Quality and Safety in Health Care Journal

Leveraging big data to guide better nurse staffing strategies

Over the past 20 years, a large body of research has documented a relationship between higher nurse-to-patient staffing ratios and better patient outcomes, including shorter hospital stays, lower rates of failure to prevent mortality after an in-hospital complication, inpatient mortality for multiple types of patients, hospital-acquired pneumonia, unplanned extubation, respiratory failure and cardiac arrest.1–5 In addition, patients report higher satisfaction when they are cared for in hospitals with higher staffing levels.6 7

To date, most studies have not identified an ‘optimal’ nurse staffing ratio,8 which creates a challenge for determining appropriate staffing levels. If increasing nurse staffing always produces at least some improvement in the quality of care, how does one determine what staffing level is best? This decision is ultimately an economic one, balancing the benefits of nurse staffing with the other...

Simulation: a key tool for refining guidelines and demonstrating they produce the desired behavioural change

Guidelines aim to align clinical care with best practice. However, simply publishing a guideline rarely triggers behavioural changes to match guideline recommendations.1–3 We thus transform guideline recommendations into actionable tasks by introducing interventions that promote behavioural changes meant to produce guideline-concordant care. Unfortunately, not much has changed in the 25 years since Oxman and colleagues concluded that we have no ‘magic bullets’ when it comes to changing clinician behaviour.4 In fact, far from magic bullets, interventions aimed at increasing the degree to which patients receive care recommended in guidelines (eg, educational interventions, reminders, audit and feedback, financial incentives, computerised decision support) typically produce disappointingly small improvements in care.5–10

Much improvement work aims to ‘make the right thing to do the easy thing to do.’ Yet, design solutions which hardwire...

Costs and consequences of using average demand to plan baseline nurse staffing levels: a computer simulation study

Background

Planning numbers of nursing staff allocated to each hospital ward (the ‘staffing establishment’) is challenging because both demand for and supply of staff vary. Having low numbers of registered nurses working on a shift is associated with worse quality of care and adverse patient outcomes, including higher risk of patient safety incidents. Most nurse staffing tools recommend setting staffing levels at the average needed but modelling studies suggest that this may not lead to optimal levels.

Objective

Using computer simulation to estimate the costs and understaffing/overstaffing rates delivered/caused by different approaches to setting staffing establishments.

Methods

We used patient and roster data from 81 inpatient wards in four English hospital Trusts to develop a simulation of nurse staffing. Outcome measures were understaffed/overstaffed patient shifts and the cost per patient-day. We compared staffing establishments based on average demand with higher and lower baseline levels, using an evidence-based tool to assess daily demand and to guide flexible staff redeployments and temporary staffing hires to make up any shortfalls.

Results

When baseline staffing was set to meet the average demand, 32% of patient shifts were understaffed by more than 15% after redeployment and hiring from a limited pool of temporary staff. Higher baseline staffing reduced understaffing rates to 21% of patient shifts. Flexible staffing reduced both overstaffing and understaffing but when used with low staffing establishments, the risk of critical understaffing was high, unless temporary staff were unlimited, which was associated with high costs.

Conclusion

While it is common practice to base staffing establishments on average demand, our results suggest that this may lead to more understaffing than setting establishments at higher levels. Flexible staffing, while an important adjunct to the baseline staffing, was most effective at avoiding understaffing when high numbers of permanent staff were employed. Low staffing establishments with flexible staffing saved money because shifts were unfilled rather than due to efficiencies. Thus, employing low numbers of permanent staff (and relying on temporary staff and redeployments) risks quality of care and patient safety.

User-testing guidelines to improve the safety of intravenous medicines administration: a randomised in situ simulation study

Background

User-testing and subsequent modification of clinical guidelines increases health professionals’ information retrieval and comprehension. No study has investigated whether this results in safer care.

Objective

To compare the frequency of medication errors when administering an intravenous medicine using the current National Health Service Injectable Medicines Guide (IMG) versus an IMG version revised with user-testing.

Method

Single-blind, randomised parallel group in situ simulation. Participants were on-duty nurses/midwives who regularly prepared intravenous medicines. Using a training manikin in their clinical area, participants administered a voriconazole infusion, a high-risk medicine requiring several steps to prepare. They were randomised to use current IMG guidelines or IMG guidelines revised with user-testing. Direct observation was used to time the simulation and identify errors. Participant confidence was measured using a validated instrument. The primary outcome was the percentage of simulations with at least one moderate-severe IMG-related error, with error severity classified by an expert panel.

Results

In total, 133 participants were randomised to current guidelines and 140 to user-tested guidelines. Fewer moderate-severe IMG-related errors occurred with the user-tested guidelines (n=68, 49%) compared with current guidelines (n=79, 59%), but this difference was not statistically significant (risk ratio: 0.82; 95% CI 0.66 to 1.02). Significantly more simulations were completed without any IMG-related errors with the user-tested guidelines (n=67, 48%) compared with current guidelines (n=26, 20%) (risk ratio: 2.46; 95% CI 1.68 to 3.60). Median simulation completion time was 1.6 min (95% CI 0.2 to 3.0) less with the user-tested guidelines. Participants who used user-tested guidelines reported greater confidence.

Conclusion

User-testing injectable medicines guidelines reduces the number of errors and the time taken to prepare and administer intravenous medicines, while increasing staff confidence.

Trial registration number

researchregistry5275.

Evaluation of the impact of an augmented model of The Productive Ward: Releasing Time to Care on staff and patient outcomes: a naturalistic stepped-wedge trial

Background

Improving the quality and efficiency of healthcare is an international priority. A range of complex ward based quality initiatives have been developed over recent years, perhaps the most influential programme has been Productive Ward: Releasing Time to Care. The programme aims to improve work processes and team efficiency with the aim of ‘releasing time’, which would be used to increase time with patients ultimately improving patient care, although this does not form a specific part of the programme. This study aimed to address this and evaluate the impact using recent methodological advances in complex intervention evaluation design.

Method

The objective of this study was to assess the impact of an augmented version of The Productive Ward: Releasing Time to Care on staff and patient outcomes. The design was a naturalistic stepped-wedge trial. The setting included fifteen wards in two acute hospitals in a Scottish health board region. The intervention was the Productive Ward: Releasing Time to Care augmented with practice development transformational change methods that focused on staff caring behaviours, teamwork and patient feedback. The primary outcomes included nurses’ shared philosophy of care, nurse emotional exhaustion, and patient experience of nurse communication. Secondary outcomes covered additional key dimensions of staff and patient experience and outcomes and frequency of emergency admissions for same diagnosis within 6 months of discharge.

Results

We recruited 691 patients, 177 nurses and 14 senior charge nurses. We found statistically significant improvements in two of the study’s three primary outcomes: patients’ experiences of nurse communication (Effect size=0.15, 95% CI; 0.05 to 0.24), and nurses’ shared philosophy of care (Effect size =0.42, 95% CI; 0.14 to 0.70). There were also significant improvements in secondary outcomes: patients’ overall rating of ward quality; nurses’ positive affect; and items relating to nursing team climate. We found no change in frequency of emergency admissions within six months of discharge.

Conclusions

We found evidence that the augmented version of The Productive Ward: Releasing Time to Care Intervention was successful in improving a number of dimensions of nurse experience and ward culture, in addition to improved patient experience and evaluations of the quality of care received. Despite these positive summary findings across all wards, intervention implementation appeared to vary between wards. By addressing the contextual factors, which may influence these variations, and tailoring some elements of the intervention, it is likely that greater improvements could be achieved.

Trial registration number

UKCRN 14195.

Enhancing feedback on performance measures: the difference in outlier detection using a binary versus continuous outcome funnel plot and implications for quality improvement

Background

Hospitals and providers receive feedback information on how their performance compares with others, often using funnel plots to detect outliers. These funnel plots typically use binary outcomes, and continuous variables are dichotomised to fit this format. However, information is lost using a binary measure, which is only sensitive to detect differences in higher values (the tail) rather than the entire distribution. This study therefore aims to investigate whether different outlier hospitals are identified when using a funnel plot for a binary vs a continuous outcome. This is relevant for hospitals with suboptimal performance to decide whether performance can be improved by targeting processes for all patients or a subgroup with higher values.

Methods

We examined the door-to-needle time (DNT) of all (6080) patients with acute ischaemic stroke treated with intravenous thrombolysis in 65 hospitals in 2017, registered in the Dutch Acute Stroke Audit. We compared outlier hospitals in two funnel plots: the median DNT versus the proportion of patients with substantially delayed DNT (above the 90th percentile (P90)), whether these were the same or different hospitals. Two sensitivity analyses were performed using the proportion above the median and a continuous P90 funnel plot.

Results

The median DNT was 24 min and P90 was 50 min. In the binary funnel plot for the proportion of patients above P90, 58 hospitals had average performance, whereas in the funnel plot around the median 14 of these hospitals had significantly higher median DNT (24%). These hospitals can likely improve their DNT by focusing on care processes for all patients, not shown by the binary outcome funnel plot. Similar results were shown in sensitivity analyses.

Conclusion

Using funnel plots for continuous versus binary outcomes identify different outlier hospitals, which may enhance hospital feedback to direct more targeted improvement initiatives.

Valuing hospital investments in nursing: multistate matched-cohort study of surgical patients

Background

There are known clinical benefits associated with investments in nursing. Less is known about their value.

Aims

To compare surgical patient outcomes and costs in hospitals with better versus worse nursing resources and to determine if value differs across these hospitals for patients with different mortality risks.

Methods

Retrospective matched-cohort design of patient outcomes at hospitals with better versus worse nursing resources, defined by patient-to-nurse ratios, skill mix, proportions of bachelors-degree nurses and nurse work environments. The sample included 62 715 pairs of surgical patients in 76 better nursing resourced hospitals and 230 worse nursing resourced hospitals from 2013 to 2015. Patients were exactly matched on principal procedures and their hospital’s size category, teaching and technology status, and were closely matched on comorbidities and other risk factors.

Results

Patients in hospitals with better nursing resources had lower 30-day mortality: 2.7% vs 3.1% (p<0.001), lower failure-to-rescue: 5.4% vs 6.2% (p<0.001), lower readmissions: 12.6% vs 13.5% (p<0.001), shorter lengths of stay: 4.70 days vs 4.76 days (p<0.001), more intensive care unit admissions: 17.2% vs 15.4% (p<0.001) and marginally higher nurse-adjusted costs (which account for the costs of better nursing resources): $20 096 vs $19 358 (p<0.001), as compared with patients in worse nursing resourced hospitals. The nurse-adjusted cost associated with a 1% improvement in mortality at better nursing hospitals was $2035. Patients with the highest mortality risk realised the greatest value from nursing resources.

Conclusion

Hospitals with better nursing resources provided better clinical outcomes for surgical patients at a small additional cost. Generally, the sicker the patient, the greater the value at better nursing resourced hospitals.

Less is more, now more than ever

Our society and health systems have been upended by COVID-19. The search for a magic bullet is desperately being sought by decision makers and the public. Yet, aside from the early availability of a diagnostic test, there remains limited evidence that laboratory or imaging tests can accurately predict clinical deterioration beyond that afforded by basic vital signs. There are currently some therapies undergoing intensive investigation yet remain premature for widespread adoption, leaving clinicians and patients feeling frustrated and helpless. It is precisely at a time of crisis that clinicians should embrace that ‘less is more’ and consider that ‘more’ medical interventions can result in harm to patients and waste of limited healthcare system resources.

Many in the scientific and clinician community have pivoted to focus on a singular goal: advancing evidence on how to care for patients with COVID-19. Importantly, there are voices within the research community urging that...

Managing teamwork in the face of pandemic: evidence-based tips

Front-line medical teams are experiencing unprecedented stressors as a result of the COVID-19 pandemic. In the face of these pressures, teamwork has become both more important and more challenging. Fortunately, numerous examples of naturally occurring cooperation are appearing at healthcare institutions around the globe, including instances of people trying to work together during the crisis who may not have done so under ‘normal’ conditions. A crisis can stimulate some people’s willingness to cooperate, for example, to ignore prior disagreements to tackle a shared predicament. But even when the intent to cooperate is present, the incessant stress present during a crisis makes it significantly harder for teams to sustain coordinated performance over time.1 2 Focused attention on teamwork is required.3

Prior research conducted on teams under stress can be used to help anticipate risk points that can adversely impact teamwork and reveal what can...

Apology laws and malpractice liability: what have we learned?

Medical error remains a far too common source of harm.1–4 After a medical error occurs, a physician has a decision to make: disclose the error and apologise, or keep quiet. Traditionally, defence attorneys and insurers counselled physicians against disclosing errors. Within the medical profession, however, the last two decades have witnessed a strong push for transparency. Healthcare organisations are adopting disclosure policies, providing training on how to talk with patients in the aftermath of an error and building communication and resolution programmes (CRP), programmes that ensure disclosure and apology to patients, followed by adverse event investigations, and when appropriate, offers of compensation or other remedies. Motivating factors for these changes include meeting ethical obligations, promoting greater patient trust and fostering patient safety.

The law is slowly evolving to support these efforts. One notable development is that 39 states now have ‘apology...

NPS MedicineWise evaluation finds changes in general practitioners prescribing of proton pump inhibitors following education programmes

I write in response to the article published in your journal "Passing the acid test? Evaluating the impact of national education initiatives to reduce proton pump inhibitor use in Australia" (Bruno C et al, BMJ Qual Saf 2019). I am writing as NPS MedicineWise evaluation found a significant impact on general practitioner (GP) prescribing of proton pump inhibitors (PPIs) following their educational programmes in 2009 and 2015. I acknowledge that the article is well written, the methods are well described and the approach includes a number of sensitivity analyses. However, I would like to highlight some key points on the analysis methods used that differ from the approach taken by NPS MedicineWise and about which I have some concerns.

The 2015 NPS MedicineWise educational programme on PPIs was part of a larger educational strategy over a decade to support best-practice prescribing of PPIs by GPs and included Pharmaceutical Benefits...

Coming to grips with seemingly conflicting results in programme evaluation: the devils in the detail

To the Editor:

We recently published findings from our study evaluating the impact of a national education initiative to improve the quality of proton pump inhibitor (PPI) prescribing in Australia in this journal.1 We write to respond to Blogg’s comment on our paper2 and address how Wu et al3 seemingly generated conflicting conclusions in their evaluation of the same programme.

Main study findings and conclusions

Over the past decade, NPS MedicineWise has led two educational programmes to better align prescribing practice with evidence-based recommendations for PPIs and reduce the risk of PPI-related harm. The first intervention occurred in April 2009, the second between April 2015 and April 2016. Both programmes disseminated information to Australian general practitioners (GPs) about reviewing the need for long-term PPI treatment and considering ‘step-down’ treatment approaches.4 The Wu et al paper evaluated the impact of both...

From kamishibai card to key card: a family-targeted quality improvement initiative to reduce paediatric central line-associated bloodstream infections

Background

Central line-associated bloodstream infections (CLABSIs) are major contributors to preventable harm in the inpatient paediatric setting. Despite multiple guidelines to reduce CLABSI, sustaining reliable central line maintenance bundle compliance remains elusive. We identified frontline and family engagement as key drivers for this initiative. The baseline CLABSI rate for all our paediatric inpatient units (January 2016–January 2017) was 1.71/1000 central line days with maintenance bundle compliance at 87.9% (monthly range 44%–100%).

Objective

To reduce CLABSI by increasing central line maintenance bundle compliance to greater than 90% using kamishibai card (K-card) audits and family ‘key card’ education.

Methods

We transitioned our central line maintenance bundle audits from checklists to directly observed K-card audits. K-cards list the central line maintenance bundle elements to be reviewed with frontline staff. Key cards are cue cards developed using a plain-language summary of CLABSI K-cards and used by frontline staff to educate families. Key cards were distributed to families of children with central lines to simultaneously engage patients, families and frontline staff after a successful implementation of the K-card audit process. A survey was used to obtain feedback from families.

Results

In the postintervention period (February 2017–December 2019), our CLABSI rate was 0.63/1000 central line days, and maintenance bundle compliance improved to 97.1% (monthly range 86%–100%, p<0.001). Of the 45 family surveys distributed, 20 (44%) were returned. Nineteen respondents (95%) reported being extremely satisfied with the key card programme and provided positive comments.

Conclusion

Combining the key card programme with K-card audits was associated with improved maintenance bundle compliance and a reduction in CLABSI. This programme has the potential for use in multiple healthcare improvement initiatives.

Quality & Safety in the Literature: January 2021

Healthcare quality and safety span multiple topics across the spectrum of academic and clinical disciplines. Keeping abreast of the rapidly growing body of work can be challenging. In this series, we provide succinct summaries of selected relevant studies published in the last several months. Some articles will focus on a particular theme, while others will highlight unique publications from high-impact medical journals.

Key points

  • Schedules limiting resident physician work hours in paediatric intensive care units to no greater than 16 continuous hours resulted in increased adverse patient safety events as compared with schedules including shift durations of 24 hours. N Engl J Med. 25 June 2020.

  • A qualitative study identified numerous facilitators and barriers to integrating behavioural health into primary care and other outpatient clinics. Ann Intern Med. 2 June 2020.

  • A systematic review and meta-analysis demonstrated that clinical decision support systems...

  • Diagnostic error in hospitals: finding forests not just the big trees

    Diagnostic errors in hospital medicine have mostly remained in uncharted waters.1 This is partly because several factors make measurement of diagnostic errors challenging. Patients are often admitted to hospitals with a tentative diagnosis and need additional diagnostic investigations to determine next steps. This evolving nature of a diagnosis makes it hard to determine when the correct diagnosis could have been established and if a more specific diagnosis was needed to start the right treatment.2 Hospitalised patients also may have diagnoses that are atypical or rare and pose dilemmas for treating clinicians. As a result, delays in diagnosis may not necessarily be related to a diagnostic error. Furthermore, what types of diagnostic errors occur in the hospital and their prevalence depends on how one defines them. Different approaches to define them have included counting missed, wrong or delayed diagnoses regardless of whether there was a process...

    Devil in the details: understanding the effects of providing electronic health record access to patients and families

    Patient advocates have long called for patients to have access to all of their healthcare data, including electronic health records (EHRs).1 In parallel, experts have suggested that providing patients with access to EHRs will improve patient engagement, care quality, and, by extension, health/healthcare outcomes.2 Prior observational studies have supported some of these claims—for example, documenting that patients are overwhelmingly interested in and satisfied with receiving their healthcare data electronically,3 to finding that patients do identify errors when they read physician notes in the EHR.4 Because studies of EHR access for patients have been conducted and disseminated across disparate clinical conditions and settings and often using varied methodologies, the systematic review by Neves et al in this issue of BMJ Quality & Safety provides a valuable contribution in assessing the impact of patients’ EHR access specifically within the randomised controlled trial (RCT)...

    Home care after elective vascular surgery: still more questions than answers

    Home care services support the goal of many patients and caregivers to live independently at home and to ‘age in place’. Home care referrals in the USA have increased nearly 60% from 2002 to 2016 resulting in an over 88% increase in spending to over US$18 billion for Medicare beneficiaries.1 In a recent 2015–2016 survey in Canada, an estimated 881 800 households, or just over 6% of all households, used home care services including nursing and personal/home support services.2 Despite the widespread use of home care services in many countries, relatively little is known about how to optimise patient outcomes in home care. Many questions remain about which patients are most likely to benefit, which services (eg, nursing, therapies, personal care) are most beneficial for which patients and what intensity and duration of services are ideal for different patient populations.

    Recently, de Mestral and colleagues identified that...

    Prevalence and characterisation of diagnostic error among 7-day all-cause hospital medicine readmissions: a retrospective cohort study

    Background

    The prevalence and aetiology of diagnostic error among hospitalised adults is unknown, though likely contributes to patient morbidity and mortality. We aim to identify and characterise the prevalence and types of diagnostic error among patients readmitted within 7 days of hospital discharge.

    Methods

    Retrospective cohort study at a single urban academic hospital examining adult patients discharged from the medical service and readmitted to the same hospital within 7 days between January and December 2018. The primary outcome was diagnostic error presence, identified through two-physician adjudication using validated tools. Secondary outcomes included severity of error impact and characterisation of diagnostic process failures contributing to error.

    Results

    There were 391 cases of unplanned 7-day readmission (5.2% of 7507 discharges), of which 376 (96.2%) were reviewed. Twenty-one (5.6%) admissions were found to contain at least one diagnostic error during the index admission. The most common problem areas in the diagnostic process included failure to order needed test(s) (n=11, 52.4%), erroneous clinician interpretation of test(s) (n=10, 47.6%) and failure to consider the correct diagnosis (n=8, 38.1%). Nineteen (90.5%) of the diagnostic errors resulted in moderate clinical impact, primarily due to short-term morbidity or contribution to the readmission.

    Conclusion

    The prevalence of diagnostic error among 7-day medical readmissions was 5.6%. The most common drivers of diagnostic error were related to clinician diagnostic reasoning. Efforts to reduce diagnostic error should include strategies to augment diagnostic reasoning and improve clinician decision-making around diagnostic studies.

    Going the extra mile -- cross-border patient handover in a European border region: qualitative study of healthcare professionals perspectives

    Background

    Cross-border healthcare is complex, increasingly frequent and causes potential risks for patient safety. In this context, cross-border handovers or the transfer of patients from one country to another deserves particular attention. Although general handover has been the topic of extensive research, little is known about the challenges of handover across national borders, especially as perceived by stakeholders. In this study, we aimed to gain insight into healthcare professionals’ perspectives on cross-border handover and ways to support this.

    Methods

    We conducted semistructured interviews with healthcare professionals (physicians, nurses, paramedics and administrative staff) in a European border region to investigate their perspectives on cross-border handover. The interviews were aimed to investigate settings of acute and planned handover. Informed by the theory of planned behaviour (TPB), interviews focused on participant perspectives. We summarised all interviews and inductively identified healthcare professionals’ perspectives. We used elements of the TPB as sensitising concepts.

    Results

    Forty-three healthcare professionals participated. Although respondents had neutral to positive attitudes, they often did not know very well what was expected of them or what influence they could have on improving cross-border handover. Challenges covered five themes: information transfer, language barriers, task division and education, policy and financial structures and cultural differences. To overcome these challenges, we proposed strategies such as providing tools and protocols, discussing and formalising collaboration, and organising opportunities to meet and get to know each other.

    Conclusion

    Healthcare professionals involved in cross-border handovers face specific challenges. It is necessary to take measures to come to a shared understanding while paying special attention to the above-mentioned challenges. Meeting in person around meaningful activities (eg, training and case discussions) can facilitate sharing ideas and community building.

    Identical or similar brand names used in different countries for medications with different active ingredients: a descriptive analysis

    Objective

    To identify US drug brand (proprietary) names that are identical or similar to drug brand names used in other countries containing different active ingredients and name confusion medication errors associated with these drugs.

    Methods

    We compared a list of brand names approved by the US Food and Drug Administration from 2006 through 2018 with a list of brand names from other countries generated by Uppsala Monitoring Centre using the WHODrug Dictionary. We evaluated drug name pairs that were identical or highly similar and had different active ingredients and searched for name confusion medication errors with these drugs.

    Results

    A total of 27 US brand names were found to be identical to 38 drug brand names in other countries with different active ingredients. A total of 74 US drug brand names were highly similar to 93 brand names in other countries for drugs containing different active ingredients. We identified name confusion medication errors for one similar name pair.

    Conclusions

    US drug brand names that are identical to or highly similar to brand names in other countries may cause confusion that can lead to medication errors such as wrong drug errors and wrong drug information being consulted. Manufacturers should consider this risk prior to submitting proposed brand names to regulatory authorities. Regulatory authorities may consider incorporating this check in their brand name reviews and work with manufacturers to eliminate the use of the same or similar brand names for products with different ingredients. Consumers filling prescriptions at foreign pharmacies should also be aware of potential name confusion.

    Pages