TAILR (Nursing-Sensitive Events and Their Association With Individual Nurse Staffing Levels) Project: Protocol for an International Longitudinal Multicenter Study.

BACKGROUND: Nursing-sensitive events (NSEs) are common, accounting for up to 77% of adverse events in hospitalized patients (eg, fall-related harm, pressure ulcers, and health care-associated infections). NSEs lead to adverse patient outcomes and impose an economic burden on hospitals due to increased medical costs through a prolonged hospital stay and additional medical procedures. To reduce NSEs and ensure high-quality nursing care, appropriate nurse staffing levels are needed. Although the link between nurse staffing and NSEs has been described in many studies, appropriate nurse staffing levels are lacking. Existing studies describe constant staffing exposure at the unit or hospital level without assessing patient-level exposure to nurse staffing during the hospital stay. Few studies have assessed nurse staffing and patient outcomes using a single-center longitudinal design, with limited generalizability. There is a need for multicenter longitudinal studies with improved potential for generalizing the association between individual nurse staffing levels and NSEs. OBJECTIVE: This study aimed (1) to determine the prevalence, preventability, type, and severity of NSEs; (2) to describe individual patient-level nurse staffing exposure across hospitals; (3) to assess the effect of nurse staffing on NSEs in patients; and (4) to identify thresholds of safe nurse staffing levels and test them against NSEs in hospitalized patients. METHODS: This international multicenter study uses a longitudinal and observational research design; it involves 4 countries (Switzerland, Sweden, Germany, and Iran), with participation from 14 hospitals and 61 medical, surgery, and mixed units. The 16-week observation period will collect NSEs using systematic retrospective record reviews. A total of 3680 patient admissions will be reviewed, with 60 randomly selected admissions per unit. To be included, patients must have been hospitalized for at least 48 hours. Nurse staffing data (ie, the number of nurses and their education level) will be collected daily for each shift to assess the association between NSEs and individual nurse staffing levels. Additionally, hospital data (ie, type, teaching status, and ownership) and unit data (ie, service line and number of beds) will be collected. RESULTS: As of January 2024, the verification process for the plausibility and comprehensibility of patients' and nurse staffing data is underway across all 4 countries. Data analyses are planned to be completed by spring 2024, with the first results expected to be published in late 2024. CONCLUSIONS: This study will provide comprehensive information on NSEs, including their prevalence, preventability, type, and severity, across countries. Moreover, it seeks to enhance understanding of NSE mechanisms and the potential impact of nurse staffing on these events. We will evaluate within- and between-hospital variability to identify productive strategies to ensure safe nurse staffing levels, thereby reducing NSEs in hospitalized patients. The TAILR (Nursing-Sensitive Events and Their Association With Individual Nurse Staffing Levels) study will focus on the optimization of scarce staffing resources. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/56262.

Timing of adverse events in patients undergoing acute and elective hip arthroplasty surgery: a multicentre cohort study using the Global Trigger Tool.

OBJECTIVE: To explore timing in relation to all types of adverse events (AEs), severity and preventability for patients undergoing acute and elective hip arthroplasty. DESIGN: A multicentre cohort study using retrospective record review with Global Trigger Tool methodology in combination with data from several registers. SETTING: 24 hospitals in 4 major regions of Sweden. PARTICIPANTS: Patients ≥18 years, undergoing acute or elective total or hemiarthroplasty of the hip, were eligible for inclusion. Reviews of weighted samples of 1998 randomly selected patient records were carried out using Global Trigger Tool methodology. The patients were followed for readmissions up to 90 days postoperatively throughout the whole country. RESULTS: The cohort consisted of 667 acute and 1331 elective patients. Most AEs occurred perioperatively and postoperatively (n=2093, 99.1%) and after discharge (n=1142, 54.1%). The median time from the day of surgery to the occurrence of AE was 8 days. The median days for different AE types ranged from 0 to 24.5 for acute and 0 to 71 for elective patients and peaked during different time periods. 40.2% of the AEs, both major and minor, occurred within postoperative days 0-5 and 86.9% of the AEs occurred within 30 days. Most of the AEs were deemed to be of major severity (n=1370, 65.5%) or preventable (n=1591, 76%). CONCLUSIONS: A wide variability was found regarding the timing of different AEs with the majority occurring within 30 days. The timing and preventability varied regarding the severity. Most of the AEs were deemed to be preventable and/or of major severity. To increase patient safety for patients undergoing hip arthroplasty surgery, a better understanding of the multifaceted nature of the timing of AEs in relation to the occurrence of differing AEs is needed.

The patient's experience of participation when admitted for elective surgical procedures: an interview study.

PURPOSE: To describe the patient's experience of participation in their care when admitted for elective surgical procedures. MATERIALS AND METHODS: A purposive sample of 14 patients who had undergone elective surgery was included in semi-structured individual interviews at a university hospital. The data was analysed using qualitative content analysis. RESULTS: One theme was identified: Creating a meaningful relationship to enable participation in the care, based on three categories; Abilities, willingness, and a lack of experience affect participation, A professional approach with an open communication and individualized information, and The importance of structural factors. CONCLUSIONS: To meet the patient's individual needs and wishes regarding participation, meaningful relationships need to be created between patient and healthcare personnel. The results also indicate that the patients have insufficient knowledge about their role regarding participation. To improve patient participation, its meaning needs to be clarified individually to the patient, emphasizing the importance to be active involved in his or her own care.

Variation in detected adverse events using trigger tools: A systematic review and meta-analysis.

BACKGROUND: Adverse event (AE) detection is a major patient safety priority. However, despite extensive research on AEs, reported incidence rates vary widely. OBJECTIVE: This study aimed: (1) to synthesize available evidence on AE incidence in acute care inpatient settings using Trigger Tool methodology; and (2) to explore whether study characteristics and study quality explain variations in reported AE incidence. DESIGN: Systematic review and meta-analysis. METHODS: To identify relevant studies, we queried PubMed, EMBASE, CINAHL, Cochrane Library and three journals in the patient safety field (last update search 25.05.2022). Eligible publications fulfilled the following criteria: adult inpatient samples; acute care hospital settings; Trigger Tool methodology; focus on specialty of internal medicine, surgery or oncology; published in English, French, German, Italian or Spanish. Systematic reviews and studies addressing adverse drug events or exclusively deceased patients were excluded. Risk of bias was assessed using an adapted version of the Quality Assessment Tool for Diagnostic Accuracy Studies 2. Our main outcome of interest was AEs per 100 admissions. We assessed nine study characteristics plus study quality as potential sources of variation using random regression models. We received no funding and did not register this review. RESULTS: Screening 6,685 publications yielded 54 eligible studies covering 194,470 admissions. The cumulative AE incidence was 30.0 per 100 admissions (95% CI 23.9-37.5; I2 = 99.7%) and between study heterogeneity was high with a prediction interval of 5.4-164.7. Overall studies' risk of bias and applicability-related concerns were rated as low. Eight out of nine methodological study characteristics did explain some variation of reported AE rates, such as patient age and type of hospital. Also, study quality did explain variation. CONCLUSION: Estimates of AE studies using trigger tool methodology vary while explaining variation is seriously hampered by the low standards of reporting such as the timeframe of AE detection. Specific reporting guidelines for studies using retrospective medical record review methodology are necessary to strengthen the current evidence base and to help explain between study variation.

Measuring adverse events following hip arthroplasty surgery using administrative data without relying on ICD-codes.

INTRODUCTION: Measure and monitor adverse events (AEs) following hip arthroplasty is challenging. The aim of this study was to create a model for measuring AEs after hip arthroplasty using administrative data, such as length of stay and readmissions, with equal or better precision than an ICD-code based model. MATERIALS AND METHODS: This study included 1 998 patients operated with an acute or elective hip arthroplasty in a national multi-centre study. We collected AEs within 90 days following surgery with retrospective record review. Additional data came from the Swedish Hip Arthroplasty Register, the Swedish National Patient Register and the Swedish National Board of Health and Welfare. We made a 2:1 split of the data into a training and a holdout set. We used the training set to train different machine learning models to predict if a patient had sustained an AE or not. After training and cross-validation we tested the best performing model on the holdout-set. We compared the results with an established ICD-code based measure for AEs. RESULTS: The best performing model was a logistic regression model with four natural age splines. The variables included in the model were as follows: length of stay at the orthopaedic department, discharge to acute care, age, number of readmissions and ED visits. The sensitivity and specificity for the new model was 23 and 90% for AE within 30 days, compared with 5 and 94% for the ICD-code based model. For AEs within 90 days the sensitivity and specificity were 31% and 89% compared with 16% and 92% for the ICD-code based model. CONCLUSION: We conclude that a prediction model for AEs following hip arthroplasty surgery, relying on administrative data without ICD-codes is more accurate than a model based on ICD-codes.

The identification of adverse events in hip fracture patients using the Global Trigger Tool: A prospective observational cohort study.

INTRODUCTION: Hip fracture is common in the elderly and is associated with high comorbidity, mortality and complication rates. There has been an increase in the investigation of healthcare-related adverse events (AEs) in some patient groups but there is limited knowledge about hip fracture patients. The aim was to explore the incidence, preventability and nature of AEs in hip fracture patients. METHODS: One hundred and sixty three hip fracture patients participated. A record review was conducted of prospectively collected data using Global Trigger Tool methodology to identify AEs up to 90 days after surgery. RESULTS: Sixty two (38.0%) of 163 patients had at least one AE (range 1-7). One hundred and two AEs were identified and 62 (60.8%) were deemed preventable. Healthcare-associated infections e.g. pneumonia, urinary tract infections and pressure ulcers were common. AEs were more common in older patients and those with pre-existing health conditions. Fifty eight (56.9%) AEs caused temporary harm and 4 (3.9%) contributed to patient death. CONCLUSION: AEs are common in hip fracture patients and most are preventable. If the focus is on improving healthcare for these patients, we should be concentrating our efforts on reducing the number of these preventable AEs, with a particular emphasis on improving the care of older patients with pre-existing health conditions.

Identifying no-harm incidents in home healthcare: a cohort study using trigger tool methodology.

BACKGROUND: Patient safety in home healthcare is largely unexplored. No-harm incidents may give valuable information about risk areas and system failures as a source for proactive patient safety work. We hypothesized that it would be feasible to retrospectively identify no-harm incidents and thus aimed to explore the cumulative incidence, preventability, types, and potential contributing causes of no-harm incidents that affected adult patients admitted to home healthcare. METHODS: A structured retrospective record review using a trigger tool designed for home healthcare. A random sample of 600 home healthcare records from ten different organizations across Sweden was reviewed. RESULTS: In the study, 40,735 days were reviewed. In all, 313 no-harm incidents affected 177 (29.5%) patients; of these, 198 (63.2%) no-harm incidents, in 127 (21.2%) patients, were considered preventable. The most common no-harm incident types were "fall without harm," "deficiencies in medication management," and "moderate pain." The type "deficiencies in medication management" was deemed to have a preventability rate twice as high as those of "fall without harm" and "moderate pain." The most common potential contributing cause was "deficiencies in nursing care and treatment, i.e., delayed, erroneous, omitted or incomplete treatment or care." CONCLUSION: This study suggests that it is feasible to identify no-harm incidents and potential contributing causes such as omission of care using record review with a trigger tool adapted to the context. No-harm incidents and potential contributing causes are valuable sources of knowledge for improving patient safety, as they highlight system failures and indicate risks before an adverse event reach the patient.

Drug Use and Type of Adverse Drug Events-Identified by a Trigger Tool in Different Units in a Swedish Pediatric Hospital.

PURPOSE: The objectives of our study were to determine drug use, type and incidence of all adverse event associated with drug or drug-related processes (Adverse Drug Events, ADE) among pediatric inpatients in relation to hospital unit and length of stay. PATIENTS AND METHODS: 600 pediatric (0-18 years) admissions at a Swedish university hospital during one year were included and stratified in blocks to 150 neonatal, surgical/orthopedic, medicine and emergency-medicine unit admissions, respectively. Adverse events were identified from medical records using a pediatric trigger tool. All triggers identifying an adverse event related to drugs and drug-related devices were included. Data on drug use were extracted from the hospital drug-data warehouse. RESULTS: In total, 17794 daily drug orders were administrated to 486 (81.0% exposed) admissions. Parental nutrition, potassium salts and morphine constituted half of all high-risk drugs prescribed. Two-thirds of intravenous irritating drug doses consisted of vancomycin, esomeprazole and meropenem. In 129 (21.5%) admissions, at least one ADE was identified, out of which 21 ADE were classified as more severe (National Coordinating Council Medication Error Reporting Prevention-Index, NCCMERP≥F). The ADE incidence was 47.4 (95% confidence interval: 39.4-57.3) per 1000 admission days and varied by unit category. In neonatal units, 56.9 (49.5-65.4) ADEs/1000 admission days were detected, in surgery/orthopedic 54.2 (40.3-72.8), in medicine 44.1 (33.1-58.7), and in emergency-medicine 14.3 (7.7-26.7) ADEs/1000 admission days were found. The most common types of ADEs were identified by triggers that were not directly aiming at drugs including insufficiently treated pain (incidence peaking already in the first days), skin, tissue or vascular harm (peaking at the end of the first week) and hospital-acquired infections (peaking in later admission days). CONCLUSION: Adverse drug events are common in pediatric patients. The incidence of ADEs and type of ADE varies by hospital unit and length of hospital stay.

The influence of depression on patient-reported outcomes for hip-fracture patients 1 year after surgery: a prospective cohort study.

BACKGROUND: Depression is common in elderly hip-fracture patients and together with cognitive impairment is associated with increased risk of mortality. AIM: We aimed to examine the influence depression has on patient-reported outcome up to 1 year after acute hip fracture. METHODS: 162 hip-fracture patients participated in the prospective observational cohort study and were followed up at baseline, and 3 and 12 months using patient-reported outcome scores. Patients with cognitive impairment were excluded. Depression was defined as a score ≥ 8 on the depression subscale of the Hospital Anxiety Depression Scale (HADS D), having a diagnosis of depression or being treated with anti-depressant medication. Hip function was assessed using Harris Hip Score (HHS), EQ-5D was used to assess health status and Quality of life, and the Pain Numerical Rating Scale (PRNS) was used to assess pain levels. A linear regression model adjusted for group, age, sex, and ASA class was used to identify risk factors for functional outcome 12 months after fracture. RESULTS: 35 patients were included in the depression group versus 127 in the control group. No statistical differences were found in the demographic data (age, sex, ASA class, fracture type, operation method, living situation, activities of daily living ADL and clinical pathway) between the groups. In the regression model, we found no correlation between depression and the patient-reported outcome. CONCLUSION: In young elderly hip fracture patients without cognitive dysfunction, depression may not be of major importance for the rehabilitation of hip function in the short term.

Exploring the incidence and nature of nursing-sensitive orthopaedic adverse events: A multicenter cohort study using Global Trigger Tool.

BACKGROUND: For decades, patient safety has been recognized as a critical global healthcare issue. However, there is a gap of knowledge of all types of adverse events sensitive to nursing care within hospitals in general and within orthopaedic care specifically. OBJECTIVES: The aim of this study is to explore the incidence and nature of nursing-sensitive adverse events following elective or acute hip arthroplasty at a national level. DESIGN: A retrospective multicenter cohort study. OUTCOME VARIABLES: Nursing-sensitive adverse events, preventability, severity and length of stay. METHODS: All patients, 18 years or older, who had undergone an elective (degenerative joint disease) or acute (fractures) hemi or total hip arthroplasty surgery at 24 hospitals were eligible for inclusion. Retrospective reviews of weighted samples of 1998 randomly selected patient records were carried out using the Swedish version of the Global Trigger Tool. The patients were followed for readmissions up to 90 days postoperatively throughout the whole country regardless of index hospital. RESULTS: A total of 1150 nursing-sensitive adverse events were identified in 728 (36.4%) of patient records, and 943 (82.0%) of the adverse events were judged preventable in the study cohort. The adjusted cumulative incidence regarding nursing-sensitive adverse events for the study population was 18.8%. The most common nursing-sensitive adverse event types were different kinds of healthcare-associated infections (40.9%) and pressure ulcers (16.5%). Significantly higher proportions of nursing-sensitive adverse events were found among female patients compared to male, p < 0.001, and patients with acute admissions compared to elective patients, p < 0.001. Almost half (48.5%) of the adverse events were temporary and of a less severe nature. On the other hand, 592 adverse events were estimated to have contributed to 3351 extra hospital days. CONCLUSIONS: This study shows the magnitude of nursing-sensitive adverse events. We found that nursing-sensitive adverse events were common, in most cases deemed preventable and were associated with different kinds of adverse events and levels of severity in orthopaedic care. Registered nurses play a vital role within the interdisciplinary team as they are the largest group of healthcare professionals, work 24/7 and spend much time at the bedside with patients. Therefore, nursing leadership at all hospital levels must assume responsibility for patient safety and authorize bedside registered nurses to deliver high-quality and sustainable care to patients.

Only 8% of major preventable adverse events after hip arthroplasty are filed as claims: a Swedish multi-center cohort study on 1,998 patients.

Background and purpose - Hip arthroplasty is one of the most performed surgeries in Sweden, and the rate of adverse events (AEs) is fairly high. All patients in publicly financed healthcare in Sweden are insured by the Mutual Insurance Company of Swedish County Councils (Löf). We assessed the proportion of patients that sustained a major preventable AE and filed an AE claim to Löf.Patients and methods - We performed retrospective record review using the Global Trigger Tool to identify AEs in a Swedish multi-center cohort consisting of 1,998 patients with a total or hemi hip arthroplasty. We compared the major preventable AEs with all patient-reported claims to Löf from the same cohort and calculated the proportion of filed claims.Results - We found 1,066 major preventable AEs in 744 patients. Löf received 62 claims for these AEs, resulting in a claim proportion of 8%. 58 of the 62 claims were accepted by Löf and received compensation. The claim proportion was 13% for the elective patients and 0.3% for the acute patients. The most common AE for filing a claim was periprosthetic joint infection; of the 150 infections found 37 were claimed.Interpretation - The proportion of filed claims for major preventable AEs is very low, even for obvious and serious AEs such as periprosthetic joint infection.

Validation of adverse events after hip arthroplasty: a Swedish multi-centre cohort study.

OBJECTIVES: Preventing adverse events (AEs) after orthopaedic surgery is a field with great room for improvement. A Swedish instrument for measuring AEs after hip arthroplasty based on administrative data from the national patient register is used by both the Swedish Hip Arthroplasty Register and the Swedish Association of Local Authorities and Regions. It has never been validated and its accuracy is unknown. The aim of this study was to validate the instrument's ability to detect AEs, and to calculate the incidence of AEs following primary hip arthroplasties. DESIGN: Retrospective cohort study using retrospective record review with Global Trigger Tool methodology in combination with register data. SETTING: 24 different hospitals in four major regions of Sweden. PARTICIPANTS: 2000 patients with either total or hemi-hip arthroplasty were recruited from the SHAR. We included both acute and elective patients. PRIMARY AND SECONDARY OUTCOME MEASURES: The sensitivity and specificity of the instrument. Adjusted cumulative incidence and incidence rate. RESULTS: The sensitivity for all identified AEs was 5.7% (95% CI: 4.9% to 6.7%) for 30 days and 14.8% (95% CI: 8.2 to 24.3) for 90 days, and the specificity was 95.2% (95% CI: 93.5% to 96.6%) for 30 days and 92.1% (95% CI: 89.9% to 93.8%) for 90 days. The adjusted cumulative incidence for all AEs was 28.4% (95% CI: 25.0% to 32.3%) for 30 days and 29.5% (95% CI: 26.0% to 33.8%) for 90 days. The incidence rate was 0.43 AEs per person-month (95% CI: 0.39 to 0.47). CONCLUSIONS: The AE incidence was high, and most AEs occurred within the first 30 days. The instrument sensitivity for AEs was very low for both 30 and 90 days, but the specificity was high for both 30 and 90 days. The studied instrument is insufficient for valid measurements of AEs after hip arthroplasty.

Adverse events in patients in home healthcare: a retrospective record review using trigger tool methodology.

OBJECTIVE: Home healthcare is an increasingly common part of healthcare. The patients are often aged, frail and have multiple diseases, and multiple caregivers are involved in their treatment. This study explores the origin, incidence, types and preventability of adverse events (AEs) that occur in patients receiving home healthcare. DESIGN: A study using retrospective record review and trigger tool methodology. SETTING AND METHODS: Ten teams with experience of home healthcare from nine regions across Sweden reviewed home healthcare records in a two-stage procedure using 38 predefined triggers in four modules. A random sample of records from 600 patients (aged 18 years or older) receiving home healthcare during 2015 were reviewed. PRIMARY AND SECONDARY OUTCOME MEASURES: The cumulative incidence of AEs found in patients receiving home healthcare; secondary measures were origin, types, severity of harm and preventability of the AEs. RESULTS: The patients were aged 20-79 years, 280 men and 320 women. The review teams identified 356 AEs in 226 (37.7%; 95% CI 33.0 to 42.8) of the home healthcare records. Of these, 255 (71.6%; 95% CI 63.2 to 80.8) were assessed as being preventable, and most (246, 69.1%; 95% CI 60.9 to 78.2) required extra healthcare visits or led to a prolonged period of healthcare. Most of the AEs (271, 76.1%; 95% CI 67.5 to 85.6) originated in home healthcare; the rest were detected during home healthcare but were related to care outside home healthcare. The most common AEs were healthcare-associated infections, falls and pressure ulcers. CONCLUSIONS: AEs in patients receiving home healthcare are common, mostly preventable and often cause temporary harm requiring extra healthcare resources. The most frequent types of AEs must be addressed and reduced through improvements in interprofessional collaboration. This is an important area for future studies.

Development of a trigger tool to identify adverse events and no-harm incidents that affect patients admitted to home healthcare.

BACKGROUND: Adverse events (AEs) and no-harm incidents are common and of great concern in healthcare. A common method for identification of AEs is retrospective record review (RRR) using predefined triggers. This method has been used frequently in inpatient care, but AEs in home healthcare have not been explored to the same extent. The aim of this study was to develop a trigger tool (TT) for the identification of both AEs and no-harm incidents affecting adult patients admitted to home healthcare in Sweden, and to describe the methodology used for this development. METHODS: The TT was developed and validated in a stepwise manner, in collaboration with experts with different skills, using (1) literature review and interviews, (2) a five-round modified Delphi process, and (3) two-stage RRRs. Ten trained teams from different sites in Sweden reviewed 600 randomly selected records. RESULTS: In all, triggers were found 4031 times in 518 (86.3%) records, with a mean of 6.7 (median 4, range 1-54) triggers per record with triggers. The positive predictive values (PPVs) for AEs and no-harm incidents were 25.4% and 16.3%, respectively, resulting in a PPV of 41.7% (range 0.0%-96.1% per trigger) for the total TT when using 38 triggers. The most common triggers were unplanned contact with physician and/or registered nurse, moderate/severe pain, moderate/severe worry, anxiety, suffering, existential pain and/or psychological pain. AEs were identified in 37.7% of the patients and no-harm incidents in 29.5%. CONCLUSION: This study shows that adapted triggers with definitions and decision support, developed to identify AEs and no-harm incidents that affect patients admitted to home healthcare, may be a valid method for safety and quality improvement work in home healthcare.

Operational strategies to manage non-elective orthopaedic surgical flows: a simulation modelling study.

OBJECTIVES: To explore the value of simulation modelling in evaluating the effects of strategies to plan and schedule operating room (OR) resources aimed at reducing time to surgery for non-elective orthopaedic inpatients at a Swedish hospital. METHODS: We applied discrete-event simulation modelling. The model was populated with real world data from a university hospital with a strong focus on reducing waiting time to surgery for patients with hip fracture. The system modelled concerned two patient groups that share the same OR resources: hip-fracture and other non-elective orthopaedic patients in need of surgical treatment. We simulated three scenarios based on the literature and interaction with staff and managers: (1) baseline; (2) reduced turnover time between surgeries by 20 min and (3) one extra OR during the day, Monday to Friday. The outcome variables were waiting time to surgery and the percentage of patients who waited longer than 24 hours for surgery. RESULTS: The mean waiting time in hours was significantly reduced from 16.2 hours in scenario 1 (baseline) to 13.3 hours in scenario 2 and 13.6 hours in scenario 3 for hip-fracture surgery and from 26.0 hours in baseline to 18.9 hours in scenario 2 and 18.5 hours in scenario 3 for other non-elective patients. The percentage of patients who were treated within 24 hours significantly increased from 86.4% (baseline) to 96.1% (scenario 2) and 95.1% (scenario 3) for hip-fracture patients and from 60.2% (baseline) to 79.8% (scenario 2) and 79.8% (scenario 3) for patients with other non-elective patients. CONCLUSIONS: Healthcare managers who strive to improve the timelines of non-elective orthopaedic surgeries may benefit from using simulation modelling to analyse different strategies to support their decisions. In this specific case, the simulation results showed that the reduction of surgery turnover times could yield the same results as an extra OR.

Waiting time to surgery is correlated with an increased risk of serious adverse events during hospital stay in patients with hip-fracture: A cohort study.

BACKGROUND: Hip fractures are common in the elderly and are associated with a high adverse event and mortality rate. Time to surgery is one of the major modifiable risk factors influencing adverse outcomes in hip-fracture patients. National guidelines and recommendations have been introduced which advocate specific time frames in which surgery should be performed i.e. within 24-48h. These time constraints have been arbitrarily set without being modelled on the linear assumption i.e. that risk increases continually over time and not within specific cut-off times. OBJECTIVES: To investigate how waiting time to surgery influenced the risk of serious adverse events in hip-fracture patients during the hospital stay and to examine how the risk increased over time. DESIGN: An observational single cohort study Participants 576 patients (72.4% females, mean [SD] age 82 [10]) years, with a hip fracture were included in the cohort study. METHODS: The outcomes of the study were the occurrence of serious adverse events during hospital stay, length of stay and one-year mortality. A structured medical record review was carried out to identify outcomes and mortality data was obtained from the Swedish National Death Registry. Waiting time to surgery was used as the exposure variable and age, sex, type of fracture, comorbidities using the American Society of Anaesthesiologists classification score and the presence of cognitive dysfunction were identified as confounders. A logistic regression analysis was performed to identify risk factors influencing outcomes. RESULTS: A total of 119 patients (20.6%) suffered 397 (range 1-5) serious adverse events during hospital stay. Every 10h of waiting time to surgery increased the risk of serious adverse events by 12% (odds ratio 1.12 [95% confidence interval 1.02-1.23]). We found no optimal cut-off times for waiting time to surgery. For every 24h of waiting time, the length of stay from surgery was increased by 0.6days (95% CI 0.1-1.1). We found no correlation between waiting time to surgery and one-year mortality. CONCLUSIONS: A large proportion of patients suffered from at least one serious adverse event after hip-fracture surgery and there are no safe limits for waiting time to surgery for hip-fracture patients. As the risk increases with every hour of waiting time, patients with higher American Society of Anesthesiologists classification scores, males and those with subtrochanteric fractures should be prioritized for surgery.

Adverse events in orthopedic care identified via the Global Trigger Tool in Sweden - implications on preventable prolonged hospitalizations.

BACKGROUND: The national incidence of adverse events (AEs) in Swedish orthopedic care has never been described. A new national database has made it possible to describe incidence, nature, preventability and consequences of AEs in Swedish orthopedic care. METHODS: We used national data from a structured two-stage record review with a Swedish modification of the Global Trigger Tool. The sample was 4,994 randomly selected orthopedic admissions in 56 hospitals during 2013 and 2014. The AEs were classified according to the Swedish Patient Safety Act into preventable or non-preventable. RESULTS: At least one AE occurred in 733 (15 %, 95 % CI 13.7-15.7) admissions. Of 950 identified AEs, 697 (73 %) were judged preventable. More than half of the AEs (54 %) were of temporary nature. The most common types of AE were healthcare-associated infections and distended urinary bladder. Patients ≥65 years had more AEs (p < 0.001), and were more often affected by pressure ulcer (p < 0.001) and urinary tract infections (p < 0.01). Distended urinary bladder was seen more frequently in patients aged 18-64 years (p = 0.01). Length of stay was twice as long for patients with AEs (p < 0.001). We estimate 232,000 extra hospital days due to AEs during these 2 years. The pattern of AEs in orthopedic care was different compared to other hospital specialties. CONCLUSIONS: Using a national database, we found AEs in 15 % of orthopedic admissions. The majority of the AEs was of temporary nature and judged preventable. Our results can be used to guide focused patient safety work.

Effects of computer reminders on complications of peripheral venous catheters and nurses' adherence to a guideline in paediatric care--a cluster randomised study.

BACKGROUND: Reminder systems in electronic patient records (EPR) have proven to affect both health care professionals' behaviour and patient outcomes. The aim of this cluster randomised trial was to investigate the effects of implementing a clinical practice guideline (CPG) for peripheral venous catheters (PVCs) in paediatric care in the format of reminders integrated in the EPRs, on PVC-related complications, and on registered nurses' (RNs') self-reported adherence to the guideline. An additional aim was to study the relationship between contextual factors and the outcomes of the intervention. METHODS: The study involved 12 inpatient units at a paediatric university hospital. The reminders included choice of PVC, hygiene, maintenance, and daily inspection of PVC site. Primary outcome was documented signs and symptoms of PVC-related complications at removal, retrieved from the EPR. Secondary outcome was RNs' adherence to a PVC guideline, collected through a questionnaire that also included RNs' perceived work context, as measured by the Alberta Context Tool. Units were allocated into two strata, based on occurrence of PVCs. A blinded simple draw of lots from each stratum randomised six units to the control and intervention groups, respectively. Units were not blinded. The intervention group included 626 PVCs at baseline and 618 post-intervention and the control group 724 PVCs at baseline and 674 post-intervention. RNs included at baseline were 212 (65.4 %) and 208 (71.5 %) post-intervention. RESULTS: No significant effect was found for the computer reminders on PVC-related complications nor on RNs' adherence to the guideline recommendations. The complication rate at baseline and post-intervention was 40.6 % (95 % confidence interval (CI) 36.7-44.5) and 41.9 % (95 % CI 38.0-45.8), for the intervention group and 40.3 % (95 % CI 36.8-44.0) and 46.9 % (95 % CI 43.1-50.7) for the control. In general, RNs' self-rated work context varied from moderately low to moderately high, indicating that conditions for a successful implementation to occur were less optimal. CONCLUSIONS: The reminders might have benefitted from being accompanied by a tailored intervention that targeted specific barriers, such as the low frequency of recorded reasons for removal, the low adherence to daily inspection of PVC sites, and the lack of regular feedback to the RNs. TRIAL REGISTRATION: Current Controlled Trials ISRCTN44819426.

Unpacking the key components of a programme to improve the timeliness of hip-fracture care: a mixed-methods case study.

BACKGROUND: Delay to surgery for patients with hip fracture is associated with higher incidence of post-operative complications, prolonged recovery and length of stay, and increased mortality. Therefore, many health care organisations launch improvement programmes to reduce the wait for surgery. The heterogeneous application of similar methods, and the multifaceted nature of the interventions, constrain the understanding of which method works, when, and how. In complex acute care settings, another concern is how changes for one patient group influence the care for other groups. We therefore set out to analyse how multiple components of hip-fracture improvement efforts aimed to reduce the time to surgery influenced that time both for hip-fracture patients and for other acute surgical orthopaedic inpatients. METHODS: This study is an observational mixed-methods single case study of improvement efforts at a Swedish acute care hospital, which triangulates control chart analysis of process performance data over a five year period with interview, document, and non-participant observation data. RESULTS: The improvement efforts led to an increase in the monthly percentage of hip-fracture patients operated within 24 h of admission from an average of 47% to 83%, with performance predictably ranging between 67% and 98% if the process continues unchanged. Meanwhile, no significant changes in lead time to surgery for other acute surgical orthopaedic inpatients were observed. Interview data indicated that multiple intervention components contributed to making the process more reliable. The triangulation of qualitative and quantitative data, however, indicated that key changes that improved performance were the creation of a process improvement team and having an experienced clinician coordinate demand and supply of surgical services daily and enhance pre-operative patient preparation. CONCLUSIONS: Timeliness of surgery for patients with hip fracture in a complex hospital setting can be substantially improved without displacing other patient groups, by involving staff in improvement efforts and actively managing acute surgical procedures.

Validation of triggers and development of a pediatric trigger tool to identify adverse events.

BACKGROUND: Little is known about adverse events (AEs) in pediatric patients. Record review is a common methodology for identifying AEs, but in pediatrics the record review tools generally have limited focus. The aim of the present study was to develop a broadly applicable record review tool to identify AEs in pediatric inpatients. METHODS: Using a broad literature review and expert opinion with a modified Delphi process, a pediatric trigger tool with 88 triggers, definitions, and descriptions including AE preventability decision support was developed and tested in a random sample of 600 hospitalized pediatric patients admitted in 2010 to a single university children's hospital. Four registered nurse-physician teams performed complete two-stage retrospective reviews of 150 records each from either neonatal, surgical/orthopedic, medicine, or emergency medicine units. RESULTS: Registered nurse review identified 296 of 600 records with triggers indicating potential AEs. Records (n = 121) with only false positive triggers not indicating any potential AEs were not forwarded to the next review stage. On subsequent physician review, 204 (34.0%) of patients were found to have had 563 AEs, range 1-27 AEs/patient. A total of 442 preventable AEs were found in 161 patients (26.8%), range 1-22. Overall, triggers were found 3,598 times in 417 (69.5%) records, with a mean of 6 (median 1, range 0-176) triggers per patient. The overall positive predictive value of the triggers was 22.9%, (range 0.0-100.0%). The final pediatric trigger tool, developed with a second Delphi round, required 29 triggers. CONCLUSIONS: AEs are common in pediatric patients and most are preventable. The main contributions of this study are to further develop and adapt trigger definitions, including AE preventability decision support, to introduce new triggers in pediatric care, as well as to apply pediatric triggers in different clinical specialties. Our findings resulted in a national pediatric trigger tool, and might also be adapted internationally. The pediatric trigger tool can help healthcare organizations to measure and analyze the AEs occurring in hospitalized children in order to improve patient safety.