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1.
Can J Surg ; 63(5): E460-E467, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-33107814

RESUMEN

BACKGROUND: Enhanced Recovery After Surgery (ERAS) protocols use evidence-based perioperative practices that reduce morbidity and length of stay and improve patient satisfaction. ERAS is considered standard of care; however, utilization remains low and substantial practice variation exists. The aim of this study was to pragmatically characterize variation in colorectal surgery practice and identify predictors of ERAS utilization. METHODS: A survey of general surgeons identified using the Ontario College of Physicians and Surgeons database was conducted. Information on basic demographic characteristics, utilization of ERAS and predictors of ERAS implementation was collected. Nine ERAS behaviours were analyzed. Multivariable analysis was used to determine effects of demographic, hospital and surgeon covariates on ERAS utilization. RESULTS: Seven hundred and ninety-seven general surgeons were invited to participate in the survey, and 235 general surgeons representing 84 Ontario hospitals responded (30% response rate). Surgeons practising in academic settings and in large community hospitals represented 30% and 47% of the respondents, respectively. A total of 20% of the respondents used all 9 ERAS behaviours consistently. Rates of diet advancement on postoperative day 0, intravenous fluid restriction and having catheter and line procedures were significantly higher among respondents who adhered to ERAS protocols than among those who did not (74% v. 54%, p = 0.004; 92% v. 80%, p = 0.01; and 91% v. 41%, p < 0.001, respectively). Respondents from academic settings reported practising nearly 1 more ERAS behaviour than those from small community hospitals (odds ratio [OR] 0.86, 95% confidence interval [CI] 0.42 to 1.31, p < 0.001). Multivariable analysis demonstrated that colorectal fellowship training or exposure to ERAS during training did not significantly affect ERAS behaviour utilization (OR 0.32, 95% CI -0.31 to 0.94, p = 0.16; OR 0.28, 95% CI -0.26 to 0.82, p = 0.16, respectively). CONCLUSION: Substantial practice variation in colorectal surgery still exists. Individual ERAS principles are commonly followed; however, ERAS behaviours are not widely formalized into hospital protocols.


Asunto(s)
Colon/cirugía , Procedimientos Quirúrgicos Electivos/efectos adversos , Recuperación Mejorada Después de la Cirugía/normas , Complicaciones Posoperatorias/prevención & control , Pautas de la Práctica en Medicina/estadística & datos numéricos , Recto/cirugía , Centros Médicos Académicos/normas , Centros Médicos Académicos/estadística & datos numéricos , Adulto , Protocolos Clínicos/normas , Femenino , Adhesión a Directriz/normas , Adhesión a Directriz/estadística & datos numéricos , Hospitales Comunitarios/normas , Hospitales Comunitarios/estadística & datos numéricos , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Ontario , Satisfacción del Paciente , Complicaciones Posoperatorias/etiología , Pautas de la Práctica en Medicina/normas , Nivel de Atención , Cirujanos/normas , Encuestas y Cuestionarios/estadística & datos numéricos
2.
Am J Trop Med Hyg ; 102(3): 553-561, 2020 03.
Artículo en Inglés | MEDLINE | ID: mdl-31933460

RESUMEN

Pulmonary tuberculosis (TB) is a major global public health problem. Thailand is listed as one of the countries with a high burden of pulmonary TB. Various factors are known to contribute to unsuccessful pulmonary TB treatment. However, studies in Thailand remain limited, especially in rural settings. This study aimed to identify the prevalence and associated factors of unsuccessful pulmonary TB treatment in community hospitals. A cross-sectional study was conducted from June-July 2019. We enrolled all patients receiving treatments in four community hospitals in central Thailand. The collected data included baseline characteristics, comorbid illnesses, a history of directly observed treatment-short course (DOTS), sputum acid-fast bacilli smear results, and chest radiography and treatment outcomes. Univariate and multivariate analyses were used to identify factors associated with unsuccessful pulmonary TB treatment. A total of 786 patients were enrolled in the study. Prevalence of unsuccessful treatment was 18.7%. Associated factors of unsuccessful pulmonary TB treatment were previously treated TB (adjusted odds ratio [AOR]: 2.1, 95% CI: 1.2-3.7), existence of comorbid illnesses (AOR: 2.8, 95% CI: 1.5-5.0), DOTS not performed (AOR: 2.5, 95% CI: 1.4-4.5), chest radiography showing multiple lung lesions at first diagnosis (AOR: 3.0, 95% CI: 1.7-5.2), no chest radiography improvement in the first follow-up (AOR: 17.7, 95% CI: 8.2-38.0), and unknown status of chest radiography in the first follow-up (AOR: 48.1, 95% CI: 22.3-103.5). Health promotion and primary care should be implemented in the communities to achieve ultimate successful treatment.


Asunto(s)
Antituberculosos/uso terapéutico , Hospitales Comunitarios/normas , Tuberculosis Pulmonar/tratamiento farmacológico , Tuberculosis Pulmonar/epidemiología , Adolescente , Adulto , Antituberculosos/administración & dosificación , Estudios Transversales , Femenino , Humanos , Masculino , Persona de Mediana Edad , Factores de Riesgo , Población Rural , Tailandia , Resultado del Tratamiento , Adulto Joven
3.
Support Care Cancer ; 28(4): 1765-1773, 2020 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-31309296

RESUMEN

PURPOSE: We explored the perceived strengths, barriers to implementation, and suggestions for sustainable implementation of a multidisciplinary model within a community-based hospital system from the physicians' perspectives. METHODS: We conducted 9 focus groups with 37 physicians involved in the care of lung cancer patients. Grounded theory methodology guided the identification of recurrent themes that emerged from the qualitative data analysis. RESULTS: The majority of study participants agreed that the multidisciplinary model could benefit patients by promoting high quality, efficient, and well-coordinated care. Co-location, financial disincentives, and time constraints were identified as major deterrents to full participation in a multidisciplinary clinic. Other perceived challenges were the integration of a multidisciplinary care model into the existing healthcare system, maintenance of referral streams, and designation of the physician primarily responsible for a patient's care. Educating physicians about the availability of a multidisciplinary clinic, establishing efficient processes for initial consultations, implementing technology for virtual participation, and using a nurse navigator with reliable closed-loop communication were suggested to improve the implementation of the multidisciplinary model. CONCLUSIONS: Physicians generally agreed that the multidisciplinary model could improve lung cancer care, but they perceived significant personal, institutional, and system-level barriers that need to be addressed for its successful implementation in a community healthcare setting.


Asunto(s)
Servicios de Salud Comunitaria , Grupos Focales , Neoplasias Pulmonares/terapia , Grupo de Atención al Paciente , Percepción , Médicos , Adulto , Servicios de Salud Comunitaria/organización & administración , Servicios de Salud Comunitaria/normas , Prestación de Atención de Salud/organización & administración , Prestación de Atención de Salud/normas , Hospitales Comunitarios/organización & administración , Hospitales Comunitarios/normas , Hospitales Comunitarios/estadística & datos numéricos , Humanos , Comunicación Interdisciplinaria , Neoplasias Pulmonares/epidemiología , Grupo de Atención al Paciente/organización & administración , Grupo de Atención al Paciente/normas , Grupo de Atención al Paciente/estadística & datos numéricos , Médicos/psicología , Médicos/estadística & datos numéricos , Derivación y Consulta , Encuestas y Cuestionarios
4.
Rural Remote Health ; 19(4): 5442, 2019 11.
Artículo en Inglés | MEDLINE | ID: mdl-31782988

RESUMEN

INTRODUCTION: In 2008, the Medical Council of New Zealand recognised rural hospital medicine as a vocational scope of practice. The aim was to provide training and professional development standards for medical practitioners working in New Zealand's rural hospitals and to encourage quality systems to become established in rural hospitals. Hokianga Health in New Zealand's far north is an established integrated health service that includes a rural hospital and serves a largely Māori community. The aim of this study was to explore how the new scope had affected health practitioners and the health service at Hokianga Health. METHODS: A case study design was used, employing qualitative methods. Documentary analysis was undertaken tracking change and development at Hokianga Health. Twenty-six documents (10 from within and 16 from outside Hokianga Health) were included in the analysis. Eleven face-to-face semi-structured interviews were conducted with employees of Hokianga Health. The interviews explored participants' views of the rural hospital medicine scope. Interviews were recorded and transcribed. Thematic analysis of the interviews was undertaken using the framework method. The two data sources were analysed separately. RESULTS: Four themes capturing the main issues were identified: (1) 'What I do': articulating the scope of medical practice at Hokianga, (2) 'What we do': the role of the hospital at Hokianga, (3) 'On the fringes', and (4) Survival. With changing regulatory policy an established part of Hokianga Health practice, the hospital aspect was outside the scope of general practice. This mismatch created a vulnerability for individual doctors and threatened the hospital service. The new scope filled the gap, rural hospital medicine together with general practice now covering the whole practice scope at Hokianga Health. With the introduction of the rural hospital medicine scope and the accompanying national definition of a rural hospital came a sense of belonging and increased connectedness, Hokianga Health and its practitioners realigning with the new scope, its policies, processes and language. The new scope brought for the first time a specific focus on the inpatient and emergency care aspects of practice at Hokianga and with this validation of the hospital aspect of the medical practitioners work. The critical importance of a fit-for-purpose scope and rural-specific postgraduate training programs in minimising inequity of care and opportunity for rural communities was emphasised. The importance of benchmarking with its associated costs was also highlighted. The main challenges identified related to the real (as well as potential) increased regulatory requirements of two separate scopes of practice for practitioners and a small rural health service working across primary and secondary care. CONCLUSION: In better equipping medical practitioners for rural hospital work and strengthening hospital systems and standards, the rural hospital medicine scope has met its intentions at Hokianga Health. The rural hospital medicine pathway is a necessary partial solution to rural medical practitioners maintaining a broad skill set. Continued flexibility is required in training programs in order to meet a range of different practitioner and rural health service needs.


Asunto(s)
Medicina General/economía , Medicina General/normas , Hospitales Comunitarios/normas , Estudios de Casos Organizacionales/estadística & datos numéricos , Atención Primaria de Salud/normas , Servicios de Salud Rural/economía , Servicios de Salud Rural/normas , Humanos , Nueva Zelanda , Guías de Práctica Clínica como Asunto
5.
BMJ Open ; 9(4): e024328, 2019 04 04.
Artículo en Inglés | MEDLINE | ID: mdl-30948568

RESUMEN

OBJECTIVES: The purpose of this study was to explore the experiences, beliefs and perceptions of intensive care unit (ICU) nurses on the management of pain, agitation and delirium (PAD) in critically ill patients. DESIGN: A qualitative descriptive study. SETTING: This study took place in a community hospital ICU located in a medium size Canadian city. PARTICIPANTS: Purposeful sampling was conducted. Participants included full-time nurses working in the ICU. Forty-six ICU nurses participated. METHODS: A total of five focus group sessions were held to collect data. There were one to three separate groups in each focus group session, with no more than seven participants in each group. There were 10 separate groups in total. A semistructured question guide was used. Thematic analysis method was adopted to analyse the data, and to search for emergent themes and patterns. RESULTS: Three main themes emerged: (1) the professional perspectives on patient wakefulness state, (2) the professional perspectives on PAD management of critically ill patients and (3) the factors impacting PAD management. Nurses have different opinions on the optimal level of patient sedation and felt that many factors, including environmental, healthcare teams, patients and family members, can influence PAD management. This potentially leads to inconsistent PAD management in critically ill patients. The nurses also believed that PAD management requires a multidisciplinary approach including healthcare teams and patients' families. CONCLUSIONS: Many external and internal factors contribute to the complexity of PAD management including the attitudes of nursing staff towards PAD. The themes emerged from this study suggested the need of a multifaceted and multidisciplinary quality improvement programme to optimise the management of PAD in the ICU.


Asunto(s)
Actitud del Personal de Salud , Cuidados Críticos , Delirio/tratamiento farmacológico , Personal de Enfermería en Hospital/psicología , Manejo del Dolor , Agitación Psicomotora/tratamiento farmacológico , Analgésicos/uso terapéutico , Canadá , Cuidados Críticos/normas , Femenino , Grupos Focales , Hospitales Comunitarios/normas , Humanos , Hipnóticos y Sedantes/uso terapéutico , Unidades de Cuidados Intensivos , Masculino , Manejo del Dolor/métodos , Grupo de Atención al Paciente , Investigación Cualitativa , Mejoramiento de la Calidad
7.
Respir Care ; 64(9): 1073-1081, 2019 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-31015388

RESUMEN

BACKGROUND: Pediatric airway management is a challenging process at community emergency departments (CEDs) due to lower pediatric volume, a lack of pediatric expertise among staff, and a lack of pediatric-specific equipment and resources. This has contributed to increased mortality in pediatric patients presenting to CEDs in comparison to pediatric academic medical centers (AMCs). We hypothesized that a collaborative program between CEDs and the state AMC would improve the quality of pediatric airway management provided by CEDs in simulated settings and the CEDs' pediatric emergency readiness scores. METHODS: This prospective, pre- and post-intervention study utilized in situ simulation and was conducted in 10 CEDs in the state of Indiana. A team from the pediatric AMC led a multi-faceted improvement program, which included post-simulation debriefing, addressing pediatric airway management issues, targeted assessment reports, access to pediatric resources, and ongoing communication with the AMC. The primary outcome of the study was improvement of simulated pediatric airway management in the CEDs. The secondary outcome was improvement of the CEDs' pediatric emergency readiness scores score. RESULTS: A total of 35 multidisciplinary teams participated in pre-intervention sessions, and 40 teams participated in post-intervention sessions. Overall adherence to a critical action checklist improved from 52% at the pre-intervention visits to 71% post-intervention (P = .003). There were significant improvements in the use of appropriate endotracheal tube (ETT) size (from 67% to 100%, P = .02), cuffed ETT (from 8% to 71%, P < .001), appropriate blade size (from 58% to 100%, P = .03), and availability of suction catheter (from 10% to 42%, P = .049). The CEDs' total pediatric emergency readiness scores score improved from 58.8 ± 15.6 pre-intervention to 75.8 ± 9.3 post-intervention (P = .01). CONCLUSIONS: A collaborative improvement program between a pediatric AMC and CEDs improved the CEDs' simulated pediatric emergency airway management. This model can be utilized to improve management of other pediatric critical conditions in these CEDs.


Asunto(s)
Centros Médicos Académicos/normas , Manejo de la Vía Aérea/normas , Servicio de Urgencia en Hospital/normas , Hospitales Comunitarios/normas , Pediatría/normas , Manejo de la Vía Aérea/métodos , Lista de Verificación , Niño , Femenino , Humanos , Indiana , Colaboración Intersectorial , Masculino , Pediatría/métodos , Estudios Prospectivos , Mejoramiento de la Calidad
8.
Br J Community Nurs ; 24(Sup3): S6-S11, 2019 Mar 01.
Artículo en Inglés | MEDLINE | ID: mdl-30817187

RESUMEN

Patients with wounds pose an important healthcare challenge. Many of these wounds are managed in community care and can take weeks or months to resolve. Delays in wound healing can be perpetuated by clinicians who make poor treatment choices, fail to recognise complications and/or do not seek timely advice. Improving patient outcomes requires a proactive approach to care that includes accurate and timely assessment and re-assessment, treatment of the underlying cause using a multidisciplinary team approach and the use of evidence-based practice and clinical judgement to develop an appropriate treatment plan. A structured approach to care, such as the newly developed T.I.M.E. clinical decision support tool, has the potential to improve wound healing outcomes and reduce the burden of chronic wounds in community nursing services.


Asunto(s)
Enfermedad Crónica/terapia , Sistemas de Apoyo a Decisiones Clínicas , Prestación de Atención de Salud/normas , Medicina Basada en la Evidencia/normas , Hospitales Comunitarios/normas , Guías de Práctica Clínica como Asunto , Medicina Estatal/normas , Heridas y Traumatismos/terapia , Humanos , Resultado del Tratamiento , Reino Unido
9.
Br J Community Nurs ; 24(Sup3): S25-S27, 2019 Mar 01.
Artículo en Inglés | MEDLINE | ID: mdl-30817188

RESUMEN

Wound care in primary settings can be complex if patients are discharged early and have comorbidities. With community nurses often working alone, it is imperative that support is available to guide clinical decision making, for example, through both senior or specialist nurses, guidelines, protocols, wound care formularies, care pathways and care plans. Unfortunately some patients try to dictate their care when at home. Community nurses must continue with a professional approach, ensuring care is delivered in a safe and appropriate way. The patient may sometimes seek reassurance when they feel vulnerable; in these scenarios it is essential for the nurse to establish a trusting relationship, offering fully informed explanations of procedures and gaining patient consent. This report describes a gentleman whose whose personal anxieties led him to refuse care.


Asunto(s)
Hospitales Comunitarios/normas , Enfermeros de Salud Comunitaria/normas , Atención de Enfermería/normas , Guías de Práctica Clínica como Asunto , Heridas y Traumatismos/enfermería , Anciano , Humanos , Masculino , Resultado del Tratamiento
10.
Br J Community Nurs ; 24(Sup3): S14-S19, 2019 Mar 01.
Artículo en Inglés | MEDLINE | ID: mdl-30817189

RESUMEN

Diabetic foot ulceration is costly, both in terms of NHS expenditure and quality of life for the patient. This article reviews the guidelines for assessment and management of the diabetic foot ulcer and provides instruction on undertaking vascular and neurological assessments of the diabetic foot. Wound assessment, with an overview of the TEXAS and SINBAD wound classification systems, is also explored, as is the importance of the 1 working day referral for expert assessment for any new diabetic foot ulcer in order to reduce wound complications, length of hospital stay and, ultimately, amputation.


Asunto(s)
Enfermedad Crónica/terapia , Pie Diabético/terapia , Hospitales Comunitarios/normas , Guías de Práctica Clínica como Asunto , Medicina Estatal/normas , Adulto , Anciano , Anciano de 80 o más Años , Prestación de Atención de Salud , Femenino , Humanos , Masculino , Persona de Mediana Edad , Reino Unido
11.
J Am Coll Surg ; 229(2): 158-163, 2019 08.
Artículo en Inglés | MEDLINE | ID: mdl-30880121

RESUMEN

BACKGROUND: We sought to evaluate change in postoperative prescription practices in an independent community-based hospital after hospital interventions and a state legislation change. STUDY DESIGN: This is a retrospective review of opioid-naïve adult subjects who underwent 5 common general surgical procedures between 2015 and 2017, including cholecystectomy, appendectomy, minimally invasive inguinal hernia repair, open inguinal hernia repair, and breast lumpectomy. Educational interventions were introduced, new statewide legislation was passed, and 129 subsequent cases were reviewed. RESULTS: Mean ± SD oral morphine equivalent (OME) prescribed for all procedures on retrospective review was 218.8 ± 113.7 (n = 722), cholecystectomy 235.3 ± 133.8 (n = 248), appendectomy 220.2 ± 103.2 (n = 175), open inguinal hernia repair 214.4 ± 97.2 (n = 119), minimally invasive inguinal hernia repair 187.7 ± 87.8 (n = 117), and lumpectomy 212.5 ± 114.5 (n = 63). There was significant variation in OME prescribed by procedure and by surgeon (p = 0.006 and p = 0.008, respectively). Review of post-intervention cases showed a significant reduction in the OME prescribed each year (mean OME 197.6 in 2015 to 2017 vs 72.3 in 2018; p < 0.005), and a 60% to 70% reduction in mean OME per procedure. Post-intervention data also revealed resolution of previously seen variation in prescription practices, and a significant increase in the percentage of patients prescribed multimodal pain therapy (23.5% in 2015 to 2017 to 31.5% in 2018; p < 0.05). CONCLUSIONS: We achieved a 60% to 70% decrease in postoperative opioid prescription at our community hospital for 5 common surgical procedures, and resolution of variation in opioid prescription practices after a hospital-wide intervention and statewide legislation.


Asunto(s)
Analgésicos Opioides/uso terapéutico , Hospitales Comunitarios/legislación & jurisprudencia , Prescripción Inadecuada/legislación & jurisprudencia , Dolor Postoperatorio/tratamiento farmacológico , Pautas de la Práctica en Medicina/legislación & jurisprudencia , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Hospitales Comunitarios/normas , Humanos , Prescripción Inadecuada/prevención & control , Prescripción Inadecuada/estadística & datos numéricos , Masculino , Michigan , Persona de Mediana Edad , Trastornos Relacionados con Opioides/etiología , Trastornos Relacionados con Opioides/prevención & control , Pautas de la Práctica en Medicina/normas , Pautas de la Práctica en Medicina/estadística & datos numéricos , Estudios Retrospectivos , Adulto Joven
12.
Transfus Apher Sci ; 58(2): 152-155, 2019 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-30639177

RESUMEN

BACKGROUND: Treatment of multiple myeloma with daratumumab (DARA) is increasing fast. Unfortunately, this antibody also attaches to red blood cells (RBCs) and mimics an autoantibody's panreactivity during pre-transfusion testing, necessitating specialized techniques, (e.g. dithiothreitol (DTT)) for alloantibody detection. Many hospitals use a reference lab for such testing, increasing both cost and turn-around time (TAT). Herein, we compare the cost and TAT, pre and post-implementation of an in-house DTT protocol. METHODS: We designed a validation of our in-house DTT protocol from Nov to Dec 2017 with full implementation on January 1, 2018. We retrospectively reviewed all pre-transfusion tests on DARA patients from Feb 2016 to April 2018, pre and post-implementation of in-house DTT testing. Descriptive statistics were used for patient demographics and a Student t-test was used to compare cost and TATs (pre and post-implementation). RESULTS: We identified 49 patients on DARA treatment requiring transfusion. Samples from these patients were sent to the reference lab 104 times and were tested in-house 28 times. The average TAT for the reference lab was 19h25 m compared to our in-house TAT of 5h9m (an average time-savings of 14h16 m). We spent approximately $33,800 ($325 per test) for 104 reference lab samples versus $806.12 (˜$28.79 per test) for in-house testing of 28 samples. CONCLUSION: We provide an easily implementable DTT protocol for pre-transfusion testing community hospitals and beyond. As more monoclonal antibodies are developed and approved for clinical use, the lessons learned with DARA will expand to deal with interference from future targeted therapies.


Asunto(s)
Anticuerpos Monoclonales/uso terapéutico , Ditiotreitol/uso terapéutico , Servicios de Atención de Salud a Domicilio/normas , Hospitales Comunitarios/normas , Centros de Atención Terciaria/normas , Anticuerpos Monoclonales/farmacología , Análisis Costo-Beneficio , Ditiotreitol/farmacología , Femenino , Humanos , Masculino , Reproducibilidad de los Resultados , Estudios Retrospectivos
13.
Perspect Health Inf Manag ; 16(Fall): 1g, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-31908630

RESUMEN

As health information management (HIM) shifts from paper-based medical records to electronic medical documentation, HIM professionals must appropriately manage their resources to produce higher results for their organization's operational and financial indicators. This case study highlights the experience of the HIM department in a small Florida community hospital in analyzing existing productivity standards and developing new standards with the purpose of improving the document imaging process. The research produced new productivity standards that more accurately represent the time HIM technicians spend performing their everyday tasks. The data collected during this period indicate that the average HIM technician was prepping 844 images an hour, scanning 601 images an hour, and indexing 482 images an hour. While a trend in productivity cannot be identified because different types of data were collected, the department's standards are now based on more consistently measurable output. The data collected during this study were used to manage the continuously changing workflow processes; improve the staff's knowledge, skills, and abilities; and identify potential areas of process improvement.


Asunto(s)
Gestión de la Información en Salud/organización & administración , Hospitales Comunitarios/organización & administración , Eficiencia Organizacional , Florida , Gestión de la Información en Salud/normas , Conocimientos, Actitudes y Práctica en Salud , Hospitales Comunitarios/normas , Humanos , Estudios de Casos Organizacionales , Competencia Profesional , Mejoramiento de la Calidad , Flujo de Trabajo
15.
J ECT ; 35(1): 21-26, 2019 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-29668495

RESUMEN

BACKGROUND: The literature provides scant guidance in effective quality assurance strategies concerning the use of electroconvulsive therapy (ECT) for the treatment of psychiatric conditions. Numerous guidelines are published that provide guidance in the delivery of care; however, little has been done to determine how a program or facility might ensure compliance to best practice for safety, tolerability, and efficacy in performing ECT. OBJECTIVE: The objective of this project was to create a quality assurance strategy specific to ECT. Determining standards for quality care and clarifying facility policy were key outcomes in establishing an effective quality assurance strategy. METHODS: An audit tool was developed utilizing quality criteria derived from a systematic review of ECT practice guidelines, peer review, and facility policy. All ECT procedures occurring over a 2-month period of May to June 2017 were retrospectively audited and compared against target compliance rates set for the facility's ECT program. Facility policy was adapted to reflect quality standards, and audit findings were used to inform possible practice change initiatives, were used to create benchmarks for continuous quality monitoring, and were integrated into regular hospital quality meetings. RESULTS: Clarification on standards of care and the use of clinical auditing in ECT was an effective starting point in the development of a quality assurance strategy. Audit findings were successfully integrated into the hospital's overall quality program, and recognition of practice compliance informed areas for future quality development and policy revision in this small community-based hospital in the southeastern United States. CONCLUSIONS: This project sets the foundation for a quality assurance strategy that can be used to help monitor procedural safety and guide future improvement efforts in delivering ECT. Although it is just the first step in creating meaningful quality improvement, setting clear standards and identifying areas of greatest clinical need were crucial beginning for this hospital's growing program.


Asunto(s)
Terapia Electroconvulsiva/normas , Garantía de la Calidad de Atención de Salud/organización & administración , Actitud del Personal de Salud , Lista de Verificación , Adhesión a Directriz , Guías como Asunto , Hospitales Comunitarios/normas , Humanos , Auditoría Médica , Enfermeras y Enfermeros , Seguridad del Paciente , Estudios Retrospectivos , Revisiones Sistemáticas como Asunto
16.
J Perianesth Nurs ; 34(1): 188-197, 2019 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-29921549

RESUMEN

PURPOSE: Enhanced recovery after surgery (ERAS) is an evidence-based practice protocol that has been shown to reduce cost, decrease length of stay (LOS), and improve surgical outcomes. DESIGN: An evidence-based practice improvement project with a multidisciplinary team translated the ERAS protocol into practice at a community hospital. The evidence-based practice improvement design allows integration of evidence into projects to improve clinical outcomes for patients. METHODS: Small tests of change using the Plan-Act-Study-Do methodology were used to evaluate the process of implementing one surgical service at a time to ensure effective outcomes. After the process was determined to be effective, patient outcomes (eg, LOS) were measured. FINDINGS: On average, LOS was decreased from 3.2 to 1.7 days. Surgical readmission rate decreased from 3% to 1%. There has been positive feedback and nursing workload has decreased with consistent processes. CONCLUSIONS: The ERAS order set continues to be modified based on the evidence and feedback from anesthesia and registered nurses. Monthly reports ensure consistency.


Asunto(s)
Recuperación Mejorada Después de la Cirugía/normas , Hospitales Comunitarios/normas , Grupo de Atención al Paciente/organización & administración , Práctica Clínica Basada en la Evidencia , Humanos , Tiempo de Internación
17.
Metas enferm ; 21(9): 57-62, nov. 2018. tab
Artículo en Español | IBECS | ID: ibc-172982

RESUMEN

OBJETIVO: describir el grado de cumplimentación del listado de verific ción de seguridad quirúrgica (LVSQ) en el servicio de quirófano de un hospital comarcal. MÉTODO: estudio descriptivo transversal llevado a cabo en el Hospital Santos Reyes de Aranda de Duero (Burgos) entre mayo de 2015 y mayo de 2016. Se realizó un muestreo aleatorio simple de 750 individuos sometidos a cirugía programada para la revisión de los LVSQ contenidos en sus historias clínicas. Se efectuó un análisis descriptivo con frecuencias absolutas y porcentajes de los ítems del listado categorizados por el momento del procedimiento quirúrgico (antes de la inducción anestésica, antes de la incisión cutánea y antes de la salida de quirófano) y por el profesional responsable de su cumplimentación (enfermera, anestesista y cirujano). RESULTADOS: se estudiaron un total de 604 listados de verificaciónde seguridad quirúrgica. Se observó una mayor cumplimentación del LVSQ en los momentos anteriores a la inducción anestésica y a la incisión cutánea que antes de la salida de quirófano y siempre en aquellos ítems cumplimentados por enfermeras. La cumplimentación de las cuestiones propias de las enfermeras rondó el 88%, fue del 49% en el caso de los ítems propios de los anestesistas y del 46,9% en los asignados a cirujanos. Fue necesario corregir el consentimiento informado en el 4,3% de las intervenciones. CONCLUSIONES: hay diferencias en la cumplimentación del LVSQ en función del momento quirúrgico y del profesional responsable. La formación del personal implicado, así como la implicación de los líderes institucionales, podría jugar un papel para conseguir una mayor adherencia en la cumplimentación


OBJECTIVE: to describe the level of compliance with the Surgical Safety Checklist (SSCL) at the Operating Room in a regional hospital. METHOD: a descriptive cross-sectional study conducted at the Hospital Santos Reyes of Aranda de Duero (Burgos) between May, 2015 and May, 2016. Simple random sampling was conducted on 750 individuals undergoing scheduled surgery, in order to review the SSCLs included in their clinical records. Descriptive analysis was conducted with absolute frequencies and percentages of the list items, classified by time point during the surgical procedure (before anesthetic induction, before skin incision, and before leaving the operating room), and by professional responsible for completion (nurse, anesthetist and surgeon). RESULTS: in total, 604 Surgical Safety Checklists were studied. Higher SSCL compliance was observed a the time point before anesthetic induction and skin incision, than before leaving the operating room, and always in those items completed by nurses. Completion of items by nurses reached about 88%; in the case of anesthetists, it was 49%, and 46.9% in those items assigned to surgeons. It was necessary to correct Informed Consents in 4.3% of interventions. CONCLUSIONS: there are differences in SSCL compliance according to the surgical time and the professional in charge. Training for the staff involved, as well as involvement by institution leaders, could play a role in order to achieve a higher adherence in terms of compliance


Asunto(s)
Hospitales Comunitarios/normas , Administración de la Seguridad/organización & administración , Lista de Verificación/métodos , España , Seguridad del Paciente/normas , Epidemiología Descriptiva , Estudios Transversales , Quirófanos/organización & administración
18.
Jt Comm J Qual Patient Saf ; 44(7): 389-400, 2018 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-30008351

RESUMEN

BACKGROUND: Through an innovative affiliation, Duke University Health System (DUHS), a large and complex academic health system, and LifePoint Health® (LifePoint [LP]) collaborated to create a joint venture, DLP Healthcare (DLP) to measurably improve culture and quality and patient safety metrics in community hospitals across the United States. A structured approach to quality was developed in DLP hospitals and later refined and spread to all LP hospitals through the National Quality Program (NQP). METHODS: The NQP was designed to drive organizationwide performance improvement through use of a framework of leadership, performance improvement, and culture. A comprehensive quality assessment of each DLP and LP hospital led to the creation of a customized improvement plan that was specific to the performance level of individual hospitals and aligned with strategic organizational goals. The improvement process was data driven, managed with defined improvement methodologies and practices, and implemented in a culture that honors teamwork, mutual respect, accountability and provider well-being. RESULTS: Implementation of the NQP has led to significant improvements in patient safety metrics and in safety culture, which have now been sustained for more than seven years. Aggregate harm, as measured by administrative claims data-based harms per 1,000 inpatient-days, was reduced by 62.5% between January 2011 and December 2017, as compared to 2010 baseline data. CONCLUSION: The LP and Duke journey to achieve high reliability in community hospitals has yielded significant improvement in measures of patient safety and culture. The results are consistent with literature supporting the link between culture and overall performance.


Asunto(s)
Hospitales Comunitarios/organización & administración , Cultura Organizacional , Seguridad del Paciente/normas , Mejoramiento de la Calidad/organización & administración , Administración de la Seguridad/organización & administración , Accidentes por Caídas/prevención & control , Benchmarking/métodos , Benchmarking/normas , Hospitales Comunitarios/normas , Humanos , Enfermedad Iatrogénica/prevención & control , Desarrollo de Programa , Evaluación de Programas y Proyectos de Salud , Mejoramiento de la Calidad/normas , Indicadores de Calidad de la Atención de Salud/normas , Administración de la Seguridad/normas , Integración de Sistemas , Estados Unidos
19.
Acad Emerg Med ; 25(12): 1385-1395, 2018 12.
Artículo en Inglés | MEDLINE | ID: mdl-29947453

RESUMEN

BACKGROUND: Approximately 90% of pediatric emergency care is provided in community emergency departments (CEDs) that care for both adults and children. Paradoxically, the majority of pediatric emergency medicine knowledge generation, quality improvement work, and clinical training occurs in children's hospitals. There is a paucity of information of perceptions on pediatric care from CED providers. This information is needed to guide the development of strategies to improve CED pediatric readiness. OBJECTIVE: The objective was to explore interprofessional CED providers' perceptions of caring for pediatric patients. METHODS: A preparticipation survey collected data on demographics, experience, and comfort in caring for children. Emergency pediatric simulations were then utilized to prime interprofessional teams for debriefings. These discussions underwent qualitative analysis by three blinded authors who coded transcripts into themes through an inductive method derived from grounded theory. The other authors participated in confirmability and dependability checks. RESULTS: A total of 171 community hospital providers from six CEDs completed surveys (49% nurses, 22% physicians, 23% technicians). The majority were PALS trained (70%) and experienced fewer than five pediatric resuscitations in their careers (61%). Most self-reported comfort in caring for acutely ill and injured children. From the debriefings, three major challenge themes emerged: 1) knowledge and skill limitations attributed to infrequency of training and actual clinical events, 2) the emotional toll of caring for a sick child, and 3) acknowledgment of pediatric specific quality and safety deficits. Subthemes focused on causes and potential mitigating factors contributing to these challenges. A solution theme highlighted novel partnering opportunities with local children's hospitals. CONCLUSION: Interprofessional CED providers perceive that caring for pediatric patients is challenging due to case infrequency, the emotional toll of caring for sick children, and pediatric quality and safety deficits in their systems. These areas of focus can be used to generate specific strategies for improving CED pediatric readiness.


Asunto(s)
Actitud del Personal de Salud , Competencia Clínica/normas , Servicio de Urgencia en Hospital/normas , Hospitales Comunitarios/normas , Adulto , Niño , Conducta Cooperativa , Servicio de Urgencia en Hospital/estadística & datos numéricos , Femenino , Hospitales Comunitarios/estadística & datos numéricos , Humanos , Masculino , Encuestas y Cuestionarios
20.
Am J Infect Control ; 46(11): 1224-1229, 2018 11.
Artículo en Inglés | MEDLINE | ID: mdl-29934205

RESUMEN

BACKGROUND: Hospital-acquired infections (HAIs) are a significant contributor to adverse patient outcomes and excess cost of inpatient care. Adjunct ultraviolet-C (UV-C) disinfection may be a viable strategy for reducing HAIs. This study aimed to measure the clinical, operational, and financial impact of a UV-C terminal disinfection intervention in a community hospital setting. METHODS: Using a pre-post study design, we compared the HAI rates of 5 multidrug-resistant bacteria (Acinetobacter baumannii, Klebsiella pneumoniae, methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus, and Pseudomonas aeruginosa) from 6 culture sites before and after a 12-month facility-wide UV-C intervention. To measure impact of UV-C disinfection on hospital operations, mean inpatient emergency room wait time was calculated. Finally, we conducted a cost saving analysis to evaluate the financial benefits of the intervention. RESULTS: Overall, 245 HAIs among 13,177 inpatients were observed during a 12-month intervention period, with an incidence rate of 3.94 per 1,000 patient days. This observed HAIs incidence was 19.2% lower than the preintervention period (4.87 vs 3.94 per 1,000 patient days; P = .006). The intervention did not adversely impact emergency department admissions (297.9 vs 296.2 minutes; P = .18) and generated a direct cost savings of $1,219,878 over a 12-month period. CONCLUSIONS: The UV-C disinfection intervention was associated with a statistically significant facility-wide reduction of multidrug-resistant HAIs and generated substantial direct cost savings without adversely impacting hospital operations.


Asunto(s)
Infección Hospitalaria/prevención & control , Desinfección/métodos , Hospitales Comunitarios/normas , Control de Infecciones/métodos , Rayos Ultravioleta , Adulto , Anciano , Anciano de 80 o más Años , Bacterias/efectos de los fármacos , Bacterias/efectos de la radiación , Infección Hospitalaria/epidemiología , Desinfección/economía , Farmacorresistencia Bacteriana Múltiple , Femenino , Hospitales Comunitarios/economía , Humanos , Control de Infecciones/economía , Masculino , Persona de Mediana Edad
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