Assessment of Rapid Response Teams at Top-Performing Hospitals for In-Hospital Cardiac Arrest.

IMPORTANCE: Rapid response teams (RRTs) are foundational to hospital response to deteriorating conditions of patients. However, little is known about differences in RRT organization and function across top-performing and non-top-performing hospitals for in-hospital cardiac arrest (IHCA) care. OBJECTIVE: To evaluate differences in design and implementation of RRTs at top-performing and non-top-performing sites for survival of IHCA, which is known to be associated with hospital performance on IHCA incidence. DESIGN, SETTING, AND PARTICIPANTS: A qualitative analysis was performed of data from semistructured interviews of 158 hospital staff members (nurses, physicians, administrators, and staff) during site visits to 9 hospitals participating in the Get With The Guidelines-Resuscitation program and consistently ranked in the top, middle, and bottom quartiles for IHCA survival during 2012-2014. Site visits were conducted from April 19, 2016, to July 27, 2017. Data analysis was completed in January 2019. MAIN OUTCOMES AND MEASURES: Semistructured in-depth interviews were performed and thematic analysis was conducted on strategies for IHCA prevention, including RRT roles and responsibilities. RESULTS: Of the 158 participants, 72 were nurses (45.6%), 27 physicians (17.1%), 27 clinical staff (17.1%), and 32 administrators (20.3%). Between 12 and 30 people at each hospital participated in interviews. Differences in RRTs at top-performing and non-top-performing sites were found in the following 4 domains: team design and composition, RRT engagement in surveillance of at-risk patients, empowerment of bedside nurses to activate the RRT, and collaboration with bedside nurses during and after a rapid response. At top-performing hospitals, RRTs were typically staffed with dedicated team members without competing clinical responsibilities, who provided expertise to bedside nurses in managing patients who were at risk for deterioration, and collaborated with nurses during and after a rapid response. Bedside nurses were empowered to activate RRTs based on their judgment and experience without fear of reprisal from physicians or hospital staff. In contrast, RRT members at non-top-performing hospitals had competing clinical responsibilities and were generally less engaged with bedside nurses. Nurses at non-top-performing hospitals reported concerns about potential consequences from activating the RRT. CONCLUSIONS AND RELEVANCE: This qualitative study's findings suggest that top-performing hospitals feature RRTs with dedicated staff without competing clinical responsibilities, that work collaboratively with bedside nurses, and that can be activated without fear of reprisal. These findings provide unique insights into RRTs at hospitals with better IHCA outcomes.

Implementing infection prevention practices across European hospitals: an in-depth qualitative assessment.

OBJECTIVE: The Prevention of Hospital Infections by Intervention and Training (PROHIBIT) project included a cluster-randomised, stepped wedge, controlled study to evaluate multiple strategies to prevent catheter-related bloodstream infection. We report an in-depth investigation of the main barriers, facilitators and contextual factors relevant to successfully implementing these strategies in European acute care hospitals. METHODS: Qualitative comparative case study in 6 of the 14 European PROHIBIT hospitals. Data were collected through interviews with key stakeholders and ethnographic observations conducted during 2-day site visits, before and 1 year into the PROHIBIT intervention. Qualitative measures of implementation success included intervention fidelity, adaptation to local context and satisfaction with the intervention programme. RESULTS: Three meta-themes emerged related to implementation success: 'implementation agendas', 'resources' and 'boundary-spanning'. Hospitals established unique implementation agendas that, while not always aligned with the project goals, shaped subsequent actions. Successful implementation required having sufficient human and material resources and dedicated change agents who helped make the intervention an institutional priority. The salary provided for a dedicated study nurse was a key facilitator. Personal commitment of influential individuals and boundary spanners helped overcome resource restrictions and intrainstitutional segregation. CONCLUSION: This qualitative study revealed patterns across cases that were associated with successful implementation. Consideration of the intervention-context relation was indispensable to understanding the observed outcomes.

A national collaborative approach to reduce catheter-associated urinary tract infections in nursing homes: A qualitative assessment.

BACKGROUND: Reducing health care-associated infections (HAIs), such as catheter-associated urinary tract infection (CAUTI), is a critical performance improvement target in nursing homes. The Agency for Healthcare Research and Quality Safety Program for Long-term Care: Health Care-Associated Infections/Catheter-Associated Urinary Tract Infection, a national performance improvement program, was designed to promote implementation of a CAUTI prevention program through state-based or regional collaboratives in more than 500 nursing homes across the United States. METHODS: Qualitative interviews were conducted with 8 purposefully selected organizational leads (who led implementation activities for a group of facilities) and 8 facility leads (who led implementation activities at a given facility) to understand implementation successes and challenges and experiences of participants involved in the program. Key themes were identified using a rapid analysis approach. RESULTS: Key themes related to general perceptions, changes due to program participation, and factors influencing program implementation were identified. In general, the program was viewed positively by organizational and facility leads with changes in catheter care practices, staff empowerment, and improvements in knowledge identified as benefits. Implementation challenges included the time required for program start-up as well as issues with staff and physician support, logistic barriers, and staffing turnover. CONCLUSIONS: Despite some challenges, the observed program success and positive views of those participating suggest that collaboratives are an important strategy for providing nursing homes with enhanced expertise and support to prevent HAIs and ensure resident safety.

Qualitative validation of the CAUTI Guide to Patient Safety assessment tool.

BACKGROUND: Hospital-acquired infection, including catheter-associated urinary tract infection (CAUTI), is common. Although CAUTI is usually preventable, hospital units may struggle to reduce CAUTI rates. The CAUTI guide to patient safety (GPS) was developed to assess a unit's CAUTI prevention activities. Our aim was to qualitatively validate the GPS. METHODS: We interviewed participants from 2 units in each of 4 hospitals. Each unit's nurse manager completed the GPS and then discussed their answers with a trained research assistant. Semistructured interviews were conducted with unit nurses and physicians. We compared the nurse managers' answers to the unit physicians' and nurses' responses and assessed agreement. RESULTS: A total of 49 participants from 4 medical intensive care units and 4 medical-surgical units were interviewed. Nurse managers found the GPS helpful and complete. There was higher agreement between nurse managers and unit nurses than with physicians. Some questions generated more disagreement than others. Our findings suggest that the GPS is comprehensive and may be best used to stimulate discussions between stakeholders to address key issues. CONCLUSIONS: Using the GPS to assess several stakeholders' views could allow a given unit to move its CAUTI prevention efforts forward in a more informed manner.

Evaluation and costs of volunteer telephone cessation follow-up counseling for Veteran smokers discharged from inpatient units: a quasi-experimental, mixed methods study.

BACKGROUND: The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework was used to evaluate the volunteer telephone smoking cessation counseling follow-up program implemented as part of the inpatient Tobacco Tactics intervention in a Veterans Affairs (VA) hospital. METHODS: This was a quasi-experimental, mixed methods design that collected data through electronic medical records (EMR), observations of telephone smoking cessation counseling calls, interviews with staff and Veterans involved in the program, and intervention costs. RESULTS: Reach: Of the 131 Veterans referred to the smoking cessation telephone follow-up program, 19% were reached 0-1 times, while 81% were reached 2-4 times. Effectiveness: Seven-day point-prevalence 60-day quit rates (abstracted from the EMR) for those who were reached 2-4 times were 26%, compared to 8% among those who were reached 0-1 times (p = 0.06). Sixty-day 24-hour point-prevalence quit rates were 33% for those reached 2-4 times, compared to 4% of those reached 0-1 times (p < 0.01). Adoption and Implementation: The volunteers correctly followed protocol and were enthusiastic about performing the calls. Veterans who were interviewed reported positive comments about the calls. The cost to the hospital was $21 per participating Veteran, and the cost per quit was $92. Maintenance: There was short-term maintenance (about 1 year), but the program was not sustainable long term. CONCLUSIONS: Quit rates were higher among those Veterans that had greater participation in the calls. Joint Commission standards for inpatient smoking with follow-up calls are voluntary, but should these standards become mandatory, there may be more motivation for VA administration to institute a hospital-based, volunteer telephone smoking cessation follow-up program. TRIAL REGISTRATION: ClinicalTrials.Gov NCT01359371.

Barriers to reducing urinary catheter use: a qualitative assessment of a statewide initiative.

IMPORTANCE: Preventing catheter-associated urinary tract infection (CAUTI), a common health care-associated infection, is important for improving the care of hospitalized patients and in meeting the goals for reduction of health care-associated infections set by the US Department of Health and Human Services. OBJECTIVE: To identify ways to enhance CAUTI prevention efforts based on the experiences of hospitals participating in the Michigan Health and Hospital Association Keystone Center for Patient Safety statewide program to reduce unnecessary use of urinary catheters (the Bladder Bundle). DESIGN: Qualitative assessment of data collected through semistructured telephone interviews with key informants at 12 hospitals and in-person interviews and site visits at 3 of the 12 hospitals. The analysis focused on perceptions and key issues identified by hospitals as influencing implementation of CAUTI prevention practices as recommended by the Bladder Bundle initiative. SETTING: Twelve purposefully sampled hospitals in Michigan. PARTICIPANTS: Key informants including infection preventionists, clinical personnel, and senior executives. RESULTS: Common barriers to Bladder Bundle implementation and appropriate urinary catheter use included (1) difficulty with nurse and physician engagement, (2) patient and family request for indwelling catheters, and (3) catheter insertion practices and customs in the emergency department. Strategies to address these barriers were also identified by several of the participating hospitals, including (1) incorporating urinary management (eg, planned toileting) as part of other patient safety programs, such as a fall reduction program, (2) explicitly discussing the risks of indwelling urinary catheters with patients and families, and (3) engaging with emergency department nurses and physicians to implement a process that ensures that appropriate indications for catheter use are followed. CONCLUSIONS AND RELEVANCE: The Bladder Bundle program provides a model for implementing strategies to reduce CAUTI. These findings provide actionable information to inform CAUTI prevention-related activities in hospitals throughout the country.