Trends in quality of primary care in the United States, 2007-2016.

During the past decade, many reforms were proposed and implemented for improving primary care in the US. This study assessed improvements in quality of primary care, using a nationally representative database. We conducted a retrospective trend analysis of National Inpatient Sample data (2007-2016). The quality of primary care was assessed using Prevention Quality Indicators (PQIs), which consist of 13 sets of preventable hospitalization conditions. PQI hospitalization decreased from 154,565 to 151,168 per million hospitalizations during the study period (relative decrease, 2.2%; P = 0.041). Age-adjusted hospitalization rate increased for diabetes short-term complications (relative increase, 46.9%; P < 0.001) and lower-extremity amputations (relative increase, 15.1%; P = 0.035). Age stratified trends showed that hospitalization rates decreased significantly in all age-groups for diabetes short-term complications. For lower-extremity amputations, hospitalization rates increased significantly in younger age groups and decreased significantly in the older age groups. All other PQIs showed either decreasing or no change in trends. Adults aged 18-64 years should be the focus for future prevention attempts for diabetes complications. Identifying and acting on the factors responsible for these changes could help in reversing the concerning trends observed in this study. Existing strategies should focus on improving access to diabetes care and self-management.

Mississippi CHAMPS: Decreasing Racial Inequities in Breastfeeding.

Mississippi CHAMPS addressed racial inequities in breastfeeding by implementing community and hospital-based practice changes in accordance with the BFHI and by parallel community work.

Reducing Unnecessary Respiratory Viral Testing to Promote High-Value Care.

BACKGROUND AND OBJECTIVES: Viral respiratory infections are common in children, and practice guidelines do not recommend routine testing for typical viral illnesses. Despite results often not impacting care, nasopharyngeal swabs for viral testing are frequently performed and are an uncomfortable procedure. The aim of this initiative was to decrease unnecessary respiratory viral testing (RVT) in the emergency department (ED) and the pediatric medicine wards (PMWs) by 50% and 25%, respectively, over 36 months. METHODS: An expert panel reviewed published guidelines and appropriate evidence to formulate an RVT pathway using plan-do-study-act cycles. A multifaceted improvement strategy was developed that included implementing 2 newer, more effective tests when testing was deemed necessary; electronic order modifications with force functions; audit and feedback; and education. By using statistical process control charts, the outcomes analyzed were the percentage of RVT ordered in the ED and the rate of RVT ordered on the PMWs. Balancing measures included return visits leading to admission and inpatient viral nosocomial outbreaks. RESULTS: The RVT rate decreased from a mean of 3.0% to 0.5% of ED visits and from 44.3 to 30.1 per 1000 patient days on the PMWs and was sustained throughout the study. Even when accounting for the new rapid influenza test available in the ED, a 50% decrease in overall ED RVT was still achieved without any significant impact on return visits leading to admission or inpatient nosocomial infections. CONCLUSIONS: Through implementation of a standardized, electronically integrated RVT pathway, a decrease in unnecessary RVT was successfully achieved. Audit and feedback, reminders, and biannual education all supported long-term sustainability of this initiative.

Safely Reducing Hospitalizations for Anaphylaxis in Children Through an Evidence-Based Guideline.

BACKGROUND: Emergency department visits for anaphylaxis have increased considerably over the past few decades, especially among children. Despite this, anaphylaxis management remains highly variable and contributes to significant health care spending. On the basis of emerging evidence, in this quality improvement project we aimed to safely decrease hospitalization rates, increase the use of cetirizine, and decrease use of corticosteroids for children with anaphylaxis by December 31, 2019. METHODS: A multipronged intervention strategy including a revised evidence-based guideline was implemented at a tertiary children's teaching hospital by using the Model for Improvement. Statistical process control was used to evaluate for changes in key measures. Length of stay and unplanned return visits within 72 hours were monitored as process and balancing measures, respectively. As a national comparison, hospitalization rates were compared with other hospitals' data from the Pediatric Health Information System. RESULTS: Hospitalizations decreased significantly from 28.5% to 11.2% from preimplementation to implementation, and the balancing measure of 72-hour revisits was stable. The proportion of patients receiving cetirizine increased significantly from 4.2% to 59.7% and use of corticosteroids decreased significantly from 72.6% to 32.4% in patients without asthma. The proportion of patients meeting length of stay criteria increased from 53.3% to 59.9%. Hospitalization rates decreased nationally over time. CONCLUSIONS: We reduced hospitalizations for anaphylaxis by 17.3% without concomitant increases in revisits, demonstrating that unnecessary hospitalizations can be safely avoided. The use of a local evidence-based guideline paired with close outcome monitoring and sustained messaging and feedback to clinicians can effectively improve anaphylaxis management.

Effect of a Quality Improvement Bundle to Standardize the Use of Intravenous Fluids for Hospitalized Pediatric Patients: A Stepped-Wedge, Cluster Randomized Clinical Trial.

Importance: Given that hypotonic maintenance intravenous fluids (IVF) may cause hospital-acquired harm, in November 2018, the American Academy of Pediatrics released a clinical practice guideline recommending the use of isotonic IVF for patients aged 28 days to 18 years without contraindications. No recommendations were made regarding laboratory monitoring; however, unnecessary laboratory tests may contribute to health care waste and harm patients. Objective: To examine the effect of a quality improvement intervention bundle on (1) increasing the mean proportion of hours per hospital day with exclusive isotonic IVF use to at least 80% and (2) decreasing the mean proportion of hospital days with laboratory tests obtained. Design, Setting, and Participants: This stepped-wedge, cluster randomized clinical trial (Standardization of Fluids in Inpatient Settings [SOFI]) was sponsored by a national quality improvement collaborative and was conducted across 106 US pediatric hospitals. The SOFI intervention period was from September 2019 to March 2020. Interventions: Hospital sites were exposed to educational materials, a clinical algorithm and order set for IVF use, electronic medical record interventions to reduce laboratory testing, and "harms of overtesting" cards. Main Outcomes and Measures: Primary outcomes were mean proportion of hours per hospital day receiving exclusive isotonic IVF and mean proportion of hospital days with laboratory test values obtained. Secondary measures included total IVF duration per hospital day, daily patient weight measurement while receiving IVF, serum sodium testing, and adverse events. Baseline data were collected for 2 months; intervention period data, 7 months. Outcomes were analyzed using linear mixed-effects regression models. Results: A total of 106 hospitals were randomly assigned to 1 of 3 intervention start dates (wedges), and 100 hospitals (94%) completed the study. In total, 5215 hospitalizations were reviewed before the intervention, and 6724 hospitalizations were reviewed after the intervention. Prior to interventions, the mean (SD) proportion of hours per day with exclusive isotonic IVF use was 88.5% (31.7%). Interventions led to an absolute increase of 5.4% (95% CI, 3.9%-6.9%) above baseline in exclusive isotonic IVF use but did not change the proportion of hospital days during which a laboratory test value was obtained (estimated difference, 0.1%; 95% CI, -1.5% to 1.7%; P = .90), IVF use duration (estimated difference, -1.2%; 95% CI, -2.9% to 0.4%), serum sodium testing, or adverse events. There was an absolute increase of 4.4% (95% CI, 2.6%-6.2%) in the mean proportion of hospital days with a patient weight measurement while receiving IVF. Conclusions and Relevance: In this stepped-wedge, cluster randomized clinical trial, an intervention bundle significantly improved the use of isotonic maintenance IVF without a concomitant increase in adverse events or electrolyte testing. Further work is required to deimplement laboratory testing. Trial Registration: ClinicalTrials.gov Identifier: NCT03924674.

Sustentabilidad hospitalaria, calidad y seguridad del paciente en el Hospital Clínico Universidad de Chile / Hospital sustainability, quality and patient safety in Hospital Clínico Universidad de Chile

The sustainability of the Universidad de Chile Clinical Hospital must be understood comprehensively; providing higher quality and safety for our patients, ensuring highest standards of medical care. The quality of care must be understood not only in complying with the minimum standards to accredit and grant GES benefits, establish agreements with health insurers and be financially competitive; It must be incorporated into its management the dimensions of quality - effectiveness, efficiency, accessibility, safety, equity and patient-centered care- minimizing the costs of non-quality work. Our Clinical Hospital, as our country's main training center in healthcare professions, must include training at the undergraduate students' curriculum in quality and patient safety issues. (AU)

Developments in National Cancer Control Programmes in Europe - Results From the Analysis of a Pan-European Survey.

INTRODUCTION: National Cancer Control Programmes (NCCPs) provide a country's policy framework for the development of cancer control, focussing on the reduction of cancer morbidity and mortality and improving quality of life of cancer patients. OBJECTIVE: Exploring and analysing to which extent some of the key elements of the European Guide for Quality National Cancer Control Programmes (Guide) are implemented in NCCPs in the EU. METHODS: Survey carried out through 30 countries, EU members, Iceland, Montenegro, Norway and Turkey, focussing on stakeholders' participation, inclusion of all the envisaged chapters from the Guide as well as implementation and dissemination. RESULTS: The results of the policy survey on European NCCPs carried out within Cancer Control Joint Action (CANCON JA) are presented. The response was 30 out of 35 countries. In total, 28 out of 30 countries, which completed the survey, had an NCCP or another cancer document. Cancer documents were mostly single documents, managed and supervised by the respective Ministries of Health and communicated to the public via websites and press. Nine documents were defined as programmes, eight as plans and six as strategies; in five countries, terminology was mixed. Regarding the content, recommended by the Guide from 2015, comprising ten chapter areas in three parts. Only 10 countries included in their NCCPs all elements suggested in the Guide. CONCLUSION: Based on our results, we can see that a more comprehensive approach in the process of NCCPs is needed. Policy should focus on the development of instruments for efficient cancer management, which would encompass the entire trajectory of the cancer care from diagnosis to survivorship and supportive care.

National Trends in Telestroke Utilization in a US Commercial Platform Prior to the COVID-19 Pandemic.

OBJECTIVES: Most data on telestroke utilization come from single academic hub-and-spoke telestroke networks. Our objective was to describe characteristics of telestroke consultations among a national sample of telestroke sites on one of the most commonly used common vendor platforms, prior to the COVID-19 public health emergency. MATERIALS AND METHODS: A commercial telestroke vendor provided data on all telestroke consultations by two specialist provider groups from 2013-2019. Kendall's τ ß nonparametric test was utilized to assess time trends. Generalized linear models were used to assess the association between hospital consult utilization and alteplase use adjusting for hospital characteristics. RESULTS: Among 67,736 telestroke consultations to 132 spoke sites over the study period, most occurred in the emergency department (90%) and for stroke indications (final clinical diagnoses: TIA 13%, ischemic stroke 39%, hemorrhagic stroke 2%, stroke mimics 46%). Stroke severity was low (median NIHSS 2, IQR 0-6). Alteplase was recommended for 23% of ischemic stroke patients. From 2013 to 2019, times from ED arrival to NIHSS, CT scan, imaging review, consult, and alteplase administration all decreased (p<0.05 for all), while times from consult start to alteplase recommendation and bolus increased (p<0.01 for both). Transfer was recommended for 8% of ischemic stroke patients. Number of patients treated with alteplase per hospital increased with increasing number of consults and hospital size and was also associated with US region in unadjusted and adjusted analyses. Longer duration of hospital participation in the network was associated with shorter hospital median door-to-needle time for alteplase delivery (39 min shorter per year, p=0.04). CONCLUSIONS: Among spoke sites using a commercial telestroke platform over a seven-year time horizon, times to consult start and alteplase bolus decreased over time. Similar to academic networks, duration of telestroke participation in this commercial network was associated with faster alteplase delivery, suggesting practice improves performance.

Health Equity and Healthcare Disparities in Plastic Surgery: What We Can Do.

Amidst the unexpected losses and challenges of 2020, healthcare disparities and health equity have presided as noteworthy topics of national discussion among healthcare workers, governmental officials, and society at large. Health equity, defined as the opportunity for everyone to be as healthy as possible, may be achieved through the alleviation of healthcare disparities. Healthcare disparities are defined as "preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations." While these concepts may be perceived as a departure from the core responsibility of plastic surgeons, it is of paramount importance to recognize how race, socioeconomic status (SES), and physical environment impact access to care, surgical outcomes, and postoperative recovery for vulnerable populations. In this communication, our purpose is two-fold: 1) to elucidate the existent healthcare disparities and associations with race and SES in craniofacial, trauma, breast, hand, and gender-affirming reconstruction; and 2) provide tangible recommendations to incorporate the concepts of health equity and healthcare disparities in clinical, research, community, and recruitment settings for plastic surgeons. Through such knowledge, plastic surgeons may glean important insights that may enhance the delivery of equitable and accessible care for patients.

RAFF-3 Trial: A Stepped-Wedge Cluster Randomised Trial to Improve Care of Acute Atrial Fibrillation and Flutter in the Emergency Department.

BACKGROUND: We sought to improve care of patients with acute atrial fibrillation (AF) and flutter (AFL) in the emergency department (ED) by implementing the Canadian Association of Emergency Physicians (CAEP) Acute AF/AFL Best Practices Checklist. METHODS: We conducted a stepped-wedge cluster randomised trial at 11 large community and academic hospital EDs in 5 Canadian provinces and enrolled consecutive AF/AFL patients. The study intervention was introduction of the CAEP Checklist with the use of a knowledge translation-implementation approach that included behaviour change techniques and organisation/system-level strategies. The primary outcome was length of stay in ED, and secondary outcomes were discharge home, use of rhythm control, adverse events, and 30-day status. Analysis used mixed-effects regression adjusting for covariates. RESULTS: Patient visits in the control (n = 314) and intervention (n = 404) periods were similar with mean age 62.9 years, 54% male, 71% onset < 12 hours, and 86% AF, 14% AFL. We observed a reduction in length of stay of 20.9% (95% confidence interval [CI] 5.5%-33.8%; P = 0.01), an increase in use of rhythm control (adjusted odds ratio [OR] 4.5, 95% CI 1.8-11.6; P = 0.002), and a decrease in use of rate-control medications (OR 0.5, 95% CI 0.2-0.9; P = 0.02). There was no change in adverse events and no strokes or deaths by 30 days. CONCLUSIONS: The RAFF-3 trial led to optimised care of AF/AFL patients with decreased ED lengths of stay, increased ED rhythm control by drug or electricity, and no increase in adverse events. Early cardioversion allows AF/AFL patients to quickly resume normal activities.

Impact of an internal medicine nocturnist service on care of patients with cancer at a large Canadian teaching hospital: a quality-improvement study.

BACKGROUND: Nocturnists (overnight hospitalists) are commonly implemented in US teaching hospitals to adhere to per-resident patient caps and improve care but are rare in Canada, where patient caps and duty hours are comparatively flexible. Our objective was to assess the impact of a newly implemented nocturnist program on perceived quality of care, code status documentation and patient outcomes. METHODS: Nocturnists were phased in between June 2018 and December 2019 at Toronto General Hospital, a large academic teaching hospital in Toronto, Ontario. We performed a quality-improvement study comparing rates of code status entry into the electronic health record at admission, in-hospital mortality, the 30-day readmission rate and hospital length of stay for patients with cancer admitted by nocturnists and by residents. Surveys were administered in June 2019 to general internal medicine faculty and residents to assess their perceptions of the impact of the nocturnist program. RESULTS: From July 2018 to June 2019, 30 nocturnists were on duty for 241/364 nights (66.5%), reducing the mean maximum overnight per-resident patient census from 40 (standard deviation [SD] 4) to 25 (SD 5) (p < 0.001). The rate of admission code status entry was 35.3% among patients admitted by residents (n = 133) and 54.9% among those admitted by nocturnists (n = 339) (p < 0.001). The mortality rate was 10.5% among patients admitted by residents and 5.6% among those admitted by nocturnists (p = 0.06), the 30-day readmission rate was 8.3% and 5.9%, respectively (p = 0.4), and the mean acute length of stay was 7.2 (SD 7.0) days and 6.4 (SD 7.8) days, respectively (p = 0.3). Surveys were completed by 15/24 faculty (response rate 62%), who perceived improvements in patient safety, efficiency and trainee education; however, only 30/102 residents (response rate 29.4%) completed the survey. INTERPRETATION: Although implementation of a nocturnist program did not affect patient outcomes, it reduced residents' overnight patient census, and improved faculty perceptions of quality of care and education, as well as documentation of code status. Our results support nocturnist implementation in Canadian teaching hospitals.

A Glimpse Into the Magnet® Program Office: The High-Performing Senior Magnet® Program Analyst Team.

The Magnet Recognition Program® has a dedicated team of RNs and non-RNs who are committed to advancing nursing and supporting healthcare organizations on their Magnet® journeys. Healthcare organizations who are either Magnet-designated or applicants for Magnet designation regularly communicate with the various members of the Magnet program office team. This perspective will highlight the roles of the senior Magnet program analysts and the assistant director of Magnet program operations.

Effectiveness of Internet and Phone-Based Interventions on Diabetes Management of Children and Adolescents With Type 1 Diabetes: A Systematic Review.

AIMS: To synthesize evidence about the impact of Internet and phone-based diabetes education and management on metabolic control, self-management behavior changes, and psychological effects among children and adolescents with type 1 diabetes mellitus (T1DM). BACKGROUND: Internet and mobile technologies were commonly used to improve diabetes management among children and adolescents with type 1 diabetes mellitus. The effectiveness of new technology-based diabetes education and management has previously not been synthesized. METHODS: PubMed, EBSCO, Cochrane Library, Web of Science, Joanna Briggs Institute Library, and the Chinese databases CNKI and Wanfang were searched from 1989 to March 2020. Two reviewers independently selected randomized controlled trials (RCTs), in English and Chinese, which compared an intervention group of new technology-based diabetes education and management with a control group of usual care. The primary outcomes were metabolic control, such as glycated hemoglobin (HbA1c), and secondary outcomes consisted of behavior changes and psychological effects, such as self-efficacy and quality of life. RESULTS: A total of 23 RCTs with 1,824 participants met the inclusion criteria. The meta-analysis showed that phone calls could significantly reduce HbA1c (MD = -.17; 95% CI [-.33, -.01]; I2  = 0%) in children and adolescents with T1DM. New technology-based diabetes education and management could significantly improve self-efficacy (SMD = 0.37; 95% CI [.07, .67]; I2  = 0%). No benefits on behavior changes and quality of life were identified. LINKING EVIDENCE TO ACTION: New technology-based diabetes education has potential benefits for children and adolescents with T1DM, such as improving metabolic control through phone calls and increasing their self-efficacy of diabetes management. Well-designed RCTs with larger sample sizes and longer intervention duration should be conducted, especially in developing countries.