 109 patients, 101 (92.7%) had a median follow-up of 24.3 months, 5 (4.6%) were lost to follow-up or were noncompliant, 2 (1.8%) were noncompliant with their follow-up imaging studies but responded to telephone interviews, and 1 (0.9%) moved to another state. At the 30-day follow-up, eight patients (7.3%) required readmission. Four complications were managed locally, and four patients (3.6%) required transfer back to the operative hospital for additional care. CONCLUSIONS: Telehealth is a great tool to provide perioperative care and long-term follow-up for patients with aortic pathologies in remote locations. Most postoperative care and complications can be managed remotely, and patient compliance for long-term follow-up is high.

Percepção de cuidados desproporcionais entre médicos seniores, médicos residentes, enfermeiros e técnicos de enfermagem em um centro de terapia intensiva / Perception of disproportionate care among staff physicians, training physicians, nurses, and practical nurses in an intensive care unit

Introdução: O aumento progressivo de medidas avançadas para manutenção da vida em pacientes com pouca expectativa de sobrevida gera percepção de cuidado desproporcional. Objetivamos averiguar a prevalência de cuidado desproporcional em equipe médica e enfermagem que atuam na Unidade de Terapia Intensiva (UTI) em um hospital público do Brasil.Métodos: Estudo transversal envolvendo equipe médica e enfermagem em uma UTI multidisciplinar de 34 leitos de um hospital terciário no sul do Brasil de janeiro a julho de 2019. Ao total 151 profissionais responderam a um questionário eletrônico anônimo.Resultados: A taxa de resposta foi de 49,5%. Cento e dezoito (78,1%) profissionais identificaram cuidado desproporcional no ambiente de trabalho. Enfermeiros e técnicos de enfermagem receberam menos treinamento formal em comunicação de fim de vida do que médicos (10,6% versus 57,6%, p < 0,001). Vinte e nove (28,1%) enfermeiros e técnicos de enfermagem e 4 (0,08%) médicos responderam que não havia discussão sobre terminalidade na UTI (p = 0,006). Quarenta e três (89,5%) médicos afirmaram que havia colaboração entre equipe médica e equipe de enfermagem, ao passo que 58 (56,3%) enfermeiros e técnicos de enfermagem discordaram da assertiva (p < 0,001).Conclusão: Este é o primeiro estudo sobre percepção de cuidado desproporcional conduzido na América Latina, envolvendo residentes e técnicos de enfermagem e um centro de alta complexidade do sistema público de saúde. A vasta maioria dos profissionais percebe a existência de cuidado desproporcional em sua prática diária, independentemente da classe profissional.

Introduction: The increased use of life-sustaining measures in patients with poor long- and middle-term expected survival concerns health care providers regarding disproportionate care. The objective of this study was to report the prevalence of perceived inappropriate care among intensive care unit (ICU) staff physicians, training physicians, nurses, and practical nurses in a Brazilian public hospital.Methods: We conducted a cross-sectional study with the medical and nursing team of a 34-bed multidisciplinary ICU of a tertiary teaching hospital in Southern Brazil from January to July 2019. A total of 151 professionals completed an anonymous electronic survey. Results: The response rate was 49.5%. One hundred and eighteen (78.1%) respondents reported disproportionate care in the work environment. Nurses and practical nurses were less likely to receive formal training on end-of-life communication compared to physicians (10.6% vs. 57.6%, p < 0.001). Twenty-nine (28.1%) nurses and practical nurses vs. 4 (0.08%) physicians claimed that there were no palliative care deliberations in the ICU (p = 0.006). Of 48 senior and junior physicians, 43 (89.5%) believed that collaboration between physicians and nurses was good, whereas 58 out of 103 (56.3%) nurses and practical nurses disagreed (p < 0.001).Conclusion: This is the first survey on the perception of inappropriate care conducted in Latin America. The study included junior physicians and practical nurses working in a high-complexity medical center associated with the Brazilian public health system. Most health care providers perceived disproportionate care in their daily practice, regardless of their professional class.

Regionalization of Congenital Heart Surgery in the United States.

The objective of this study is to simulate regionalization of congenital heart surgery (CHS) in the United States and assess the impact of such a system on travel distance and mortality. Patients ≤18 years of age who underwent CHS were identified in 2012 State Inpatient Databases. Operations were stratified by the Risk Adjustment for Congenital Heart Surgery, version 1 (RACHS-1) method, with high risk defined as RACHS-1 levels 4-6. Regionalization was simulated by progressive closure of hospitals, beginning with the lowest volume hospital. Patients were moved to the next closest hospital. Analyses were conducted (1) maintaining original hospital mortality rates and (2) estimating mortality rates based on predicted surgical volumes after absorbing moved patients. One hundred fifty-three hospitals from 36 states performed 1 or more operation (19,064 operations). With regionalization wherein, all hospitals performed >310 operations, 37 hospitals remained, from 12.5% to 17.4% fewer deaths occurred (83-116/666), and median patient travel distance increased from 38.5 to 69.6 miles (P < 0.01). When only high-risk operations were regionalized, 3.9-5.9% fewer deaths occurred (26-39/666), and the overall mortality rate did not change significantly. Regionalization of CHS in the United States to higher volume centers may reduce mortality with minimal increase in patient travel distance. Much of the mortality reduction may be missed if solely high-risk patients are regionalized.

Validação colaborativa de macrodimensões e indicadores-chave para avaliação de performance de serviços de saúde no Brasil / Collaborative validation of macrodimensions and key indicators for health services performance evaluation in Brazil

RESUMO A criação do Sistema Único de Saúde (SUS) no Brasil, em 1988, representou avanços na organização sistêmica e descentralização da gestão única; entretanto, passados 30 anos a governança de resultados parece frágil. A nova gestão pública tem exigido esforços de monitoramento de resultados, controladoria e responsabilização dos gastos (accountability). Este estudo explora a translação de conhecimentos de uma amostra de gestores e profissionais (stakeholders), para validação de um painel de indicadores do SUS. A aplicação dos instrumentos de captação e validação das percepções obteve resultados das três fases iniciais (n=108) que consolidaram um instrumento aplicado para validação de campo (n=112), cuja análise descritiva validou cinco dimensões e 24 indicadores-chave para gestão de resultados em organizações de saúde. A análise inferencial gerou um modelo final que garantiu confiabilidade e validade das cinco dimensões (macrodomínios), mas apenas de 17 indicadores (domínios) de desempenho propostos pelos decisores a partir de seus conhecimentos prévios.

ABSTRACT The creation of the Unified Health System (SUS) in Brazil, in 1988, represented advances in the systemic organization and decentralization of the unified management; however, after 30 years the governance of results seems fragile. The new public management has demanded efforts to monitor results, controllership and accountability. This study explores the translation of knowledge from a sample of managers and professionals (stakeholders), for validation of a panel of SUS indicators. The application of perceptual capture and validation instruments yielded results from the three initial phases (n=108), which consolidated an instrument validated for field validation (n=112), whose descriptive analysis validated five dimensions and 24 key indicators for management of results in health organizations. Inferential analysis generated a final model that guaranteed reliability and validity of the five dimensions (macrodomains), but only of 17 performance indicators (domains) proposed by the decision makers based on their previous knowledge.

Professional Society Leadership in Health Care Quality: The Society of Thoracic Surgeons Experience.

In 1989 the Society of Thoracic Surgeons (STS) initiated the STS National Database, which subsequently became the cornerstone of a multifaceted STS quality program. METHODS: The STS quality program is overseen by the STS Council on Quality, Research, and Patient Safety, which has four components. The Workforce on Research Development, in collaboration with the STS Research Center, coordinates clinical research based on the STS National Database, all of which is focused on improving clinical outcomes. The Workforce on Evidence Based Surgery develops clinical practice guidelines and expert consensus documents to foster the use of best practices. The Workforce on Patient Safety disseminates high-reliability practices from within and outside health care to improve the safety of cardiothoracic surgical care. The Workforce on National Databases consists of four subspecialty registries (adult cardiac, congenital cardiac, general thoracic, mechanical circulatory support [Intermacs and Pedimacs]) and multiple functionally oriented task forces (Quality Measurement, Quality Initiatives, Public Reporting, Informatics, Patient-Reported Outcomes, and Aortic Surgery). RESULTS: Between 1998 and 2016, the rates of coronary artery bypass grafting surgery adverse outcomes decreased substantially, including operative mortality (-31.3%), renal failure (-56.3%), stroke (-43.5%), reoperation (-65.7%), and sternal infection (-50.0%). Comparable increases in process measure compliance included internal mammary artery use (32%), preoperative beta-blocker use (83.1%), discharge antiplatelet drugs (22.9%), discharge antilipid drugs (78.6%), and discharge beta-blockers (54.1%). CONCLUSION: The STS quality program has achieved remarkable, continuing improvements in patient safety and quality over several decades. The components of this program can be replicated by other health care professional societies to advance quality and safety for their patient populations.

Development of a gastroschisis core outcome set.

OBJECTIVE: Outcome reporting heterogeneity impedes identification of gold standard treatments for children born with gastroschisis. Use of core outcome sets (COSs) in research reduces outcome reporting heterogeneity and ensures that studies are relevant to patients. The aim of this study was to develop a gastroschisis COS. DESIGN AND SETTING: Systematic reviews and stakeholder nomination were used to identify candidate outcomes that were subsequently prioritised by key stakeholders in a three-phase online Delphi process and face-to-face consensus meeting using a 9-point Likert scale. In phases two and three of the Delphi process, participants were shown graphical and numerical representations of their own, and all panels scores for each outcome respectively and asked to review their previous score in light of this information. Outcomes were carried forward to the consensus meeting if prioritised by two or three stakeholder panels in the third phase of the Delphi process. The COS was formed from outcomes where ≥70% of consensus meeting participants scored the outcome 7-9 and <15% of participants scored it 1-3. RESULTS: 71 participants (84%) completed all phases of the Delphi process, during which 87 outcomes were assessed. Eight outcomes, mortality, sepsis, growth, number of operations, severe gastrointestinal complication, time on parenteral nutrition, liver disease and quality of life for the child, met criteria for inclusion in the COS. CONCLUSIONS: Eight outcomes have been included in the gastroschisis COS as a result of their importance to key stakeholders. Implementing use of the COS will increase the potential for identification of gold standard treatments for the management of children born with gastroschisis.

Using Lean Process Improvement to Enhance Safety and Value in Orthopaedic Surgery: The Case of Spine Surgery.

Lean methodology was developed in the manufacturing industry to increase output and decrease costs. These labor organization methods have become the mainstay of major manufacturing companies worldwide. Lean methods involve continuous process improvement through the systematic elimination of waste, prevention of mistakes, and empowerment of workers to make changes. Because of the profit and productivity gains made in the manufacturing arena using lean methods, several healthcare organizations have adopted lean methodologies for patient care. Lean methods have now been implemented in many areas of health care. In orthopaedic surgery, lean methods have been applied to reduce complication rates and create a culture of continuous improvement. A step-by-step guide based on our experience can help surgeons use lean methods in practice. Surgeons and hospital centers well versed in lean methodology will be poised to reduce complications, improve patient outcomes, and optimize cost/benefit ratios for patient care.

Collaborative Quality Improvement in the Congenital Heart Defects: Development of the ASSIST Consortium and a Preliminary Surgical Outcomes Report.

OBJECTIVE: ASSIST is the first Brazilian initiative in building a collaborative quality improvement program in pediatric cardiology and congenital heart disease. The purposes of this manuscript are: (a) to describe the development of the ASSIST project, including the historical, philosophical, organizational, and infrastructural components that will facilitate collaborative quality improvement in congenital heart disease care; (b) to report past and ongoing challenges faced; and (c) to report the first preliminary data analysis. METHODS: A total of 614 operations were prospectively included in a comprehensive online database between September 2014 and December 2015 in two participating centers. Risk Adjustment for Congenital Heart Surgery (RACHS) 1 and Aristotle Basic Complexity (ABC) scores were obtained. Descriptive statistics were provided, and the predictive values of the two scores for mortality were calculated by multivariate logistic regression models. RESULTS: Many barriers and challenges were faced and overcome. Overall mortality was 13.4%. Independent predictors of in-hospital death were: RACHS-1 categories (3, 4, and 5/6), ABC level 4, and age group (≤ 30 days, and 30 days - 1 year). CONCLUSION: The ASSIST project was successfully created over a solid base of collaborative work. The main challenges faced, and overcome, were lack of institutional support, funding, computational infrastructure, dedicated staff, and trust. RACHS-1 and ABC scores performed well in our case mix. Our preliminary outcome analysis shows opportunities for improvement.

Structure and work process in primary care and hospitalizations for sensitive conditions.

OBJECTIVE: The objective of this study is to investigate whether the characteristics of the structure of primary health units and the work process of primary care teams are associated with the number of hospitalizations for primary care sensitive conditions. METHODS: In this ecological study, we have analyzed data of Brazilian municipalities related to sociodemographic characteristics, coverage of care programs, structure of primary health units, and work process of primary care teams. We have obtained the data from the first cycle of the Brazilian Program for Improving Access and Quality of the Primary Care, of the Department of Information Technology of the Brazilian Unified Health System, the Brazilian Institute of Geography and Statistics, and the United Nations Development Programme. The associations have been estimated using negative binomial regression coefficients (ß) and respective 95% confidence intervals, with a hierarchical approach in three levels (alpha = 5%). RESULTS: In the adjusted analysis for the outcome in 2013, in the distal level, the coverage of the Bolsa Família Program (ß = -0.001) and private insurance (ß = -0.01) had a negative association, and the human development index (ß = 1.13), the proportion of older adults (ß = 0.05) and children under the age of five (ß = 0.05), and the coverage of the Community Health Agent Strategy (ß = 0.002) showed positive association with hospitalizations for primary care sensitive conditions. In the intermediate level, minimum hours (ß = -0.14) and availability of vaccines (ß = -0.16) showed a negative association, and availability of medications showed a positive association (ß = 0.16). In the proximal level, only the variable of matrix support (ß = 0.10) showed a positive association. The variables in the adjusted analysis of the number of hospitalizations for primary care sensitive conditions in 2014 presented the same association as in 2013. CONCLUSIONS: The characteristics of the structure of primary health units and the work process of the primary care teams impact the number of hospitalizations for primary care sensitive conditions in Brazilian municipalities. OBJETIVO: Investigar se características da estrutura das unidades básicas de saúde e do processo de trabalho das equipes de atenção básica estão associadas ao número de internações por condições sensíveis à atenção primária. MÉTODOS: Neste estudo ecológico, foram analisados dados de municípios brasileiros relativos a características sociodemográficas, de cobertura de programas assistenciais, de estrutura das unidades básicas de saúde e processo de trabalho das equipes de atenção básica. Os dados foram obtidos do primeiro ciclo do Programa de Melhoria do Acesso e Qualidade da Atenção Básica, do Departamento de Informática do Sistema Único de Saúde, do Instituto Brasileiro de Geografia e Estatística e do Programa das Nações Unidas. Estimaram-se as associações por meio de coeficientes de regressão binomial negativa (ß) e respectivos intervalos de confiança a 95%, com abordagem hierarquizada em três blocos (alpha = 5%). RESULTADOS: Na análise ajustada, para o desfecho em 2013, no bloco distal, a cobertura do Programa Bolsa Família (ß = -0,001) e de plano privado (ß = -0,01) apresentaram associação negativa; e o índice de desenvolvimento humano (ß = 1,13), a proporção de pessoa idosa (ß = 0,05) e de menor de cinco anos (ß = 0,05) e a cobertura da Estratégia de Agentes Comunitários de Saúde (ß = 0,002) mostraram associação positiva com internações por condições sensíveis à atenção primária. No bloco intermediário, apresentaram associação negativa o horário mínimo (ß = -0,14) e a disponibilidade de vacina (ß = -0,16); e associação positiva, a disponibilidade de medicamentos (ß = 0,16). No bloco proximal, apenas a variável apoio matricial (ß = 0,10) mostrou associação positiva. Na análise ajustada do número de internações por condições sensíveis à atenção primária em 2014, as variáveis apresentaram o mesmo sentido de associação de 2013. CONCLUSÕES: Características da estrutura das unidades básicas de saúde e do processo de trabalho das equipes de atenção básica impactam no número de internações por condições sensíveis à atenção primária nos municípios brasileiros.

Collaborative quality improvement in the congenital heart defects: development of the assist consortium and a preliminary surgical outcomes report

Abstract Objective: ASSIST is the first Brazilian initiative in building a collaborative quality improvement program in pediatric cardiology and congenital heart disease. The purposes of this manuscript are: (a) to describe the development of the ASSIST project, including the historical, philosophical, organizational, and infrastructural components that will facilitate collaborative quality improvement in congenital heart disease care; (b) to report past and ongoing challenges faced; and (c) to report the first preliminary data analysis. Methods: A total of 614 operations were prospectively included in a comprehensive online database between September 2014 and December 2015 in two participating centers. Risk Adjustment for Congenital Heart Surgery (RACHS) 1 and Aristotle Basic Complexity (ABC) scores were obtained. Descriptive statistics were provided, and the predictive values of the two scores for mortality were calculated by multivariate logistic regression models. Results: Many barriers and challenges were faced and overcome. Overall mortality was 13.4%. Independent predictors of in-hospital death were: RACHS-1 categories (3, 4, and 5/6), ABC level 4, and age group (≤ 30 days, and 30 days - 1 year). Conclusion: The ASSIST project was successfully created over a solid base of collaborative work. The main challenges faced, and overcome, were lack of institutional support, funding, computational infrastructure, dedicated staff, and trust. RACHS-1 and ABC scores performed well in our case mix. Our preliminary outcome analysis shows opportunities for improvement.

[A standard data set for the evaluation of venous leg ulcers in selective contracts : National consensus]. / Standarddatensatz für die Evaluation bei Selektivverträgen bei Ulcus cruris : Nationaler Konsensus.

BACKGROUND: Selective agreements are becoming increasingly important in health care management. To date, no standard recommendations for the evaluation of selective contracts are available. OBJECTIVES: Against this background, a recommendation on the evaluation of selective contracts in patients with leg ulcers (LU) was developed and approved by the nationwide consensus conference. MATERIALS AND METHODS: Based on a systematic literature review and followed by a manual search through other possible evaluation indicators in the care of patients with LU, a Delphi-based consensus process was performed by various scientific societies, professional associations, insurances and supply networks. RESULTS: For the evaluation of efficiency and quality of care, a recommendation on the evaluation of selective agreements with patients with LU was consented in six meetings and in five multistage online surveys. In total, 44 evaluation indicators were identified in the quality subareas structure, process, and outcome. The outcome indicators are divided into clinical, patient-related, and cost-related indicators. CONCLUSIONS: The developed evaluation indicators represent the quality of care in patients with LU. The indicators can be applied individually, depending on the agreed contract-specific supply target. After implementation of this national standard, the comparability of selective agreements in the management of patients with LU can be ensured and consolidated.

Structure and work process in primary care and hospitalizations for sensitive conditions / Estrutura e processo de trabalho na atenção primária e internações por condições sensíveis

ABSTRACT OBJECTIVE The objective of this study is to investigate whether the characteristics of the structure of primary health units and the work process of primary care teams are associated with the number of hospitalizations for primary care sensitive conditions. METHODS In this ecological study, we have analyzed data of Brazilian municipalities related to sociodemographic characteristics, coverage of care programs, structure of primary health units, and work process of primary care teams. We have obtained the data from the first cycle of the Brazilian Program for Improving Access and Quality of the Primary Care, of the Department of Information Technology of the Brazilian Unified Health System, the Brazilian Institute of Geography and Statistics, and the United Nations Development Programme. The associations have been estimated using negative binomial regression coefficients (β) and respective 95% confidence intervals, with a hierarchical approach in three levels (alpha = 5%). RESULTS In the adjusted analysis for the outcome in 2013, in the distal level, the coverage of the Bolsa Família Program (β = -0.001) and private insurance (β = -0.01) had a negative association, and the human development index (β = 1.13), the proportion of older adults (β = 0.05) and children under the age of five (β = 0.05), and the coverage of the Community Health Agent Strategy (β = 0.002) showed positive association with hospitalizations for primary care sensitive conditions. In the intermediate level, minimum hours (β = -0.14) and availability of vaccines (β = -0.16) showed a negative association, and availability of medications showed a positive association (β = 0.16). In the proximal level, only the variable of matrix support (β = 0.10) showed a positive association. The variables in the adjusted analysis of the number of hospitalizations for primary care sensitive conditions in 2014 presented the same association as in 2013. CONCLUSIONS The characteristics of the structure of primary health units and the work process of the primary care teams impact the number of hospitalizations for primary care sensitive conditions in Brazilian municipalities.

RESUMO OBJETIVO Investigar se características da estrutura das unidades básicas de saúde e do processo de trabalho das equipes de atenção básica estão associadas ao número de internações por condições sensíveis à atenção primária. MÉTODOS Neste estudo ecológico, foram analisados dados de municípios brasileiros relativos a características sociodemográficas, de cobertura de programas assistenciais, de estrutura das unidades básicas de saúde e processo de trabalho das equipes de atenção básica. Os dados foram obtidos do primeiro ciclo do Programa de Melhoria do Acesso e Qualidade da Atenção Básica, do Departamento de Informática do Sistema Único de Saúde, do Instituto Brasileiro de Geografia e Estatística e do Programa das Nações Unidas. Estimaram-se as associações por meio de coeficientes de regressão binomial negativa (β) e respectivos intervalos de confiança a 95%, com abordagem hierarquizada em três blocos (alpha = 5%). RESULTADOS Na análise ajustada, para o desfecho em 2013, no bloco distal, a cobertura do Programa Bolsa Família (β = -0,001) e de plano privado (β = -0,01) apresentaram associação negativa; e o índice de desenvolvimento humano (β = 1,13), a proporção de pessoa idosa (β = 0,05) e de menor de cinco anos (β = 0,05) e a cobertura da Estratégia de Agentes Comunitários de Saúde (β = 0,002) mostraram associação positiva com internações por condições sensíveis à atenção primária. No bloco intermediário, apresentaram associação negativa o horário mínimo (β = -0,14) e a disponibilidade de vacina (β = -0,16); e associação positiva, a disponibilidade de medicamentos (β = 0,16). No bloco proximal, apenas a variável apoio matricial (β = 0,10) mostrou associação positiva. Na análise ajustada do número de internações por condições sensíveis à atenção primária em 2014, as variáveis apresentaram o mesmo sentido de associação de 2013. CONCLUSÕES Características da estrutura das unidades básicas de saúde e do processo de trabalho das equipes de atenção básica impactam no número de internações por condições sensíveis à atenção primária nos municípios brasileiros.

A comparative study of drug listing recommendations and the decision-making process in Australia, the Netherlands, Sweden, and the UK.

Drug listing recommendations from health technology assessment (HTA) agencies often fail to coincide with one another. We conducted a comparative analysis of listing recommendations in Australia (PBAC), the Netherlands (CVZ), Sweden (TLV) and the UK (NICE) over time, examined interagency agreement, and explored how process-related factors-including time delay between HTA evaluations, therapeutic indication and orphan drug status, measure of health economic value, and comparator-impacted decision-making in drug coverage. Agreement was poor to moderate across HTA agency listing recommendations, yet it increased as the delay between HTA agency appraisals decreased, when orphan drugs were assessed, and when medicines deemed to provide low value (immunosuppressants, antineoplastics) were removed from the sample. International differences in drug listing recommendations seem to occur in part due to inconsistencies in how the supporting evidence informs assessment, but also to differences in how domestic priorities shape the value-based decision-making process.

Predicting Which Patients Will Benefit From Palliative Care: Use of Bundles, Triggers, and Protocols.

Intensive care units provide a wide range of care to patients with serious or life-threatening conditions. This care provides excellent state-of-the-art interventions, often concentrated on meeting national health priorities and performance measures. Overall patient care and the resultant outcomes in the intensive care unit are superb. However, one area that needs improvement is the provision of high-quality palliative care (PC) and end-of-life care. Many providers and administrators now realize implementing PC in the critical care setting is vital to optimal patient outcomes. PC improves patient and family satisfaction and quality of life, reduces length of stay and 30-day readmission rates, and patients can live longer with PC.

Priorities for Evaluating Palliative Care Outcomes in Intensive Care Units.

Defining the quality of intensive care unit (ICU) care when patients are dying is challenging. Palliative care has been recommended to improve outcomes of dying ICU patients; however, traditional ICU quality indicators do not always align with palliative care. Evidence suggests that some aspects of ICU care improve when palliative care is integrated; however, consensus is lacking concerning the outcomes that should be measured. Overcoming challenges to measuring palliative care will require consensus development and rigorous research on the best way to evaluate ICU palliative care services.

Donabedian's structure-process-outcome quality of care model: Validation in an integrated trauma system.

BACKGROUND: According to Donabedian's health care quality model, improvements in the structure of care should lead to improvements in clinical processes that should in turn improve patient outcome. This model has been widely adopted by the trauma community but has not yet been validated in a trauma system. The objective of this study was to assess the performance of an integrated trauma system in terms of structure, process, and outcome and evaluate the correlation between quality domains. METHODS: Quality of care was evaluated for patients treated in a Canadian provincial trauma system (2005-2010; 57 centers, n = 63,971) using quality indicators (QIs) developed and validated previously. Structural performance was measured by transposing on-site accreditation visit reports onto an evaluation grid according to American College of Surgeons criteria. The composite process QI was calculated as the average sum of proportions of conformity to 15 process QIs derived from literature review and expert opinion. Outcome performance was measured using risk-adjusted rates of mortality, complications, and readmission as well as hospital length of stay (LOS). Correlation was assessed with Pearson's correlation coefficients. RESULTS: Statistically significant correlations were observed between structure and process QIs (r = 0.33), and process and outcome QIs (r = -0.33 for readmission, r = -0.27 for LOS). Significant positive correlations were also observed between outcome QIs (r = 0.37 for mortality-readmission; r = 0.39 for mortality-LOS and readmission-LOS; r = 0.45 for mortality-complications; r = 0.34 for readmission-complications; 0.63 for complications-LOS). CONCLUSION: Significant correlations between quality domains observed in this study suggest that Donabedian's structure-process-outcome model is a valid model for evaluating trauma care. Trauma centers that perform well in terms of structure also tend to perform well in terms of clinical processes, which in turn has a favorable influence on patient outcomes. LEVEL OF EVIDENCE: Prognostic study, level III.

Difficult airway response team: a novel quality improvement program for managing hospital-wide airway emergencies.

BACKGROUND: Difficult airway cases can quickly become emergencies, increasing the risk of life-threatening complications or death. Emergency airway management outside the operating room is particularly challenging. METHODS: We developed a quality improvement program-the Difficult Airway Response Team (DART)-to improve emergency airway management outside the operating room. DART was implemented by a team of anesthesiologists, otolaryngologists, trauma surgeons, emergency medicine physicians, and risk managers in 2005 at The Johns Hopkins Hospital in Baltimore, Maryland. The DART program had 3 core components: operations, safety, and education. The operations component focused on developing a multidisciplinary difficult airway response team, standardizing the emergency response process, and deploying difficult airway equipment carts throughout the hospital. The safety component focused on real-time monitoring of DART activations and learning from past DART events to continuously improve system-level performance. This objective entailed monitoring the paging system, reporting difficult airway events and DART activations to a Web-based registry, and using in situ simulations to identify and mitigate defects in the emergency airway management process. The educational component included development of a multispecialty difficult airway curriculum encompassing case-based lectures, simulation, and team building/communication to ensure consistency of care. Educational materials were also developed for non-DART staff and patients to inform them about the needs of patients with difficult airways and ensure continuity of care with other providers after discharge. RESULTS: Between July 2008 and June 2013, DART managed 360 adult difficult airway events comprising 8% of all code activations. Predisposing patient factors included body mass index >40, history of head and neck tumor, prior difficult intubation, cervical spine injury, airway edema, airway bleeding, and previous or current tracheostomy. Twenty-three patients (6%) required emergent surgical airways. Sixty-two patients (17%) were stabilized and transported to the operating room for definitive airway management. There were no airway management-related deaths, sentinel events, or malpractice claims in adult patients managed by DART. Five in situ simulations conducted in the first program year improved DART's teamwork, communication, and response times and increased the functionality of the difficult airway carts. Over the 5-year period, we conducted 18 airway courses, through which >200 providers were trained. CONCLUSIONS: DART is a comprehensive program for improving difficult airway management. Future studies will examine the comparative effectiveness of the DART program and evaluate how DART has impacted patient outcomes, operational efficiency, and costs of care.