Sustainability of a program to reduce unnecessary urethral catheter use at a Veterans Affairs hospital.

We assessed the long-term sustainability of a quality improvement intervention to reduce urethral catheter use at a Veterans Affairs (VA) hospital. During the 8 years after the initial intervention, point-prevalence surveillance showed that urethral catheter use continued to decrease (OR, 0.91; 95% CI, 0.86-0.97; P = .003) and that appropriateness of catheter use remained unchanged.

Effects of an Electronic Medical Record Intervention on Appropriateness of Transthoracic Echocardiograms: A Prospective Study.

BACKGROUND: Transthoracic echocardiograms (TTEs) account for approximately half of U.S. spending on cardiac imaging. We developed an electronic medical record (EMR)-based decision-support algorithm for TTE ordering and hypothesized that it would increase the appropriateness of TTE orders. METHODS: This prospective observational study was performed at the Veterans Affairs Ann Arbor Healthcare System. From October to December 2016 (preintervention), consecutive TTEs ordered in the inpatient, outpatient, and emergency department settings were included. In May 2017, a decision-support algorithm was incorporated into the EMR, giving immediate feedback to providers. Chart review was performed for TTEs ordered from June to August 2017 (early intervention) and from June to August 2018 (late intervention). Appropriateness was determined based on the 2011 appropriate use criteria for echocardiography. RESULTS: Appropriate TTE orders increased from 87.6% preintervention to 94.5% at early intervention (z = 0.00018) but decreased to 90.0% at late intervention (z = 0.51, compared with preintervention). Among patients with no previous TTEs in our system, 95.3% of TTEs were appropriate, compared with 87.7% of TTEs for patients with prior TTEs within 30 days prior (odds ratio = 2.85; 95% CI, 1.18-6.31; P = .005). CONCLUSIONS: The EMR algorithm initially increased the percentage of appropriate TTEs, but this effect decayed over time. Further study is needed to develop EMR-based interventions that will have lasting impacts on provider ordering patterns.

Using A3 thinking to improve the STAT medication process.

BACKGROUND: Although the term STAT conveys a sense of urgency, it is sometimes used to circumvent a system that may be too slow to accomplish tasks in a timely manner. We describe a quality-improvement project undertaken by a US Department of Veterans Affairs (VA) hospital to improve the STAT medication process. METHODS: We adapted A3 Thinking, a problem-solving process common in Lean organizations, to our problem. In the discovery phase, a color-coded flow map of the existing process was constructed, and a real-time STAT order was followed in a modified "Go to the Gemba" exercise. In the envisioning phase, the team brainstormed to come up with as many improvement ideas as possible, which were then prioritized based on the anticipated effort and impact. The team then identified initial experiments to be carried out in the experimentation phase; each experiment followed a standard Plan-Do-Study-Act cycle. RESULTS: On average, the number of STAT medications ordered per month decreased by 9.5%. The average time from STAT order entry to administration decreased by 21%, and time from medication delivery to administration decreased by 26%. Improvements were also made in technician awareness of STAT medications and nurse notification of STAT medication delivery. CONCLUSIONS: Adapting A3 Thinking for process improvement was a low-cost/low-tech option for a VA facility. The A3 Thinking process led to a better understanding of the meaning of STAT across disciplines, and promoted a collaborative culture in which other hospital-wide problems may be addressed in the future.

A multimodal intervention to reduce urinary catheter use and associated infection at a Veterans Affairs Medical Center.

We assessed the impact of a quality improvement intervention to reduce urinary catheter use and associated urinary tract infections (UTIs) at a single hospital. After implementation, UTIs were reduced by 39% ([Formula: see text]). Additionally, we observed a slight decrease in catheter use and the number of catheters without an appropriate indication.

Introducing the patient safety professional: why, what, who, how, and where?

BACKGROUND: Hospital-acquired complications, such as nosocomial infection, falls, and venous thromboembolism, are well known to be frequent and morbid. Unfortunately, prevention remains challenging. Two widely touted prevention strategies-checklists and reminders-have inherent barriers that limit their use as general solutions to these endemic problems. Likewise, relying upon additional vigilance and efforts of those already caring for patients may guarantee that hospital-acquired complications persist, given the time pressures already constraining bedside clinicians. Consequently, we recommend a new type of clinical role in the hospital setting, the "Patient Safety Professional" (PSP), be considered to ensure that each patient receives individualized prevention strategies to minimize the hazards of hospitalization. THE ROLE OF THE PSP: We envision the PSP would be an APRN who would assess assigned patients for hospital-acquired complications following explicit protocols relevant to a short list of safety targets; prioritize identified complications based on morbidity, mortality, and hospital costs; and develop and implement plans to decrease hospital-acquired complications, in consultation with physicians and staff nurses on the unit. We have recently hired such an individual at our hospital and describe-through several vignettes-what our PSP does on a daily basis. EVALUATION OF THE PSP: The rollout, benefits, and costs of PSPs should be carefully evaluated before widespread dissemination is considered. Process measures and clinical outcomes should be monitored. Physician, nurse, and patient satisfaction also need to be assessed. CONCLUSIONS: Far from replacing the duties of frontline physicians and nurses assigned to care for the patient, we believe that a PSP will strengthen the safety net for hospitalized patients and serve as an expert resource.