Results of a national system-wide quality improvement initiative for the implementation of evidence-based infection prevention practices in Brazilian hospitals.

BACKGROUND: Quality improvement (QI) methods are recommended to address healthcare-associated infections (HCAIs) in hospitals, but whereas internal initiatives have been widely studied, there is little evidence on the application and effect of a QI approach from an external system-wide perspective. AIM: To analyse the effect of a national system-wide QI initiative aimed at promoting HCAI prevention via regulatory interventions in Brazil. METHODS: A QI cycle approach designed and assessed with a before-and-after quasi-experimental design was implemented by the Brazilian Health Regulatory Agency (ANVISA), targeting 1869 hospitals. Eleven evidence-based quality indicators related to HCAI prevention and a composite measure were assembled, shared, and assessed; the intervention to improve was then based on participatory multifaceted regulatory actions. Absolute and relative improvements were estimated after the intervention. FINDINGS: In all, 563 hospitals (30.1% response) totalling 86,837 beds participated in the baseline assessment, and 681 hospitals (36.4% response) totalling 101,231 beds in the second. Ten of the 11 criteria improved (P < 0.05), as well as the composite indicator (P = 0.001) in all the regions of the country, particularly in the group of hospitals participating at baseline. 'Hand hygiene (HH) infrastructure' reached 100% (baseline: 97.9; P = 0.001), 'HH protocol' 96.9% (baseline: 92.9; P = 0.001), 'HH monitoring' 70% (baseline: 60.7; P < 0.001) and 'existence of antimicrobial prescription protocol' 80.7% (baseline: 73.2; P < 0.001), among others. The HCAI rates of the participating hospitals decreased after the intervention (P < 0.05). CONCLUSION: The QI cycle approach was useful in guiding system-wide interventions for patient safety. External regulation was feasible and effective in promoting internal HCAI prevention nationwide.

[Advanced knowledge of patient preferences for end-of-life care in national health service hospitals of the Murcia Region]. / Conocimiento de las preferencias de los pacientes terminales en los hospitales públicos de la Región de Murcia.

BACKGROUND AND OBJECTIVE: Provision of unwanted end-of-life care is an adverse event that can be avoided and is regulated by law. One of the Safe Practices recommended by the National Quality Forum (NQF) is "Ensure that patient preferences regarding end-of-life care are known". Our objective is to assess compliance with this recommendation, and the associated socio-professional factors, in the National Health Service hospitals in the Murcia Region (Spain). METHODS: Cross-sectional study in 8 hospitals. We measured structure (existence and characteristics of guidelines about advance directives) and process (frequency with which healthcare providers enquire about the preferences of terminally ill patients) indicators, constructed according to the NQF recommendation. The process indicator was measured using a questionnaire distributed to a sample of clinical personnel (n=3141). A descriptive analysis of the results was performed. The association of socio-professional variables with asking patient's preferences (dependent variable) was analysed using multivariate logistic regression. RESULTS: One of the eight assessed hospitals has valid guidelines. Only 12% of professionals (n=607), (95% confidence interval [CI], 9.4-14.6), responded that they always enquire about the preferences of terminally ill patients in their departments. The existence of guidelines is significantly associated with this response (odds ratio [OR]=18.1; 95% CI, 2.28-143.83) and working in surgical departments with a negative response (OR=0.15; 95% CI, 0.04-0.65). CONCLUSIONS: There is a very low compliance with the NQF recommendation, evidenced by the lack of guidelines and the low frequency in which terminally ill patients are asked about their preferences for life-sustaining treatment. Implementation of guidelines may help to improve this situation, which is significantly worse in surgical services.