10,984 research outputs found
Implementation of an Oral Hygiene Protocol for Adults Patients on Acute Care Units
Practice Problem: Patients diagnosed with non-mechanically ventilated aspiration pneumonia can result in increased levels of care, longer lengths of stay, and are 8.4 more likely to die while hospitalized. Oral hygiene protocols have led to promising outcomes, evidenced by fewer cases of aspiration pneumonia in adult patients on medical surgical units.
PICOT: The PICOT question that guided this project was in adult non-mechanically ventilated hospital patients, does an Oral Hygiene Protocol (OHP) compared to current practice affect hospital acquired aspiration pneumonia during hospitalization.
Evidence: Fourteen studies met inclusion criteria that support the implementation of an evidence – based oral hygiene protocol in adult patients on a medical surgical unit.
Intervention: Implementation of an OHP included education and training about enhanced oral hygiene and the direct correlation to hospital acquired aspiration pneumonia. Nursing staff were required to perform and document oral hygiene care at least once each shift in the electronic health record (EHR). The incident rates of aspiration pneumonia after hospitalization were obtained pre- and post-implementation.
Outcome: There were no case of non-mechanically ventilated aspiration pneumonia during the project period. The highest rates of compliance with documenting oral hygiene care by the nursing staff was during week one at 32% (n = 6) and week two at 5% (n = 1).
Conclusion: The results of this project may provide support for establishing enhanced oral hygiene care for adult patients on medical surgical units to decrease the incidence of non-mechanically ventilated aspiration pneumonia
Variability in Catheter-Associated Asymptomatic Bacteriuria Rates Among Individual Nurses in Intensive Care Units: An Observational Cross-Sectional Study
Catheter-associated asymptomatic bacteriuria (CAABU) is frequent in intensive care units (ICUs) and contributes to the routine use of antibiotics and to antibiotic-resistant infections. While nurses are responsible for the implementation of CAABU-prevention guidelines, variability in how individual nurses contribute to CAABU-free rates in ICUs has not been previously explored. This study’s objective was to examine the variability in CAABU-free outcomes of individual ICU nurses. This observational cross-sectional study used shift-level nurse-patient data from the electronic health records from two ICUs in a tertiary medical center in the US between July 2015 and June 2016. We included all adult (18+) catheterized patients with no prior CAABU during the hospital encounter and nurses who provided their care. The CAABU-free outcome was defined as a 0/1 indicator identifying shifts where a previously CAABU-free patient remained CAABU-free (absence of a confirmed urine sample) 24–48 hours following end of shift. The analytical approach used Value-Added Modeling and a split-sample design to estimate and validate nurse-level CAABU-free rates while adjusting for patient characteristics, shift, and ICU type. The sample included 94 nurses, 2,150 patients with 256 confirmed CAABU cases, and 21,729 patient shifts. Patients were 55% male, average age was 60 years. CAABU-free rates of individual nurses varied between 94 and 100 per 100 shifts (Wald test: 227.88, P\u3c0.001) and were robust in cross-validation analyses (correlation coefficient: 0.66, P\u3c0.001). Learning and disseminating effective CAABU-avoidance strategies from top-performers throughout the nursing teams could improve quality of care in ICUs
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Implementing pediatric inpatient asthma pathways.
ObjectivePathways are succinct, operational versions of evidence-based guidelines. Studies have demonstrated pathways improve quality of care for children hospitalized with asthma, but we have limited information on other key factors to guide hospital leaders and clinicians in pathway implementation efforts. Our objective was to evaluate the adoption, implementation, and reach of inpatient pediatric asthma pathways.MethodsThis was a mixed-methods study of hospitals participating in a national collaborative to implement pathways. Data sources included electronic surveys of implementation leaders and staff, field observations, and chart review of children ages 2-17 years admitted with a primary diagnosis of asthma. Outcomes included adoption by hospitals, pathway implementation factors, and reach of pathways to children hospitalized with asthma. Quantitative data were analyzed using descriptive statistics and multivariable regression. Qualitative data were analyzed using thematic content analysis.ResultsEighty-five hospitals enrolled; 68 (80%) adopted/completed the collaborative. These 68 hospitals implemented pathways with overall high fidelity, implementing a median of 5 of 5 core pathway components (Interquartile Range [IQR] 4-5) in a median of 5 months (IQR 3-9). Implementation teams reported a median time cost of 78 h (IQR: 40-120) for implementation. Implementation leaders reported the values of pathway implementation included improvements in care, enhanced interdisciplinary collaboration, and access to educational resources. Leaders reported barriers in modifying electronic health records (EHRs), and only 63% of children had electronic pathway orders placed.ConclusionsHospitals implemented pathways with high fidelity. Barriers in modifying EHRs may have limited the reach of pathways to children hospitalized with asthma
Diagnostic error increases mortality and length of hospital stay in patients presenting through the emergency room
Background: Diagnostic errors occur frequently, especially in the emergency room. Estimates about the
consequences of diagnostic error vary widely and little is known about the factors predicting error. Our
objectives thus was to determine the rate of discrepancy between diagnoses at hospital admission and
discharge in patients presenting through the emergency room, the discrepancies’ consequences, and factors
predicting them.
Methods: Prospective observational clinical study combined with a survey in a University-affiliated tertiary
care hospital. Patients’ hospital discharge diagnosis was compared with the diagnosis at hospital admittance
through the emergency room and classified as similar or discrepant according to a predefined scheme by
two independent expert raters. Generalized linear mixed-effects models were used to estimate the effect of
diagnostic discrepancy on mortality and length of hospital stay and to determine whether characteristics of
patients, diagnosing physicians, and context predicted diagnostic discrepancy.
Results: 755 consecutive patients (322 [42.7%] female; mean age 65.14 years) were included.
The discharge diagnosis differed substantially from the admittance diagnosis in 12.3% of cases. Diagnostic
discrepancy was associated with a longer hospital stay (mean 10.29 vs. 6.90 days; Cohen’s d 0.47; 95%
confidence interval 0.26 to 0.70; P = 0.002) and increased patient mortality (8 (8.60%) vs. 25(3.78%); OR 2.40; 95% CI 1.05
to 5.5 P = 0.038). A factor available at admittance that predicted diagnostic discrepancy was the diagnosing physician’s
assessment that the patient presented atypically for the diagnosis assigned (OR 3.04; 95% CI 1.33–6.96; P = 0.009).
Conclusions: Diagnostic discrepancies are a relevant healthcare problem in patients admitted through the
emergency room because they occur in every ninth patient and are associated with increased in-hospital
mortality. Discrepancies are not readily predictable by fixed patient or physician characteristics; attention
should focus on context
The risk of community-acquired pneumonia among 9803 patients with coeliac disease compared to the general population: a cohort study
Background: Patients with coeliac disease are considered as individuals for whom pneumococcal vaccination is advocated.
Aim: To quantify the risk of community-acquired pneumonia among patients with coeliac disease, assessing whether vaccination against streptococcal pneumonia modified this risk.
Methods: We identified all patients with coeliac disease within the Clinical Practice Research Datalink linked with English Hospital Episodes Statistics between April 1997 and March 2011 and up to 10 controls per patient with coeliac disease frequency matched in 10-year age bands. Absolute rates of community-acquired pneumonia were calculated for patients with coeliac disease compared to controls stratified by vaccination status and time of diagnosis using Cox regression in terms of adjusted hazard ratios (HR).
Results: Among 9803 patients with coeliac disease and 101 755 controls, respectively, there were 179 and 1864 first community-acquired pneumonia events. Overall absolute rate of pneumonia was similar in patients with coeliac disease and controls: 3.42 and 3.12 per 1000 person-years respectively (HR 1.07, 95% CI 0.91–1.24). However, we found a 28% increased risk of pneumonia in coeliac disease unvaccinated subjects compared to unvaccinated controls (HR 1.28, 95% CI 1.02–1.60). This increased risk was limited to those younger than 65, was highest around the time of diagnosis and was maintained for more than 5 years after diagnosis. Only 26.6% underwent vaccination after their coeliac disease diagnosis.
Conclusions: Unvaccinated patients with coeliac disease under the age of 65 have an excess risk of community-acquired pneumonia that was not found in vaccinated patients with coeliac disease. As only a minority of patients with coeliac disease are being vaccinated there is a missed opportunity to intervene to protect these patients from pneumonia
Electronic Health Record Documentation: Is it an accurate indicator of quality of care for mechanically ventilated patients?
Background: Ventilator associated pneumonia is one of the leading hospital acquired infections associated with increased mortality and lengths of stay in mechanically ventilated patients.
Hypothesis: It is hypothesized that the introduction of chlorhexidine gluconate will show reduction in the incidences of ventilator associated pneumonia and a greater reduction with tooth brushing vs oral swabbing. It is also hypothesized that the electronic health record will provide more evidence of quality of care than an external EHR sources.
Methods: The non-randomized, non-sampled population included 98 patient records that met the inclusion criteria. The external tool, Automated Vent Bundle tool provided information as to which patients were mechanically ventilated in the Surgical Intensive Care Unit during years 2011 and 2012 day to day during each month. Each EHR was searched for the documentation of CHG during periods of mechanical ventilation.
Results: There was not any significant difference noted in the reduction of VAP during years 2008 and 2009 in which swabs and tooth brushing were utilized. In 2010, significant decrease was noted in the rate of VAP from years 2009 and 2010 with a reduction of VAP by 27% from 4.1 in 2009 to 1.1 in 2010.
Conclusion: VAP rates and ventilator days were reduced as a direct result of implementation of CHG. External data sources provided more information than the data collected from the EHR. More research is needed in the evaluation of quality of care concerning electronic clinical documentation
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