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2.
BJOG ; 128(3): 584-592, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-33426798

RESUMO

OBJECTIVE: To evaluate the impact of a care bundle (antenatal information to women, manual perineal protection and mediolateral episiotomy when indicated) on obstetric anal sphincter injury (OASI) rates. DESIGN: Multicentre stepped-wedge cluster design. SETTING: Sixteen maternity units located in four regions across England, Scotland and Wales. POPULATION: Women with singleton live births between October 2016 and March 2018. METHODS: Stepwise region by region roll-out every 3 months starting January 2017. The four maternity units in a region started at the same time. Multi-level logistic regression was used to estimate the impact of the care bundle, adjusting for time trend and case-mix factors (age, ethnicity, body mass index, parity, birthweight and mode of birth). MAIN OUTCOME MEASURES: Obstetric anal sphincter injury in singleton live vaginal births. RESULTS: A total of 55 060 singleton live vaginal births were included (79% spontaneous and 21% operative). Median maternal age was 30 years (interquartile range 26-34 years) and 46% of women were primiparous. The OASI rate decreased from 3.3% before to 3.0% after care bundle implementation (adjusted odds ratio 0.80, 95% CI 0.65-0.98, P = 0.03). There was no evidence that the effect of the care bundle differed according to parity (P = 0.77) or mode of birth (P = 0.31). There were no significant changes in caesarean section (P = 0.19) or episiotomy rates (P = 0.16) during the study period. CONCLUSIONS: The implementation of this care bundle reduced OASI rates without affecting caesarean section rates or episiotomy use. These findings demonstrate its potential for reducing perineal trauma during childbirth. TWEETABLE ABSTRACT: OASI Care Bundle reduced severe perineal tear rates without affecting caesarean section rates or episiotomy use.


Assuntos
Parto Obstétrico/normas , Lacerações/epidemiologia , Complicações do Trabalho de Parto/epidemiologia , Melhoria de Qualidade/estatística & dados numéricos , Adulto , Canal Anal/lesões , Cesárea/efeitos adversos , Cesárea/normas , Cesárea/estatística & dados numéricos , Análise por Conglomerados , Parto Obstétrico/efeitos adversos , Parto Obstétrico/estatística & dados numéricos , Inglaterra/epidemiologia , Episiotomia/efeitos adversos , Episiotomia/normas , Episiotomia/estatística & dados numéricos , Feminino , Humanos , Lacerações/prevenção & controle , Modelos Logísticos , Complicações do Trabalho de Parto/prevenção & controle , Períneo/lesões , Gravidez , Projetos de Pesquisa , Fatores de Risco , Escócia/epidemiologia , País de Gales/epidemiologia
3.
Nurs Outlook ; 68(4): 523-527, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32896305

RESUMO

Patients with complex and chronic illnesses and those who have significant needs related to care coordination and transitions of care are dependent on access to healthcare providers who are skilled at meeting the distinct needs of these populations and are current in the latest evidence-based practices and guidelines. Clinical nurse specialists (CNSs) are uniquely qualified to care for patients with complex illnesses as well as having the skills to optimize care for entire populations with complex needs. The absence of consistent legislative advanced practice registered nurse recognition of CNSs prevents health care systems from optimal use of this advanced practice registered nurse role to improve and provide safe and quality care for these patients. Additional barriers in optimal utilization of CNSs include lack of consistency: in title protection and licensing from state to state; ensuring patient access through identification and tracking of CNS numbers across the United States in order to determine workforce and educational program requirements; and ensuring appropriate reimbursement for care provided by CNSs. Therefore, it is the position of the American Academy of Nursing that addressing public and private sector regulatory, legislative, and policy concerns related to CNSs is essential to achieving optimal population health outcomes across the nation.


Assuntos
Guias como Assunto , Enfermeiras Clínicas/estatística & dados numéricos , Enfermeiras Clínicas/normas , Melhoria de Qualidade/estatística & dados numéricos , Melhoria de Qualidade/normas , Qualidade da Assistência à Saúde/estatística & dados numéricos , Qualidade da Assistência à Saúde/normas , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estados Unidos
4.
PLoS One ; 15(8): e0237703, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32797091

RESUMO

BACKGROUND: As part of a partnership between the Institute for Healthcare Improvement and the Ethiopian Federal Ministry of Health, woreda-based quality improvement collaboratives took place between November 2016 and December 2017 aiming to accelerate reduction of maternal and neonatal mortality in Lemu Bilbilu, Tanqua Abergele and Duguna Fango woredas. Before starting the collaboratives, assessments found inaccuracies in core measures obtained from Health Management Information System reports. METHODS AND RESULTS: Building on the quality improvement collaborative design, data quality improvement activities were added and we used the World Health Organization review methodology to drive a verification factor for the core measures of number of pregnant women that received their first antenatal care visit, number of pregnant women that received antenatal care on at least four visits, number of pregnant women tested for syphilis and number of births attended by skilled health personnel. Impact of the data quality improvement was assessed using interrupted time series analysis. We found accurate data across all time periods for Tanqua Abergele. In Lemu Bilbilu and Duguna Fango, data quality improved for all core metrics over time. In Duguna Fango, the verification factor for number of pregnant women that received their first antenatal care visit improved from 0.794 (95%CI 0.753, 0.836; p<0.001) pre-intervention by 0.173 (95%CI 0.128, 0.219; p<0.001) during the collaborative; and the verification factor for number of pregnant women tested for syphilis improved from 0.472 (95%CI 0.390, 0.554; p<0.001) pre-intervention by 0.460 (95%CI 0.369, 0.552; p<0.001) during the collaborative. In Lemu Bilbilu, the verification factor for number of pregnant women receiving a fourth antenatal visit rose from 0.589 (95%CI 0.513, 0.664; p<0.001) at baseline by 0.358 (95%CI 0.258, 0.458; p<0.001) post-intervention; and skilled birth attendance rose from 0.917 (95%CI 0.869, 0.965) at baseline by 0.083 (95%CI 0.030, 0.136; p<0.001) during the collaborative. CONCLUSIONS: A Data quality improvement initiative embedded within woreda clinical improvement collaborative improved accuracy of data used to monitor maternal and newborn health services in Ethiopia.


Assuntos
Sistemas de Informação Administrativa , Serviços de Saúde Materna , Cuidado Pré-Natal , Melhoria de Qualidade , Confiabilidade dos Dados , Etiópia , Feminino , Humanos , Recém-Nascido , Análise de Séries Temporais Interrompida/estatística & dados numéricos , Sistemas de Informação Administrativa/estatística & dados numéricos , Serviços de Saúde Materna/estatística & dados numéricos , Gravidez , Cuidado Pré-Natal/estatística & dados numéricos , Melhoria de Qualidade/estatística & dados numéricos , Organização Mundial da Saúde
5.
Public Health Rep ; 135(4): 442-451, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32639897

RESUMO

OBJECTIVES: Coordinated measurement strategies are needed to inform collaborative approaches to improve access to and quality of care for persons with sickle cell disease (SCD). The objective of our study was to develop a multilevel measurement strategy to assess improvements in access to and quality of care for persons with SCD in 4 US regions. METHODS: From 2014 through 2017, regional grantees in the Sickle Cell Disease Treatment Demonstration Program collected administrative and patient-level electronic health record (EHR) data to assess quality improvement initiatives. Four grantees-covering 29 US states and territories and an SCD population of 56 720-used a collective impact model to organize their work. The grantees collected administrative data from state Medicaid and Medicaid managed care organizations (MCOs) at multiple points during 2014-2017 to assess improvements at the population level, and local patient-level data were abstracted from site-level EHRs at regular intervals to track improvements over time. RESULTS: Administrative data were an important source of understanding population-level improvements but were delayed, whereas patient-level data were more sensitive to small-scale quality improvements. CONCLUSIONS: We established a shared measurement approach in partnership with Medicaid and Medicaid MCO stakeholders that can be leveraged to effectively support quality improvement initiatives for persons with SCD in the United States.


Assuntos
Anemia Falciforme/terapia , Assistência à Saúde/estatística & dados numéricos , Assistência à Saúde/normas , Guias de Prática Clínica como Assunto , Melhoria de Qualidade/estatística & dados numéricos , Melhoria de Qualidade/normas , Humanos , Estados Unidos/epidemiologia
6.
J Hosp Infect ; 105(4): 710-716, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32553893

RESUMO

The rapid growth of the coronavirus disease 2019 (COVID-19) pandemic, limited availability of personal protective equipment, and uncertainties regarding transmission modes of severe acute respiratory syndrome coronavirus-2 have heightened concerns for the safety of healthcare workers (HCWs). Systematic studies of occupational risks for COVID-19 in the context of community risks are difficult and have only recently started to be reported. Ongoing quality improvement studies in various locales and within many affected healthcare institutions are needed. A template design for small-scale quality improvement surveys is proposed. Such surveys have the potential for rapid implementation and completion, are cost-effective, impose little administrative or workforce burden, can reveal occupational risks while taking community risks into account, and can be repeated easily with short time intervals between repetitions. This article describes a template design and proposes a survey instrument that is easily modifiable to fit the particular needs of various healthcare institutions in the hope of beginning a collaborative effort to refine the design and instrument. These methods, along with data management and analytic techniques, can be widely useful and shared globally. The authors' goal is to facilitate quality improvement surveys aimed at reducing the risk of occupational infection of HCWs during the COVID-19 pandemic.


Assuntos
Infecções por Coronavirus/diagnóstico , Diagnóstico Precoce , Guias como Assunto , Pessoal de Saúde/estatística & dados numéricos , Transmissão de Doença Infecciosa do Paciente para o Profissional/prevenção & controle , Equipamento de Proteção Individual/normas , Pneumonia Viral/diagnóstico , Melhoria de Qualidade/normas , Adulto , Betacoronavirus , Feminino , Humanos , Transmissão de Doença Infecciosa do Paciente para o Profissional/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Pandemias , Equipamento de Proteção Individual/estatística & dados numéricos , Melhoria de Qualidade/estatística & dados numéricos , Fatores de Risco , Inquéritos e Questionários , Estados Unidos
7.
Br J Anaesth ; 125(1): e119-e129, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32493580

RESUMO

BACKGROUND: Inconsistent and poorly coordinated systems of tracheostomy care commonly result in frustrations, delays, and harm. Quality improvement strategies described by exemplar hospitals of the Global Tracheostomy Collaborative have potential to mitigate such problems. This 3 yr guided implementation programme investigated interventions designed to improve the quality and safety of tracheostomy care. METHODS: The programme management team guided the implementation of 18 interventions over three phases (baseline/implementation/evaluation). Mixed-methods interviews, focus groups, and Hospital Anxiety and Depression Scale questionnaires defined outcome measures, with patient-level databases tracking and benchmarking process metrics. Appreciative inquiry, interviews, and Normalisation Measure Development questionnaires explored change barriers and enablers. RESULTS: All sites implemented at least 16/18 interventions, with the magnitude of some improvements linked to staff engagement (1536 questionnaires from 1019 staff), and 2405 admissions (1868 ICU/high-dependency unit; 7.3% children) were prospectively captured. Median stay was 50 hospital days, 23 ICU days, and 28 tracheostomy days. Incident severity score reduced significantly (n=606; P<0.01). There were significant reductions in ICU (-;0.25 days month-1), ventilator (-;0.11 days month-1), tracheostomy (-;0.35 days month-1), and hospital (-;0.78 days month-1) days (all P<0.01). Time to first vocalisation and first oral intake both decreased by 7 days (n=733; P<0.01). Anxiety decreased by 44% (from 35.9% to 20.0%), and depression decreased by 55% (from 38.7% to 18.3%) (n=385; both P<0.01). Independent economic analysis demonstrated £33 251 savings per patient, with projected annual UK National Health Service savings of £275 million. CONCLUSIONS: This guided improvement programme for tracheostomy patients significantly improved the quality and safety of care, contributing rich qualitative improvement data. Patient-centred outcomes were improved along with significant efficiency and cost savings across diverse UK hospitals. CLINICAL TRIAL REGISTRATION: IRAS-ID-206955; REC-Ref-16/LO/1196; NIHR Portfolio CPMS ID 31544.


Assuntos
Avaliação de Programas e Projetos de Saúde/métodos , Melhoria de Qualidade/estatística & dados numéricos , Traqueostomia/métodos , Traqueostomia/normas , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Feminino , Hospitais , Humanos , Lactente , Masculino , Pessoa de Meia-Idade , Inquéritos e Questionários , Reino Unido , Adulto Jovem
8.
Rev Esp Salud Publica ; 942020 May 05.
Artigo em Espanhol | MEDLINE | ID: mdl-32382000

RESUMO

OBJECTIVE: Terminal patients and their relatives must know their real situation, and be treated according to the principle of autonomy, to establish therapeutic objectives adapted each one, according to their needs and decisions. The objective of this study is to identify the sufficient existence of records in the Medical Histories of terminal patients, which indicate their situation, such as the information given to the patients, or the LET, No-RCP or Z.51.5 codes, and the statistical relation they have with the sociodemographic and clinical variables. METHODS: Cross-sectional study in a third-level hospital, with patients admitted between January and December 2017, who died with terminal illness criteria. Data were collected from the medical records, and, fundamentally, from the nursing clinical notes. The statistical analysis was performed with the SPSS program, version 22. RESULTS: Participants were 140 people, 54.3% men, of 78.51 (SD=13.5) of middle age. People up to 70 years of age received less information (Odds ratio (OR): 0.077, 95% Confidence interval (CI): 0.015-0.390) and lower sedation (OR: 0.366, 95% CI: 0.149-0.899). Proceeding from city reduced the probability of receiving information (OR: 0.202; IC95%: 0.058-0.705). Presenting dyspnea reduced LTE (OR: 0.44, 95% CI: 0.20-093), No CPR (0.29, 95% CI: 0.12-0.68) and sedation (OR: 0.27; 95% CI: 0.12-060). Fatigue increased the probability of being Non-CPR (OR: 2.77, 95% CI: 1.166-6.627) and of receiving sedation (OR: 2.6, 95% CI: 1.065-6.331). CONCLUSIONS: Efforts to empower the patient in the decision of their process and the management of the information of their diagnosis and prognosis are still lacking. A greater and better clinical records facilitates knowing how actions are developed, allowing to identify and implement ethical and responsible interventions.


Assuntos
Diretivas Antecipadas/ética , Registros Médicos , Participação do Paciente , Autonomia Pessoal , Melhoria de Qualidade/ética , Assistência Terminal/ética , Centros de Atenção Terciária/ética , Adulto , Diretivas Antecipadas/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Tomada de Decisões/ética , Feminino , Hospitalização , Humanos , Consentimento Livre e Esclarecido/ética , Consentimento Livre e Esclarecido/normas , Consentimento Livre e Esclarecido/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Participação do Paciente/métodos , Participação do Paciente/estatística & dados numéricos , Melhoria de Qualidade/estatística & dados numéricos , Estudos Retrospectivos , Espanha , Assistência Terminal/normas , Assistência Terminal/estatística & dados numéricos , Centros de Atenção Terciária/normas , Centros de Atenção Terciária/estatística & dados numéricos
9.
Int J Pediatr Otorhinolaryngol ; 134: 110025, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32304856

RESUMO

OBJECTIVE: Value-based care models are becoming instrumental in structuring clinical care delivery in our healthcare climate. Our objective was to determine the value associated with implementation of a Family-Centered Care Coordination (FCCC) program for neonates undergoing tracheostomy. METHODS: A multi-disciplinary FCCC program was implemented at the Massachusetts Eye and Ear Infirmary and MassGeneral Hospital for Children in January 2013. This program is designed to ensure a safe transition out of the hospital for children undergoing tracheostomy, reduce re-admission rates, and increase caregiver quality of life (QOL). Study participants included neonates undergoing tracheostomy in 2012 and 2015. This retrospective cohort study examined length of stay (LOS), utilized time-driven activity-based costing to estimate the cost of care, assessed caregiver QOL with 1-month Pediatric Tracheostomy Health Status Instrument (PTHSI) scores, and assessed complications with 6-month Medical Complications Associated with Pediatric Tracheostomy (MCAT) scores. RESULTS: Following implementation of the FCCC program, average LOS decreased from 30.5 days (range 17-39) to 16.6 days (range 9-23). The largest process improvement (cost reduction of 61%) occurred in the discharge-planning phase. The overall cost per care cycle was reduced by 36%. A large clinically meaningful benefit was demonstrated for PTHSI (effect size 0.80) as well as MCAT scores (effect size 9.35). CONCLUSIONS: We demonstrated the higher outcomes, including reductions in caregiver burden and complication rates, and the lower costs associated with implementation of the FCCC program for neonates undergoing tracheostomy.


Assuntos
Continuidade da Assistência ao Paciente/organização & administração , Custos de Cuidados de Saúde/estatística & dados numéricos , Assistência Centrada no Paciente/organização & administração , Traqueostomia , Adaptação Psicológica , Cuidadores/psicologia , Continuidade da Assistência ao Paciente/estatística & dados numéricos , Análise Custo-Benefício , Feminino , Nível de Saúde , Humanos , Recém-Nascido , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Masculino , Massachusetts , Alta do Paciente/economia , Alta do Paciente/estatística & dados numéricos , Assistência Centrada no Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/prevenção & controle , Melhoria de Qualidade/organização & administração , Melhoria de Qualidade/estatística & dados numéricos , Qualidade de Vida/psicologia , Estudos Retrospectivos , Traqueostomia/educação , Traqueostomia/psicologia
10.
Healthc Q ; 23(1): 53-59, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32249740

RESUMO

Over the past 15 years, Cancer Care Ontario has used a robust performance management approach to drive improvements in care. Each year, priority indicators and targets are selected or retained, and performance is reviewed quarterly with each of Ontario's Regional Cancer Programs. Improvement support and encouragement are provided, such as data analysis, program ranking, communities of practice, consultations, action plan requests and certificates. This article analyzes data on 28 indicators prioritized over these years and demonstrates that 25 have shown sustained improvement over time. The performance management approach, lessons learned and gaps in knowledge are described to inform future research and practice.


Assuntos
Neoplasias/diagnóstico , Neoplasias/terapia , Garantia da Qualidade dos Cuidados de Saúde/estatística & dados numéricos , Melhoria de Qualidade/estatística & dados numéricos , Humanos , Ontário , Garantia da Qualidade dos Cuidados de Saúde/métodos , Garantia da Qualidade dos Cuidados de Saúde/normas
11.
J Grad Med Educ ; 12(1): 80-85, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-32089797

RESUMO

Background: In 2014, the Accreditation Council for Graduate Medical Education (ACGME) formally mandated trainee (resident and fellow) participation in health care quality improvement (QI) projects as one of the Clinical Learning Environment Review (CLER) Pathways to Excellence. Subsequent national reviews showed large variations in how QI education is conducted, as well as a significant mismatch between educational and organizational goals. Objective: We developed a web-based platform to engage trainees in QI that better aligned with best practice methodology and matched identified institutional priorities. Methods: A needs assessment survey was distributed to trainees to understand the obstacles to compliance with ACGME QI requirements. Based on the results, a web-based clearinghouse, called the QI Platform, was developed and launched in July 2016, and utilization was analyzed in February 2019. Results: A total of 196 of 440 needs assessment surveys (45%) were completed. Themes extracted from surveys to identify barriers in QI participation included difficulties designing projects, lack of mentorship or expert support, and difficulty engaging an interprofessional team. Over 2.5 years, 151 projects were registered on the platform. Of these, 17 (11%) were collaborative entries. At the time of analysis, 166 of 437 trainees (38%) were listed as participants in active QI projects. A total of 22 projects were archived as complete, and 68 incomplete projects were reassigned to the "Ideas" section as works in progress after lead trainee graduation. Conclusions: An institutional QI Platform clearinghouse for GME QI projects was feasible to develop and maintain, and it appeared acceptable to most GME programs and trainees for recording and tracking QI projects, and linking these to hospital QI priorities.


Assuntos
Educação de Pós-Graduação em Medicina/estatística & dados numéricos , Internato e Residência/estatística & dados numéricos , Melhoria de Qualidade/estatística & dados numéricos , Acreditação , Educação de Pós-Graduação em Medicina/métodos , Humanos , Internet , Informática Médica , Determinação de Necessidades de Cuidados de Saúde , Avaliação de Programas e Projetos de Saúde , Sociedades Médicas , Inquéritos e Questionários
12.
Acta Diabetol ; 57(7): 827-834, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32086612

RESUMO

AIMS: Our aim was to explore optimal treatment decisions for HbA1c control for type 2 diabetes mellitus patients and assess the impact on potential improvements in quality of life compared with current guidelines. METHODS: We analyzed a large dataset of HbA1c levels, diabetes-related key risk factors and medication dispensed to 70,069 patients with type 2 diabetes from polyclinics and a large public hospital in Singapore during January 1, 2008, to December 31, 2015. A Markov decision process (MDP) model was developed to determine the optimal treatment policy concerning medication management for glycemic control over a long-term treatment period. We assessed the model performance by comparing quality-adjusted life years (QALYs) gained by the model with those derived by a conventional Markov model informed by current clinical guidelines. RESULTS: Numerical results showed that optimal treatment strategies derived by the MDP model could increase the total expected QALYs by as much as 0.27 years for patients at higher risk such as old age, high HbA1c levels and smokers. In particular, the improvements in QALYs gained for patients with HbA1c levels of 9% (75 mmol/mol) and above were higher than those with lower HbA1c levels. However, the potential improvements appeared to be marginal for patients at lower risk compared with current guidelines. CONCLUSIONS: Use of data-driven prescriptive analytics would help clinicians make evidence-based treatment decisions for HbA1c control for patients with type 2 diabetes, in particular for those at high risk.


Assuntos
Glicemia/metabolismo , Diabetes Mellitus Tipo 2/sangue , Diabetes Mellitus Tipo 2/terapia , Hemoglobina A Glicada/metabolismo , Cadeias de Markov , Melhoria de Qualidade , Adulto , Idoso , Estudos de Coortes , Tomada de Decisões/fisiologia , Diabetes Mellitus Tipo 2/tratamento farmacológico , Diabetes Mellitus Tipo 2/epidemiologia , Feminino , Hemoglobina A Glicada/análise , Humanos , Masculino , Adesão à Medicação/estatística & dados numéricos , Pessoa de Meia-Idade , Melhoria de Qualidade/normas , Melhoria de Qualidade/estatística & dados numéricos , Qualidade de Vida , Anos de Vida Ajustados por Qualidade de Vida , Estudos Retrospectivos , Singapura/epidemiologia
13.
G Ital Nefrol ; 37(1)2020 Feb 12.
Artigo em Italiano | MEDLINE | ID: mdl-32068362

RESUMO

In 2011, a first peritoneal dialysis audit was held in the Lazio region to analyze the problems hindering the spread of this method and to improve the quality of care through the sharing of best practices across Centers. A scientific board was therefore set up, representing all the Centers offering PD, in order to assess clinical effectiveness using KPIs (Key Performance Indicators) and to quantify the objectives to be achieved. The analysis made it possible to identify the main problems and take action, all the while monitoring progress through KPIs. A second audit was carried out in 2017 and the collected data was analyzed and compared with the findings of the previous study. Overall, data showed an increase in prevalence, although the incidence showed a slight decrease. Indicators on the change of dialysis treatment, the dropout from domiciliary treatment and the incidence of late referral appeared stable over time. A slight improvement was observed in clinical data on peritonitis and on the length of hospitalization. All participants in the audit declared that sharing and discussing clinical practices had been really useful. In addition, through the drafting of practical documents (guides for patients, guidance on informed consent, protocols of clinical follow-up), a number of tools have been provided to ensure a uniformly high level of care across the different regional Centers.


Assuntos
Comitês Consultivos/organização & administração , Benchmarking , Auditoria Médica , Diálise Peritoneal/estatística & dados numéricos , Melhoria de Qualidade/estatística & dados numéricos , Hemodiálise no Domicílio/estatística & dados numéricos , Humanos , Itália , Falência Renal Crônica/terapia , Tempo de Internação , Auditoria Médica/métodos , Pacientes Desistentes do Tratamento/estatística & dados numéricos , Diálise Peritoneal/efeitos adversos , Diálise Peritoneal/normas , Diálise Peritoneal Ambulatorial Contínua/estatística & dados numéricos , Peritonite/epidemiologia , Melhoria de Qualidade/normas , Encaminhamento e Consulta , Resultado do Tratamento
14.
BMJ Open Qual ; 9(1)2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-32024672

RESUMO

INTRODUCTION: A zoning system is used to ensure that service users receive appropriate levels of support while they are using community mental health team (CMHT) services. Patients are split into red, amber and green zones and are discussed in a daily morning meeting to ensure management plans are in place. We identified that the meeting was an area for improvement as initial feedback indicated that the meeting was repetitive, newcomers to the team found that they did not understand why patients were in different zones and discussions were not being documented. Our three aims for the project were to improve staff-rated satisfaction by 25%, to improve weekly documentation of discussions to 100% and to improve the quality of information handed over by 25% over 4 months. METHODS: We used the Model for Improvement and "plan, do, study, act" (PDSA) cycles to test change ideas such as having someone chair the meeting, use of a 'situation, background, assessment, recommendation, decision' (SBARD) format to handover, introduction of a blue zone for inpatients and documentation in a specific part of the electronic notes at a specific time. RESULTS: We did not find our PDSA cycles led to a consistent change in satisfaction, quality and efficiency. We found an improvement of SBARD use up to 100% although this was not always consistent and an improvement in documentation to 100% for 3 weeks however this was not sustained. CONCLUSION: On examining barriers to change, we found the key to sustaining improvement is in ensuring multidisciplinary team member involvement at all stages of the Quality Improvement project.


Assuntos
Serviços Comunitários de Saúde Mental/métodos , Equipe de Assistência ao Paciente/normas , Melhoria de Qualidade/organização & administração , Serviços Comunitários de Saúde Mental/normas , Serviços Comunitários de Saúde Mental/tendências , Humanos , Equipe de Assistência ao Paciente/estatística & dados numéricos , Avaliação de Processos em Cuidados de Saúde/métodos , Melhoria de Qualidade/estatística & dados numéricos
15.
Emerg Med J ; 37(4): 193-199, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31915264

RESUMO

OBJECTIVE: We developed a discrete event simulation model to evaluate the impact on system flow of a quality improvement (QI) initiative that included a time-specific protocol to decrease the time to antibiotic delivery for children with cancer and central venous catheters who present to a paediatric ED with fever. METHODS: The model was based on prospective observations and retrospective review of ED processes during the maintenance phase of the QI initiative between January 2016 and June 2017 in a large, urban, academic children's hospital in New York City, USA. We compared waiting time for full evaluation (WT) and length of stay (LOS) between a model with and a model without the protocol. We then gradually increased the proportion of patients receiving the protocol in the model and recorded changes in WT and LOS. RESULTS: We validated model outputs against administrative data from 2016, with no statistically significant differences in average WT or LOS for any emergency severity index (ESI). There were no statistically significant differences in these flow metrics between the model with and the model without the protocol. By increasing the proportion of total patients receiving this protocol, from 0.2% to 1.3%, the WT increased by 2.8 min (95% CI: 0.6 to 5.0) and 7.6 min (95% CI: 2.0 to 13.2) for ESI 2 and ESI 3 patients, respectively. This represents a 14.0% increase in WT for ESI 3 patients. CONCLUSIONS: Simulation modelling facilitated the testing of system effects for a time-specific protocol implemented in a large, urban, academic paediatric ED, showing no significant impact on patient flow. The model suggests system resilience, demonstrating no detrimental effect on WT until there is a 7-fold increase in the proportion of patients receiving the protocol.


Assuntos
Simulação por Computador/normas , Eficiência Organizacional/normas , Tempo de Internação/estatística & dados numéricos , Melhoria de Qualidade/estatística & dados numéricos , Simulação por Computador/estatística & dados numéricos , Aglomeração , Eficiência Organizacional/estatística & dados numéricos , Serviço Hospitalar de Emergência/organização & administração , Serviço Hospitalar de Emergência/estatística & dados numéricos , Humanos , Modelos Organizacionais , Cidade de Nova Iorque , Medicina de Emergência Pediátrica/métodos , Estudos Prospectivos , Estudos Retrospectivos
17.
Aust J Rural Health ; 28(1): 60-66, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31970843

RESUMO

PROBLEM: In the Katherine region, Northern Territory, barriers to eye care for Aboriginal and Torres Strait Islander people include unclear eye care referral processes, challenges coordinating patient eye care between various providers, complex socioeconomic determinants and a lengthy outpatient ophthalmology waiting list. DESIGN: Mixed methods participatory approach using a regional needs analysis, clinical file audit and stakeholder survey, to develop, implement and monitor quality improvement strategies. SETTING: Collaboration with Aboriginal Community Controlled Health Services and regional eye care stakeholders in the Katherine region. KEY MEASURES FOR IMPROVEMENT: Clinical audit data captured frequency and rates of primary eye checks, ophthalmology referrals and spectacle prescriptions. A survey was developed and applied to assess stakeholder perspectives of regional eye care systems. STRATEGY FOR CHANGE: Quality improvement strategies informed by regional data (clinical audits and survey) included increasing service delivery to match eye care needs, primary eye care training for Aboriginal Community Controlled Health Services staff, updating Aboriginal Community Controlled Health Services primary care templates and forming a regional eye care coalition group. EFFECTS OF CHANGE: Post-implementation, rates and frequency of recorded optometry examinations, number of spectacles prescribed and rates of annual dilated fundus examinations for patients with diabetes increased. There was a decrease in the number of patients with diabetes who had never had an eye examination. Eye care stakeholders perceived a marked improvement in the effectiveness of the regional eye care system. LESSONS LEARNT: Our findings highlight the importance of engaging services and stakeholders to ensure a systems approach that is evidence-informed, contextually appropriate and reflects commitment to improved eye health outcomes.


Assuntos
Serviços de Saúde Comunitária/organização & administração , Promoção da Saúde/métodos , Serviços de Saúde do Indígena/organização & administração , Grupo com Ancestrais Oceânicos/educação , Grupo com Ancestrais Oceânicos/estatística & dados numéricos , Optometria/educação , Melhoria de Qualidade/organização & administração , Adulto , Idoso , Idoso de 80 Anos ou mais , Serviços de Saúde Comunitária/estatística & dados numéricos , Feminino , Serviços de Saúde do Indígena/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Northern Territory , Melhoria de Qualidade/estatística & dados numéricos , Inquéritos e Questionários
18.
J Acad Nutr Diet ; 120(3): 363-370, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31948795

RESUMO

BACKGROUND: Implementation of updated nutrition standards for school meals began during school year (SY) 2012-2013. The standards were designed to improve the nutritional quality of the meals and their consistency with the Dietary Guidelines for Americans. OBJECTIVE: To assess the nutritional quality of school lunches and breakfasts after the updated standards were in place and compare it with the nutritional quality of the meals before the updated standards. DESIGN: School menu data were used from two cross-sectional, nationally representative studies of schools participating in the National School Lunch Program during SY 2014-2015 (School Nutrition and Meal Cost Study) and SY 2009-2010 (fourth School Nutrition Dietary Assessment Study). PARTICIPANTS/SETTING: The analysis used 1 week of school menu data from 1,206 schools at lunch and 1,110 schools at breakfast for SY 2014-2015, and 884 schools at lunch and 802 schools at breakfast for SY 2009-2010. OUTCOME MEASURES: Healthy Eating Index 2010 scores were estimated. STATISTICAL ANALYSES: Descriptive analyses were conducted to estimate mean Healthy Eating Index 2010 total and component scores for school meals. Scores are expressed as a percentage of maximum possible scores. Two-tailed t tests were used to assess differences in scores before and after updated standards were in place. RESULTS: Total Healthy Eating Index 2010 scores for school lunches and breakfasts increased significantly after the updated standards. Between SY 2009-2010 and SY 2014-2015, the total score for school lunches increased from 58% of the maximum score to 82%, and the total score for school breakfasts increased from 50% to 71% (P<0.05). For both meals, component scores increased by more than 20 percentage points for whole grains, refined grains, and empty calories, as well as for greens and beans for lunches and whole fruit and sodium for breakfasts. CONCLUSIONS: The updated nutrition standards for schools meals significantly improved the nutritional quality of the meals and their consistency with the Dietary Guidelines for Americans.


Assuntos
Dieta Saudável/estatística & dados numéricos , Serviços de Alimentação/estatística & dados numéricos , Valor Nutritivo , Melhoria de Qualidade/estatística & dados numéricos , Serviços de Saúde Escolar/estatística & dados numéricos , Desjejum , Criança , Estudos Transversais , Dieta Saudável/normas , Feminino , Serviços de Alimentação/normas , Implementação de Plano de Saúde , Humanos , Almoço , Masculino , Planejamento de Cardápio/normas , Política Nutricional , Avaliação de Programas e Projetos de Saúde , Serviços de Saúde Escolar/normas , Estados Unidos
19.
J Trauma Nurs ; 27(1): 29-36, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31895316

RESUMO

Traumatic injury survivors often face a difficult recovery. Surgical and invasive procedures, prolonged monitoring in the intensive care unit (ICU), and constant preventive vigilance by medical staff guide standards of care to promote positive outcomes. Recently, patients with traumatic injuries have benefited from early mobilization, a multidisciplinary approach to increasing participation in upright activity and walking. The purpose of this project was to determine the impact of an early mobility program in the trauma ICU on length of stay (LOS), ventilator days, cost, functional milestones, and rehabilitation utilization. A quality improvement project compared outcomes and cost before and after the implementation of an early mobility program. The trauma team assigned daily mobility levels to trauma ICU patients. Nursing and rehabilitation staff collaborated to set daily goals and provide mobility-based interventions. Forty-four patients were included in the preintervention group and 43 patients in the early mobility group. Physical therapy and occupational therapy were initiated earlier in the early mobilization group (p = .044 and p = .026, respectively). Improvements in LOS, duration of mechanical ventilation, time to out-of-bed activity and walking, and discharge disposition were not significant. There were no adverse events related to the early mobility initiative. Activity intolerance resulted in termination of 7.1% of mobility sessions. The development and initiation of a trauma-specific early mobility program proved to be safe and reduce patient care costs. In addition, the program facilitated earlier initiation of physician and occupational therapies. Although not statistically significant, retrospective data abstraction provides evidence of fewer ICU and total hospital days, earlier extubations, and greater proactive participation in functional activities.


Assuntos
Deambulação Precoce/economia , Deambulação Precoce/enfermagem , Unidades de Terapia Intensiva/economia , Melhoria de Qualidade/economia , Centros de Traumatologia/economia , Ferimentos e Lesões/economia , Ferimentos e Lesões/enfermagem , Adulto , Idoso , Currículo , Deambulação Precoce/estatística & dados numéricos , Educação Médica Continuada/organização & administração , Feminino , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Melhoria de Qualidade/estatística & dados numéricos , Centros de Traumatologia/estatística & dados numéricos
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