Adverse events reporting during the COVID-19 pandemic in a Danish region: a retrospective analysis.

The 2020 onset of the COVID-19 pandemic globally strained healthcare. Healthcare systems worldwide had to rapidly reorganize, impacting service delivery, patient care, and care-seeking behaviors. This left little time to assess the pandemic's effects on patient safety. This paper investigates COVID-19's influence on patient safety in a Danish region, using data from the national reporting system for adverse events during the initial COVID-19 surge in early 2020. This retrospective analysis investigated how the early phase of the COVID-19 pandemic (January-September 2020) affected the incidence of adverse events in a Danish Region, comparing it to the same period in 2019. Data were sourced from the Danish Patient Safety Database and regional systems. Adverse events were reported numerically. Descriptive statistics were employed to describe the percentage difference in adverse events and hospital activity, as well as the rate of adverse events per 1000 activities. Additionally, COVID-19-specific adverse events from April 2020 to March 2021 were identified and analyzed, categorizing them into seven risk areas across various healthcare sectors. During Denmark's initial COVID-19 surge in early 2020, the North Denmark Region's hospitals reported a significant decrease in adverse events, with a 42.5% drop in March 2020 compared to March 2019. From January to September 2020, the number of adverse events dropped 8.5% compared to the same period in 2019. In the same period, hospital activity declined by 10.2%. The ratio of reported adverse events per 1000 hospital activities thus decreased in early 2020 but showed only a minor difference overall for January-September compared to 2019. Between April 2020 and March 2021, out of 5703 total adverse events, 324 (5.7%) were COVID-19 related. COVID-19-related events were categorized into seven distinct risk areas, reflecting diverse impacts across healthcare sectors including hospitals, general practices, pre-hospital care, and specialized services. The initial decline in reporting of adverse events likely resulted from rapid healthcare changes and under-prioritization of the reporting system during the acute phase. However, a near return to pre-pandemic reporting levels suggests a resilient reporting system despite the crisis. The study's strength lies in the comprehensive data from Danish reporting systems, though it acknowledges potential underreporting and doesn't measure the pandemic's overall impact on patient safety.

Towards reliable forecasting of healthcare capacity needs: A scoping review and evidence mapping.

BACKGROUND: The COVID-19 pandemic has highlighted the critical importance of robust healthcare capacity planning and preparedness for emerging crises. However, healthcare systems must also adapt to more gradual temporal changes in disease prevalence and demographic composition over time. To support proactive healthcare planning, statistical capacity forecasting models can provide valuable information to healthcare planners. This systematic literature review and evidence mapping aims to identify and describe studies that have used statistical forecasting models to estimate healthcare capacity needs within hospital settings. METHOD: Studies were identified in the databases MEDLINE and Embase and screened for relevance before items were defined and extracted within the following categories: forecast methodology, measure of capacity, forecast horizon, healthcare setting, target diagnosis, validation methods, and implementation. RESULTS: 84 studies were selected, all focusing on various capacity outcomes, including number of hospital beds/ patients, staffing, and length of stay. The selected studies employed different analytical models grouped in six items; discrete event simulation (N = 13, 15 %), generalized linear models (N = 21, 25 %), rate multiplication (N = 15, 18 %), compartmental models (N = 14, 17 %), time series analysis (N = 22, 26 %), and machine learning not otherwise categorizable (N = 12, 14 %). The review further provides insights into disease areas with infectious diseases (N = 24, 29 %) and cancer (N = 12, 14 %) being predominant, though several studies forecasted healthcare capacity needs in general (N = 24, 29 %). Only about half of the models were validated using either temporal validation (N = 39, 46 %), cross-validation (N = 2, 2 %) or/and geographical validation (N = 4, 5 %). CONCLUSION: The forecasting models' applicability can serve as a resource for healthcare stakeholders involved in designing future healthcare capacity estimation. The lack of routine performance validation of the used algorithms is concerning. There is very little information on implementation and follow-up validation of capacity planning models.

Disparities in prehospital and emergency surgical care among patients with perforated ulcers and a history of mental illness: a nationwide cohort study.

PURPOSE: To compare patients with and without a history of mental illness on process and outcome measures in relation to prehospital and emergency surgical care for patients with perforated ulcer. METHODS: A nationwide registry-based cohort study of patients undergoing emergency surgery for perforated ulcer. We used data from the Danish Prehospital Database 2016-2017 and the Danish Emergency Surgery Registry 2004-2018 combined with data from other Danish databases. Patients were categorized according to severity of mental health history. RESULTS: We identified 4.767 patients undergoing emergency surgery for perforated ulcer. Among patients calling the EMS with no history of mental illness, 51% were identified with abdominal pain when calling the EMS compared to 31% and 25% among patients with a history of moderate and major mental illness, respectively. Median time from hospital arrival to surgery was 6.0 h (IQR: 3.6;10.7). Adjusting for age, sex and comorbidity, patients with a history of major mental illness underwent surgery 46 min (95% CI: 4;88) later compared to patients with no history of mental illness. Median number of days-alive-and-out-of-hospital at 90-day follow-up was 67 days (IQR: 0;83). Adjusting for age, sex and comorbidity, patients with a history of major mental illness had 9 days (95% CI: 4;14) less alive and out-of-hospital at 90-day follow-up. CONCLUSION: One-third of the population had a history of mental illness or vulnerability. Patients with a history of major mental illness were less likely to be identified with abdominal pain if calling the EMS prior to arrival. They had longer delays from hospital arrival to surgery and higher mortality.

Quality and Predictors of Diabetes Care Among Patients With Schizophrenia: A Danish Nationwide Study.

OBJECTIVE: Patients with schizophrenia have a high prevalence of diabetes, but data on diabetes care quality for these patients are limited. This nationwide study compared the quality of diabetes care among individuals with and without schizophrenia and identified predictors of care quality. METHODS: In a population-based cohort study, 83,813 individuals with diabetes seen at hospital outpatient clinics between 2005 and 2013, including 669 with comorbid schizophrenia, were identified from Danish registries. High-quality diabetes care was defined as having received ≥80% of guideline-recommended process performance measures. Variables assessed as predictors of diabetes care included patient-specific (sex, age, smoking, substance abuse, Global Assessment of Functioning score, and duration of schizophrenia), provider-specific (quality of schizophrenia care), and system-specific (annual patient contact volume of the diabetes clinic) factors. RESULTS: Compared with individuals with diabetes only, those with diabetes and schizophrenia were less likely to receive high-quality diabetes care (relative risk [RR]=.91, 95% confidence interval [CI]=.88-.95) and less likely to receive several individual process performance measures of diabetes care, including blood pressure monitoring (RR=.98, CI=.96-.99), treatment with antihypertensive drugs (RR=.83, CI=.70-.97) and angiotensin-converting enzyme/angiotensin II receptor inhibitors (RR=.72, CI=.55-.93), screening for albuminuria (RR=.96, CI=.93-.99), eye examination at least once every second year (RR=.97, CI=.94-.99), and foot examination (RR=.96, CI=.93-.99). Predictors of poor diabetes care among individuals with schizophrenia included documented drug abuse and low contact volume of the diabetes clinic. CONCLUSIONS: Individuals with schizophrenia received lower-quality diabetes care compared with those without schizophrenia. However, absolute differences in care were modest.

Off-hours admission and quality of hip fracture care: a nationwide cohort study of performance measures and 30-day mortality.

OBJECTIVE: Higher risks of adverse outcomes have been reported for patients admitted acutely during off-hours. However, in relation to hip fracture, the evidence is inconsistent. We examined whether time of admission influenced compliance with performance measures, surgical delay and 30-day mortality in patients with hip fracture. DESIGN: Cohort study. SETTING: Data from The Danish Multidisciplinary Hip Fracture Registry linked with data from Danish National Registries. PARTICIPANTS: Danish patients undergoing hip fracture surgery, aged >65 years, admitted 1 March 2010 to 30 November 2013 (N = 25 305). EXPOSURE: Off-hours: weekday evenings and nights, and weekends. MAIN OUTCOME MEASURES: Meeting specific performance measures, surgical delay and mortality. RESULTS: No differences were found in patient characteristics or in meeting performance measures (RRs from 0.99 [95% CI: 0.98-1.01] to 1.01 [95% CI: 0.99-1.02]. When comparing admission on weekdays (evenings and nights vs. days), off-hours admission was associated with a lower risk of surgical delay (adjusted OR 0.75 [95% CI: 0.66-0.85]) while no differences in 30-day mortality was found (adjusted OR 0.91 [95% CI: 0.80-1.04]. When comparing admission during weekends with admission during weekdays, off-hours admission was associated with a higher risk of surgical delay (adjusted OR 1.19 [95% CI: 1.05-1.37]) and a higher 30-day mortality risk (adjusted OR 1.13 [95% CI: 1.04-1.23]. The risk of surgical delay appeared not to explain the excess 30-day mortality. CONCLUSIONS: Patients admitted off-hours and on-hours received similar quality of care. The risk of surgical delay and 30 days mortality was higher among patients admitted during weekends; explanations need to be clarified.

Potentially inappropriate prescriptions in patients admitted to a psychiatric hospital.

Background Very little is known about the general appropriateness of prescribing for psychiatric patients. Aims To identify prevalence and types of potentially inappropriate prescribing (PIP) of psychotropic and somatic medications, to assess the severity of potential clinical consequences and to identify possible predictive factors of PIP in a sample of adult psychiatric in-patients. Methods A descriptive, cross-sectional design using medication reviews by clinical pharmacologists to identify PIP during a 3-month period. The setting was in-patient units in a psychiatric department of a Danish university hospital during a 3-month period (September 2013-November 2013). Patients medication lists (n = 207) were reviewed at the time of admission and all identified PIPs were assessed for potential consequences by clinical pharmacologists. Results There were 349 PIP identified in 1291 prescriptions. The proportion of patients found to have at least one PIP was 123/207 (59%) and the proportions of patients with at least one PIP assessed to be potentially serious or fatal was 69/207 (33%) and 24/207 (12%), respectively. Interactions between drugs 125/207 (36%) and too high doses of drugs 56/207 (16%) were the most frequent PIP. Predictive factors for PIP were polypharmacy (>5 prescriptions) and having one or more somatic diagnoses. Conclusion PIP is common in psychiatric patients and potentially fatal. Particularly polypharmacy (>5 prescriptions) and concomitant somatic illness were associated with the probability of PIP. Improving the quality of prescribing might benefit from an interprofessional approach and thus better training of physicians and nurses is needed in order to minimize PIP.

Pain and bleeding are the main determinants of unscheduled contacts after outpatient tonsillectomy.

INTRODUCTION: The objective of this prospective cohort study was to measure the medical technical quality of outpatient tonsillectomy in Danish ear, nose & throat practices by indicators, standards and prognostic factors. MATERIAL AND METHODS: According to standardised and validated specific questionnaires, quality of surgery was measured in terms of postoperative bleeding, pain, gastrointestinal problems and infection. RESULTS: A total of 614 patients were included. 11% were younger than four years, and 93% were observed for less than four hours. A total of 23% had unscheduled postoperative contacts. Almost 12% of the patients contacted a physician due to pain; a percentage that exceeds the chosen standard of 10%. 4% were hospitalised due to bleeding exceeding the chosen standard of 1%. Secondary haemostatic procedures were performed in 2% of the patients. The indication chronic tonsillitis, being an adult, and a postoperative observation shorter than four hours increased the risk of unscheduled contacts. CONCLUSION: Outpatient tonsillectomy seems safe in Denmark. A minimum postoperative observation period of four hours will reduce the need for postoperative contacts. Because of the potentially life-threatening risk related to tonsillectomy, careful patient selection is mandatory and continuous monitoring of the quality of the procedure is essential. FUNDING: Not relevant. TRIAL REGISTRATION: Not relevant.

[Quality of outpatient tonsillectomy performed in ear, nose & throat practice]. / Kvaliteten af ambulant tonsillektomi udført i øre-naese-hals-praksis. Udvikling og valg af indikatorer, standarder og prognostiske faktorer.

In Danish healthcare there are increasing demands in the field of hospital care on performance and outcome measurement and quality improvement in relation to a number of diseases. Hitherto, corresponding measurements of quality have not been carried out among private specialized practitioners. The present project describes the development and selection of evidence-based national indicators, standards, and case mix factors in terms of prognostic factors with the purpose of measuring quality of out-patient tonsillectomy in Danish ear, nose & throat practices.

[Patient safety in a health technology assessment perspective]. / Patientsikkerhed i medicinsk teknologivurderingsperspektiv.

The Danish Act of Patient Safety entered into force in 2004. This paper studies the consequences of the Act for the health care system and its users by a literature evaluation and an interview study with key persons. Despite the substantial resources spent on the reporting system, no evidence is found that the Act has an improved effect on patient safety. One of the biggest barriers for reporting adverse events is a lack of follow-up and feedback. Research into the patient's role on preventing adverse events is limited. The possibilities created by the Act should be utilized to their full potential.

[Measuring patient safety--why and how?]. / Måling af patientsikkerhed--hvorfor og hvordan?

Patient safety measurement from e.g. indicators, audits and questionnaires is used for risk management. Five years after the Danish Act on Patient Safety came into force, it remains unknown if health care is getting safer. The perspective of implementing patient safety methods for systematic monitoring is that it will become possible to continuously estimate the prevalence and incidence of patient safety problems. The lesson learnt in quality improvement is that it will pay back in terms of improvement in patient safety. For this purpose validated methods are needed.

National quality measurement using clinical indicators: the Danish National Indicator Project.

This article describes the Danish National Indicator Project that aims to document and improve the quality of care at national level. Specific clinical indicators, standards, and prognostic factors have been developed for eight diseases (e.g. lung cancer). It has been implemented in all clinical departments in Denmark. Participation is mandatory. Results related to lung cancer are presented and discussed. The experiences from 2000 to 2008 indicate that the quality of care related to the eight diseases improve over time and that that performance and outcome measurement will get paid in terms of quality improvement.

Selection of indicators for continuous monitoring of patient safety: recommendations of the project 'safety improvement for patients in Europe'.

BACKGROUND: Initiatives to improve patient safety have high priority among health professionals and politicians in most developed countries. Currently, however, assessment of patient safety problems relies mainly on case-based methodologies. The evidence for their efficiency and reproducibility, proving that safety of care has improved with their usage, is questionable. The exact incidence and prevalence of patient safety quality problems are unknown. Therefore, there is a need for firm, evidence-based methods to survey and develop patient safety and derived activities. OBJECTIVE: The objective of this paper is to describe a method to select patient safety indicators and present the indicators derived through this process. METHODS: The patient safety indicators were derived and recommended for use in a formalized consensus process based on literature review, targeted information gathering, expert consultation and rating procedures. RESULTS: A total of 42 indicators, of which 28 originated from existing international indicator programmes, were selected. The processes and outcome indicators that were recommended for institutional-level use in Europe were 24, covering safety of care aspects such as culture, infections, surgical complications, medication errors, obstetrics, falls and specific diagnostic areas. CONCLUSION: The patient safety indicators recommended present a set of possible measures of patient safety. One of the future perspectives of implementing patient safety indicators for systematic monitoring is that it will be possible to continuously estimate the prevalence and incidence of patient safety quality problems. The lesson learnt from quality improvement is that it will pay off in terms of improving patient safety.

National benchmarking between the Nordic countries on the quality of care.

This paper describes the Nordic Indicator Project that aims at describing and analysing the quality of care for important diseases in the Nordic countries (Denmark, Finland, Greenland, Iceland, Norway and Sweden). The Council of Ministers decided to appoint a working group for quality mapping with the aim of giving Nordic citizens, politicians, health workers and authorities the opportunity to evaluate and compare performance across the Nordic countries. The working group selected 36 prioritised quality indicators, including cancer indicators, for benchmarking between the Nordic countries. Additionally, 40 'potential indicators' have been identified for future developments. This international projects document how difficult it is to do international benchmarking. The experience of the Nordic Council of Ministers Quality Project has shown that even for common indicators as survival and mortality rates for breast cancer, colorectal cancer and lung cancer etc., it is difficult to yield data that are representative to the international nations as a whole. It seems that modern health care systems are not able do document their quality. At national and international level we need to invest in quality measurement systems and in international collaboration.

30-days mortality in patients with perforated peptic ulcer: A national audit.

BACKGROUND: In 2005, The Danish National Indicator Project (DNIP) reported findings on patients hospitalized with perforated ulcer. The indicator "30-days mortality" showed major discrepancy between the observed mortality of 28% and the chosen standard (10%). RATIONALE: An audit committee was appointed to examine quality problems linked to the high mortality. The purpose was to (i) examine patient characteristics, (ii) evaluate the appropriateness of the standard, and (iii) audit all cases of deaths within 30 days after surgery. METHODS: Four hundred and twelve consecutive patients were included and used for the analyses of patient characteristics. The evaluation of the standard was based on a literature review, and a structured audit was performed according to the 115 deaths that occurred. RESULTS: The mean age was 69.1 years, 42.0% had one co-morbid disease and 17.7% had two co-morbid diseases. 45.9% had an American Association of Anaesthetists score of 3-4. We found no results on mortality in studies similar to ours. The audit process indicated that the postoperative observation of patients was insufficient. DISCUSSION: As a result of this study, the standard for mortality was increased to 20%, and the new indicators for postoperative monitoring were developed. The DNIP continues to evaluate if these initiatives will improve the results on mortality.

Clinical quality indicators of venous leg ulcers: development, feasibility, and reliability.

In the clinical setting, diagnosis and treatment of venous leg ulcers can vary considerably from patient to patient. The first step to reducing this variation is to document venous leg ulcer care through use of quantitative scientific documentation principles. This requires the development of valid and reliable evidence-based quality indicators of venous leg ulcer care. A Scandinavian multidisciplinary, cross-sectional panel of wound healing experts developed clinical quality indicators on the basis of scientific evidence from the literature and subsequent group nominal consensus of the panel; an independent medical doctor tested the feasibility and reliability of these clinical indicators, assessing the quality of medical technical care on 100 consecutive venous leg ulcer patients. Main outcome measures were healing, recurrence, pain, venous disease diagnosis, differential diagnosis and treatment, and inter- and intra-rater reliability. The indicators proved feasible and reliable to measure (inter-rater kappa = 0.79, P < 0.01 and intra-rater kappa = 0.89, P < 0.1). Within 3 months of initial examination, venous etiology was verified by duplex in 61 of the 98 participating patients (62%) and 31 (32%) were assessed for venous surgery. Distal arterial pressure was measured following initial examination in 33 of the patients (34%). All patients (100%) were prescribed compression therapy. Of the 98 patients, 11 (11%) had ulcers recur in 3 months and 72 (73%) healed in 12 months, which is in line with the literature. It is feasible to reliably measure the quality of medical technical venous leg ulcer care in the clinical setting using a few strategic clinically relevant indicators of quality.

Nationwide continuous quality improvement using clinical indicators: the Danish National Indicator Project.

OBJECTIVE: In most countries there is no mandatory national system to track the quality of care delivered to the citizens. This paper describes an example of a national indicator project that aims at documenting and improving the quality of care nationwide. ANALYSIS: The Danish National Indicator Project was established in 2000 as a nationwide multidisciplinary quality improvement project. From 2000 to 2002, disease-specific clinical indicators and standards were developed for six diseases (stroke, hip fracture, schizophrenia, acute gastrointestinal surgery, heart failure, and lung cancer). Indicators and standards have been implemented in all clinical units and departments in Denmark treating patients with the six diseases, and participation is mandatory. All clinical units and departments receive their results every month. National and regional audit processes are organized to explain the results and to prepare implementation of improvements. All results are published in order to inform the public, and to give patients and relatives the opportunity to make informed choices. CONCLUSION: The surveillance of health care quality is greatly aided by the use of relevant quantitative indicators. This paper describes how it is possible to organize nationwide monitoring using clinical indicators.

Impact of delay on diagnosis and treatment of primary lung cancer.

Lung cancer continues to be a devastating disease that defies nearly all the therapeutic endeavours to improve the 5-year survival. Survival is determined to a large extent by age, morphology and stage. Early presymptomatic detection by screening has as yet failed to demonstrate any effect of such programmes. At the moment, medical healthcare units invest a significant proportion of their resources to eliminating waiting times in diagnosis and treatment in order to improve outcome. The aim of this literature review is to investigate whether waiting times and delays have any bearing on prognosis and treatment. Specifically, the hypothesis is raised that longer delays are associated with poorer survival or more advanced stage disease and may explain the poorer survival rate. Large-scale cohort studies within well-defined catchment areas are required both to establish the prognostic impact of delays and to understand the natural progression of lung cancers.