Coproducing a library of videos to support families caring for children with gastrostomies: A mixed-methods evaluation with family carers and clinicians.

INTRODUCTION: Many families now perform specialist medical procedures at home. Families need appropriate training and support to do this. The aim of this study was to evaluate a library of videos, coproduced with parents and healthcare professionals, to support and educate families caring for a child with a gastrostomy. METHODS: A mixed-methods online survey evaluating the videos was completed by 43 family carers who care for children with gastrostomies and 33 healthcare professionals (community-based nurses [n = 16], paediatricians [n = 6], dieticians [n = 6], hospital-based nurses [n = 4], paediatric surgeon [n = 1]) from the United Kingdom. Participants watched a sample of videos, rated statements on the videos and reflected on how the videos could be best used in practice. RESULTS: Both family carers and healthcare professionals perceived the video library as a valuable resource for parents and strongly supported the use of videos in practice. All healthcare professionals and 98% (n = 42) of family carers agreed they would recommend the videos to other families. Family carers found the videos empowering and easy to follow and valued the mixture of healthcare professionals and families featured in the videos. Participants gave clear recommendations for how different video topics should fit within the existing patient pathway. DISCUSSION: Families and healthcare professionals perceived the videos to be an extremely useful resource for parents, supporting them practically and emotionally. Similar coproduced educational materials are needed to support families who perform other medical procedures at home. PATIENT OR PUBLIC CONTRIBUTION: Two parent representatives attended the research meetings from conception of the project and were involved in the design, conduct and dissemination of the surveys. The videos themselves were coproduced with several different families.

A Protocol is not Enough: Enhanced Recovery Program-Based Care and Clinician Adherence Associated with Shorter Stay After Colorectal Surgery.

BACKGROUND: Randomised trials have shown an Enhanced Recovery Program (ERP) can shorten stay after colorectal surgery. Previous research has focused on patient compliance neglecting the role of care providers. National data on implementation and adherence to standardised care are lacking. We examined care organisation and delivery including the ERP, and correlated this with clinical outcomes. METHODS: A cross-sectional questionnaire was administered to surgeons and nurses in August-October 2015. All English National Health Service Trusts providing elective colorectal surgery were invited. Responses frequencies and variation were examined. Exploratory factor analysis was performed to identify underlying features of care. Standardised factor scores were correlated with elective clinical outcomes of length of stay, mortality and readmission rates from 2013-15. RESULTS: 218/600 (36.3%) postal responses were received from 84/90 (93.3%) Trusts that agreed to participate. Combined with email responses, 301 surveys were analysed. 281/301 (93.4%) agreed or strongly agreed that they had a standardised, ERP-based care protocol. However, 182/301 (60.5%) indicated all consultants managed post-operative oral intake similarly. After factor analysis, higher hospital average ERP-based care standardisation and clinician adherence score were significantly correlated with reduced length of stay, as well as higher ratings of teamwork and support for complication management. CONCLUSIONS: Standardised, ERP-based care was near universal, but clinician adherence varied markedly. Units reporting higher levels of clinician adherence achieved the lowest length of stay. Having a protocol is not enough. Careful implementation and adherence by all of the team is vital to achieve the best results.

Outlier identification in colorectal surgery should separate elective and nonelective service components.

BACKGROUND: The identification of health care institutions with outlying outcomes is of great importance for reporting health care results and for quality improvement. Historically, elective surgical outcomes have received greater attention than nonelective results, although some studies have examined both. Differences in outlier identification between these patient groups have not been adequately explored. OBJECTIVE: The aim of this study was to compare the identification of institutional outliers for mortality after elective and nonelective colorectal resection in England. DESIGN: This was a cohort study using routine administrative data. Ninety-day mortality was determined by using statutory records of death. Adjusted Trust-level mortality rates were calculated by using multiple logistic regression. High and low mortality outliers were identified and compared across funnel plots for elective and nonelective surgery. SETTINGS: All English National Health Service Trusts providing colorectal surgery to an unrestricted patient population were studied. PATIENTS: Adults admitted for colorectal surgery between April 2006 and March 2012 were included. INTERVENTION(S): Segmental colonic or rectal resection was performed. MAIN OUTCOME MEASURES: The primary outcome measured was 90-day mortality. RESULTS: Included were 195,118 patients, treated at 147 Trusts. Ninety-day mortality rates after elective and nonelective surgery were 4% and 18%. No unit with high outlying mortality for elective surgery was a high outlier for nonelective mortality and vice versa. Trust level, observed-to-expected mortality for elective and nonelective surgery, was moderately correlated (Spearman ρ = 0.50, p< 0.001). LIMITATIONS: This study relied on administrative data and may be limited by potential flaws in the quality of coding of clinical information. CONCLUSIONS: Status as an institutional mortality outlier after elective and nonelective colorectal surgery was not closely related. Therefore, mortality rates should be reported for both patient cohorts separately. This would provide a broad picture of the state of colorectal services and help direct research and quality improvement activities.

An observational study of the frequency, severity, and etiology of failures in postoperative care after major elective general surgery.

OBJECTIVE: To investigate the nature of process failures in postoperative care, to assess their frequency and preventability, and to explore their relationship to adverse events. BACKGROUND: Adverse events are common and are frequently caused by failures in the process of care. These processes are often evaluated independently using clinical audit. There is little understanding of process failures in terms of their overall frequency, relative risk, and cumulative effect on the surgical patient. METHODS: Patients were observed daily from the first postoperative day until discharge by an independent surgeon. Field notes on the circumstances surrounding any nonroutine or atypical event were recorded. Field notes were assessed by 2 surgeons to identify failures in the process of care. Preventability, the degree of harm caused to the patient, and the underlying etiology of process failures were evaluated by 2 independent surgeons. RESULTS: Fifty patients undergoing major elective general surgery were observed for a total of 659 days of postoperative care. A total of 256 process failures were identified, of which 85% were preventable and 51% directly led to patient harm. Process failures occurred in all aspects of care, the most frequent being medication prescribing and administration, management of lines, tubes, and drains, and pain control interventions. Process failures accounted for 57% of all preventable adverse events. Communication failures and delays were the main etiologies, leading to 54% of process failures. CONCLUSIONS: Process failures are common in postoperative care, are highly preventable, and frequently cause harm to patients. Interventions to prevent process failures will improve the reliability of surgical postoperative care and have the potential to reduce hospital stay.

Patients' attitudes towards patient involvement in safety interventions: results of two exploratory studies.

BACKGROUND: In recent years, patient-focused interventions have been introduced aimed at increasing patient involvement in safety-related behaviours. However, patients' attitudes towards these interventions and comfort in participating in the recommended behaviours remain largely unexplored. OBJECTIVE: To evaluate patients' attitudes towards a video and leaflet aimed at encouraging patient involvement in safety-related behaviours. DESIGN: Two exploratory studies employing a within-subjects mixed-methods design. SETTING: Six hospital wards on an inner-city London teaching hospital. PARTICIPANTS: Medical and surgical inpatients: 80 patients in study 1 (mean age 55; 69% men) and 80 patients in study 2 (mean age 52; 60% men). INTERVENTION: Patients watched the PINK patient safety video (study 1) or read the National Patient Safety Agency's 'Please Ask' about staying in hospital leaflet (study 2). MAIN OUTCOME MEASURES: Perceived comfort in participating in safety-related behaviours; attitudes towards the video or leaflet. RESULTS: Both video and leaflet increased patients' perceived comfort in engaging in some (but not all) safety-related behaviours (P < 0.05). In both studies, the majority of patients questioned whether the intervention could help to reduce medical errors in health care. Suggestions on how the video/leaflet could be improved mainly related to content and layout. CONCLUSION: Video and leaflet could be effective at encouraging patient involvement in some safety-related behaviours. Further in-depth research on patients' attitudes towards different educational materials is required to help inform future policies and interventions in this very important but under-researched area.

Meeting the ambition of measuring the quality of hospitals' stroke care using routinely collected administrative data: a feasibility study.

OBJECTIVE: To examine the potential for using routinely collected administrative data to compare the quality and safety of stroke care at a hospital level, including evaluating any bias due to variations in coding practice. DESIGN: A retrospective cohort study of English hospitals' performance against six process and outcome indicators covering the acute care pathway. We used logistic regression to adjust the outcome measures for case mix. SETTING: Hospitals in England. PARTICIPANTS: Stroke patients (ICD-10 I60-I64) admitted to English National Health Service public acute hospitals between April 2009 and March 2010, accounting for 91 936 admissions. MAIN OUTCOME MEASURE: The quality and safety were measured using six indicators spanning the hospital care pathway, from timely access to brain scans to emergency readmissions following discharge after stroke. RESULTS: There were 182 occurrences of hospitals performing statistically differently from the national average at the 99.8% significance level across the six indicators. Differences in coding practice appeared to only partially explain the variation. CONCLUSIONS: Hospital administrative data provide a practical and achievable method for evaluating aspects of stroke care across the acute pathway. However, without improvements in coding and further validation, it is unclear whether the cause of the variation is the quality of care or the result of different local care pathways and data coding accuracy.

A systematic proactive risk assessment of hazards in surgical wards: a quantitative study.

OBJECTIVE: To identify and prioritize hazards in surgical wards and recommend interventions. BACKGROUND: Retrospective and prospective studies report the frequency and severity of surgical adverse events, but not in sufficient detail to allow interventions to be recommended in surgical wards. METHODS: Seventy hours of observations were used to record all activities occurring in surgical wards, and from these activities health care processes were derived. Fifty-nine patients and staff quantified the hazard associated with each health care process through a risk assessment survey. Modified health care failure mode and effects analysis was applied to the most hazardous of these processes to quantify the hazard of their associated failures. Cause analysis was applied to the most hazardous failures within analyzed processes. Interventions addressing the prioritized failures were recommended. RESULTS: Surgical ward observations identified 81 activities. The risk assessment survey was used to quantify the hazard associated with 10 health care processes derived from these activities. The 5 most hazardous processes were prioritized for modified health care failure mode and effects analysis including hand hygiene, isolation of infection, vital signs, medication delivery, and hand off. Of 190 failures within these processes, 50 (26%) were considered hazardous and did not have effective control measures in place. The causes of these failures allowed interventions to be recommended. CONCLUSIONS: Proactive risk assessments were used to systematically identify and prioritize hazards in surgical wards and allowed interventions to be recommended. These are practical tools that can determine where patient safety efforts should be targeted in clinical health care environments.

Quantitative analysis of intraoperative communication in open and laparoscopic surgery.

BACKGROUND: Communication is important for patient safety in the operating room (OR). Several studies have assessed OR communications qualitatively or have focused on communication in crisis situations. This study used prospective, quantitative observation based on well-established communication theory to assess similarities and differences in communication patterns between open and laparoscopic surgery. METHODS: Based on communication theory, a standardized proforma was developed for assessment in the OR via real-time observation of communication types, their purpose, their content, and their initiators/recipients. Data were collected prospectively in real time in the OR for 20 open and 20 laparoscopic inguinal hernia repairs. Assessors were trained and calibrated, and their reliability was established statistically. RESULTS: During 1,884 min of operative time, 4,227 communications were observed and analyzed (2,043 laparoscopic vs 2,184 open communications). The mean operative duration (laparoscopic, 48 min vs open, 47 min), mean communication frequency (laparoscopic, 102 communications/procedure vs open, 109 communications/procedure), and mean communication rate (laparoscopic, 2.13 communications/min vs open, 2.23 communications/min) did not differ significantly across laparoscopic and open procedures. Communications were most likely to be initiated by surgeons (80-81 %), to be received by either other surgeons (46-50%) or OR nurses (38-40 %), to be associated with equipment/procedural issues (39-47 %), and to provide direction for the OR team (38-46%) in open and laparoscopic cases. Moreover, communications in laparoscopic cases were significantly more equipment related (laparoscopic, 47 % vs open, 39 %) and aimed significantly more at providing direction (laparoscopic, 46 % vs open, 38 %) and at consulting (laparoscopic, 17 % vs open, 12 %) than at sharing information (laparoscopic, 17 % vs open, 31 %) (P < 0.001 for all). CONCLUSIONS: Numerous intraoperative communications were found in both laparoscopic and open cases during a relatively low-risk procedure (average, 2 communications/min). In the observed cases, surgeons actively directed and led OR teams in the intraoperative phase. The lack of communication between surgeons and anesthesiologists ought to be evaluated further. Simple, inexpensive interventions shown to streamline intraoperative communication and teamworking (preoperative briefing, surgeons' mental practice) should be considered further.

Information needs in operating room teams: what is right, what is wrong, and what is needed?

BACKGROUND: Safe surgical care requires effective information transfer between members of the operating room (OR) team. The present study aims to assess directly, systematically, and comprehensively, information needs of all OR team-members. METHODS: Thirty-three OR team-members (16 surgeons/anesthesiologists, 17 nurses) took part in a mixed-method interview. Participants indicated what information they need, their problems accessing it, and potential interventions to improve information transfer. They also rated the importance of different sources of information and the quality (accuracy, availability, timeliness, completeness, and clarity) of the information that they typically receive. Theme extraction and statistical analyses (descriptive and inferential) were used to analyze the data. RESULTS: The patient emerged as the top source of information. Surgeons and anesthesiologists relied more on information from fellow clinicians, as well as information originating from diagnostic and imaging labs. They were also more critical about the quality of the information than nursing personnel. Anesthesiologists emerged as the most reliable source of information, whereas information coming from surgeons was deemed lacking in quality (even by surgeons themselves). Finally, the more time participants had spent working in ORs, the more negative views they had about the information that they receive-an unexpected finding. Communication skills training, standardized communication protocols, and information technology (IT) systems to function as a central information repository were the top three proposed interventions. CONCLUSIONS: This study comprehensively maps information sources, problems, and solutions expressed by OR end-users. Recent developments in skills training modules and patient safety interventions for the OR (Surgical Safety Checklist) are discussed as potential interventions that will ameliorate communication in ORs, with a view to enhance patient safety and surgical care.

A longitudinal, multi-level comparative study of quality and safety in European hospitals: the QUASER study protocol.

BACKGROUND: although there is a wealth of information available about quality improvement tools and techniques in healthcare there is little understanding about overcoming the challenges of day-to-day implementation in complex organisations like hospitals. The 'Quality and Safety in Europe by Research' (QUASER) study will investigate how hospitals implement, spread and sustain quality improvement, including the difficulties they face and how they overcome them. The overall aim of the study is to explore relationships between the organisational and cultural characteristics of hospitals and how these impact on the quality of health care; the findings will be designed to help policy makers, payers and hospital managers understand the factors and processes that enable hospitals in Europe to achieve-and sustain-high quality services for their patients. METHODS/DESIGN: in-depth multi-level (macro, meso and micro-system) analysis of healthcare quality policies and practices in 5 European countries, including longitudinal case studies in a purposive sample of 10 hospitals. The project design has three major features: • a working definition of quality comprising three components: clinical effectiveness, patient safety and patient experience • a conceptualisation of quality as a human, social, technical and organisational accomplishment • an emphasis on translational research that is evidence-based and seeks to provide strategic and practical guidance for hospital practitioners and health care policy makers in the European Union. Throughout the study we will adopt a mixed methods approach, including qualitative (in-depth, narrative-based, ethnographic case studies using interviews, and direct non-participant observation of organisational processes) and quantitative research (secondary analysis of safety and quality data, for example: adverse incident reporting; patient complaints and claims). DISCUSSION: the protocol is based on the premise that future research, policy and practice need to address the sociology of improvement in equal measure to the science and technique of improvement, or at least expand the discipline of improvement to include these critical organisational and cultural processes. We define the 'organisational and cultural characteristics associated with better quality of care' in a broad sense that encompasses all the features of a hospital that might be hypothesised to impact upon clinical effectiveness, patient safety and/or patient experience.

Training and support for caring for a child's gastrostomy: a survey with family carers.

Objective: The aim of this study was to explore family carers' experiences of training and ongoing support for caring for their child's gastrostomy, and to get their views on how this could be improved. Methods: A mixed-methods online survey with 146 family carers (eg, parents, grandparents) who care for a child with a gastrostomy. Family carers rated their own experience of training and support and made recommendations for how training and support could be improved for future families. Results: The nature and extent of the training family carers reported receiving varied considerably. Many felt that the demonstrations they received in hospital were too brief. Two in five family carers rated their confidence caring for their child's gastrostomy as very low in the first few weeks after surgery. Parents valued ongoing learning and support from other parents and support from community nurses. Videos and simulation practice were rated as useful formats of training, in addition to face-to-face supervised practice with a clinician. Parents liked how real life the example video shown was, and rated nearly all suggested video topics as 'very helpful', especially troubleshooting topics. Conclusions: Our study found substantial variability in family carers' descriptions of the training and support they received to care for their child's gastrostomy. Training often did not meet family carers' needs. We need to invest in better training and support for families and learn from their recommendations. Improvements to training and support for families (eg, through instructional videos) have the potential to improve family carers' confidence and competence, and reduce the risk of problems and complications which cause harm to children and increase demand on National Health Service (NHS) resources.

How to do no harm: empowering local leaders to make care safer in low-resource settings.

In a companion paper, we showed how local hospital leaders could assess systems and identify key safety concerns and targets for system improvement. In the present paper, we consider how these leaders might implement practical, low-cost interventions to improve safety. Our focus is on making immediate safety improvements both to directly improve patient care and as a foundation for advancing care in the longer-term. We describe a 'portfolio' approach to safety improvement in four broad categories: prioritising critical processes, such as checking drug doses; strengthening the overall system of care, for example, by introducing multiprofessional handovers; control of known risks, such as only using continuous positive airway pressure when appropriate conditions are met; and enhancing detection and response to hazardous situations, such as introducing brief team meetings to identify and respond to immediate threats and challenges. Local clinical leaders and managers face numerous challenges in delivering safe care but, if given sufficient support, they are nevertheless in a position to bring about major improvements. Skills in improving safety and quality should be recognised as equivalent to any other form of (sub)specialty training and as an essential element of any senior clinical or management role. National professional organisations need to promote appropriate education and provide coaching, mentorship and support to local leaders.

First do no harm: practitioners' ability to 'diagnose' system weaknesses and improve safety is a critical initial step in improving care quality.

Healthcare systems across the world and especially those in low-resource settings (LRS) are under pressure and one of the first priorities must be to prevent any harm done while trying to deliver care. Health care workers, especially department leaders, need the diagnostic abilities to identify local safety concerns and design actions that benefit their patients. We draw on concepts from the safety sciences that are less well-known than mainstream quality improvement techniques in LRS. We use these to illustrate how to analyse the complex interactions between resources and tools, the organisation of tasks and the norms that may govern behaviours, together with the strengths and vulnerabilities of systems. All interact to influence care and outcomes. To employ these techniques leaders will need to focus on the best attainable standards of care, build trust and shift away from the blame culture that undermines improvement. Health worker education should include development of the technical and relational skills needed to perform these system diagnostic roles. Some safety challenges need leadership from professional associations to provide important resources, peer support and mentorship to sustain safety work.

Analysis of paediatric long-term ventilation incidents in the community.

AIM: To describe the nature and causes of reported patient safety incidents relating to care in the community for children dependent on long-term ventilation with the further aim of improving safety. METHODS: We undertook an analysis of patient safety incident data relating to long-term ventilation in the community using incident reports from England and Wales' National Reporting and Learning System occurring between January 2013 and December 2017. Manual screening by two authors identified 220 incidents which met the inclusion criteria. The free text for each report was descriptively analysed to identify the problems in the delivery of care, the contributory factors and the patient outcome. RESULTS: Common problems in the delivery of care included issues with faulty equipment and the availability of equipment, and concerns around staff competency. There was a clearly stated harm to the child in 89 incidents (40%). Contributory factors included staff shortages, out of hours care, and issues with packaging and instructions for equipment. CONCLUSIONS: This study identifies a range of problems relating to long-term ventilation in the community, some of which raise serious safety concerns. The provision of services to support children on long-term ventilation and their families needs to improve. Priorities include training of staff, maintenance and availability of equipment, support for families and coordination of care.

Observational teamwork assessment for surgery: construct validation with expert versus novice raters.

OBJECTIVE: To test the construct validity of the Observational Teamwork Assessment for Surgery (OTAS) tool. SUMMARY BACKGROUND DATA: Poor teamwork in surgical teams has been implicated in adverse events to patients. The OTAS is a tool that assesses teamwork in real time for the entire surgical team. Existing empirical research on OTAS has yet to explore how expert versus novice tool users use the tool to assess teamwork in the operating room. METHODS: Data were collected in 12 elective procedures by an expert/expert (N = 6) and an expert/novice (N = 6) pair of raters. Five teamwork behaviors (communication, coordination, leadership, monitoring, and cooperation) were scored via observation pre, intra, and postoperatively by blind raters. RESULTS: Significant and sizeable correlations were obtained in 12 of 15 behaviors in the expert/expert pair, but only in 3 of 15 behaviors in the expert/novice pair. Significant differences in mean scores were obtained in 3 of 15 behaviors in the expert/expert pair, but in 11 of 15 behaviors in the expert/novice pair. Total OTAS scores exhibited strong correlations and no significant differences in ratings in the expert/expert pair. In the expert/novice pair no correlations were obtained and there were significant differences in mean scores. The overall size of inconsistency in the scoring was 2% for expert/expert versus 15% for expert/novice. CONCLUSIONS: OTAS exhibits adequate construct validity as assessed by consistency in the scoring by expert versus novices-ie, expert raters produce significantly more consistent scoring than novice raters. Further validation should assess the learning curve for novices in OTAS. Relationships between OTAS, measures of technical skill, and behavioral responses to surgical crises should also be quantified.

Distracting communications in the operating theatre.

RATIONALE AND AIMS: Research suggests that there are problems of communication effectiveness in surgery. Here we describe the content, initiators and recipients of communications that intrude or interfere with individual surgical cases. We also consider the level at which the surgical team and its team members are distracted by these case-irrelevant communications (CICs). METHODS: Two psychologist observers sampled 48 general surgery procedures and they recorded the initiator and the recipient of CIC events, their content and the level of observable distraction that they caused. RESULTS: Irrelevant comments and queries (i.e. 'small-talk') accounted for half of the observed CICs. From the remaining CICs that we observed, most were related to the organization and administration of the case-list, to operating theatre provisions and to teaching junior staff. Surgeons initiated a third of the observed CICs, while receiving two thirds of them. External staff visiting the operating theatre initiated the most distracting communications. The CICs addressed to surgeons introduced significantly less distraction to the operating theatre than those addressed to anaesthetists and nurses. CONCLUSIONS: Some of the observed CICs contributed to the administration of the operating theatre case-list. Nonetheless, this communication can interfere with highly sensitive work. More effectively co-ordinated communication could reduce this interference. More research should assess the communication effectiveness and the impact of CICs on task performance in the operating theatre.