Improving the governance of patient safety in emergency care: a systematic review of interventions

OBJECTIVES: To systematically review interventions that aim to improve the governance of patient safety within emergency care on effectiveness, reliability, validity and feasibility.DESIGN: A systematic review of the literature.METHODS: PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature, the Cochrane Database of Systematic Reviews and PsychInfo were searched for studies published between January 1990 and July 2014. We included studies evaluating interventions relevant for higher management to oversee and manage patient safety, in prehospital emergency medical service (EMS) organisations and hospital-based emergency departments (EDs). Two reviewers independently selected candidate studies, extracted data and assessed study quality. Studies were categorised according to study quality, setting, sample, intervention characteristics and findings.RESULTS: Of the 18 included studies, 13 (72%) were non-experimental. Nine studies (50%) reported data on the reliability and/or validity of the intervention. Eight studies (44%) reported on the feasibility of the intervention. Only 4 studies (22%) reported statistically significant effects. The use of a simulation-based training programme and well-designed incident reporting systems led to a statistically significant improvement of safety knowledge and attitudes by ED staff and an increase of incident reports within EDs, respectively.CONCLUSIONS: Characteristics of the interventions included in this review (eg, anonymous incident reporting and validation of incident reports by an independent party) could provide useful input for the design of an effective tool to govern patient safety in EMS organisations and EDs. However, executives cannot rely on a robust set of evidence-based and feasible tools to govern patient safety within their emergency care organisation and in the chain of emergency care. Established strategies from other high-risk sectors need to be evaluated in emergency care settings, using an experimental design with valid outcome measures to strengthen the evidence base

Comorbidities and the referral pathway to access joint replacement surgery: an exploratory qualitative study

This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.The research was funded by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care North Thames (CLAHRC) at Barts Health NHS Trust

Are patients discharged with care? A qualitative study of perceptions and experiences of patients, family members and care providers

Background: Advocates for quality and safety havecalled for healthcare that is patient-centred anddecision-making that involves patients.Objective: The aim of the paper is to explore thebarriers and facilitators to patient-centred care in thehospital discharge process.Methods: A qualitative study using purposive samplingof 192 individual interviews and 26 focus groupinterviews was conducted in five European Unioncountries with patients and/or family members,hospital physicians and nurses, and community generalpractitioners and nurses. A modified Grounded Theoryapproach was used to analyse the data.Results: The barriers and facilitators were classified into15 categories from which four themes emerged:(1) healthcare providers do not sufficiently prioritisedischarge consultations with patients and family membersdue to time restraints and competing care obligations;(2) discharge communication varied from instructingpatients and family members to shared decision-making;(3) patients often feel unprepared for discharge, andpostdischarge care is not tailored to individual patientneeds and preferences; and (4) pressure on availablehospital beds and community resources affect thedischarge process.Conclusions: Our findings suggest that involvement ofpatients and families in the preparations for discharge isdetermined by the extent towhich care providers arewillingand able to accommodate patients’ and families’ capabilities,needs and preferences. Future interventions should bedirected at healthcare providers’ attitudes and theirorganisation’s leadership, with afocus on improvingcommunication among care providers, patients and families,and between hospital and community care providers

Risk Factors for Prolonged Length of Stay of Older Patients in an Academic Emergency Department: A Retrospective Cohort Study

Emergency departments (EDs) are challenged with a growing population of older patients. These patients are at risk for a prolonged length of stay (LOS) at the ED and face more complications and poorer clinical outcomes. We aimed to identify risk factors for a prolonged LOS of older patients at the ED. For this retrospective clinical database study, we analyzed medical records of 2000 patients ≥70 years old presenting at the ED of a large level I trauma center in the Netherlands. LOS above the 75th percentile of LOS at our ED, 293 minutes, was considered prolonged. After bivariate analysis, we identified associations between LOS and patient, organizational, and clinical factors. Associations with a p < 0.05 were inserted in multivariable logistic regression models. We analyzed 1048 men (52%) and 952 women (48%) with a mean age of 78 ± 6.2 years. Risk factors for prolonged LOS of older patients at the ED were follows: higher number (more than one) of consultations (OR [odds ratio] 2.4, CI [confidence interval] 2.0-2.91), or diagnostic interventions (OR 1.5, CI 1.4-1.7); presenting complaints of a neurological (OR 2.2, CI 1.0-4.5) or internal medicine focus (OR 2.6, CI 1.4-4.6); patients with an altered consciousness (OR 3.3, CI 1.6-6.6); treatment by physicians of the departments of surgery (OR 3.4, CI 2.2-5.2), internal medicine (OR 2.6, CI 1.9-3.7), or pulmonology (OR 2.2, CI 1.4-3.6); and urgency category of ≥ U1. Awareness of factors associated with prolonged LOS of older patients presenting at the ED is essential. Physicians should recognize and take these factors into account, in order to improve clinical outcomes of the (strongly increasing) population of older patients at the ED

Consensus-based indicators for evaluating and improving the quality of regional collaborative networks of intensive care units:Results of a nationwide Delphi study

PURPOSE: To select a consensus-based set of relevant and feasible indicators for monitoring and improving the quality of regional ICU network collaboratives. METHODS: A three-round Delphi study was conducted in the Netherlands between April and July 2022. A multidisciplinary expert panel prioritized potentially relevant and feasible indicators in two questionnaire rounds with two consensus meetings between both rounds. The RAND/UCLA appropriateness method was used to categorize indicators and synthesize results. A core set of highest ranked indicators with consensus-based levels of relevance and feasibility were finally tested in two ICU networks to assess their measurability. RESULTS: Twenty-four indicators were deemed as relevant and feasible. Seven indicators were selected for the core set measuring the standardized mortality rate in the region (n = 1) and evaluating the presence, content and/or follow-up of a formal plan describing network structures and policy agreements (n = 3), a long-term network vision statement (n = 1), and network meetings to reflect on and learn from outcome data (n = 2). The practice tests led to minor reformulations. CONCLUSIONS: This study generated relevant and feasible indicators for monitoring and improving the quality of ICU network collaboratives based on the collective opinion of various experts. The indicators may help to effectively govern such networks

Distribution of Sulfate-Reducing and Methanogenic Bacteria in Anaerobic Aggregates Determined by Microsensor and Molecular Analyses

Using molecular techniques and microsensors for H(2)S and CH(4), we studied the population structure of and the activity distribution in anaerobic aggregates. The aggregates originated from three different types of reactors: a methanogenic reactor, a methanogenic-sulfidogenic reactor, and a sulfidogenic reactor. Microsensor measurements in methanogenic-sulfidogenic aggregates revealed that the activity of sulfate-reducing bacteria (2 to 3 mmol of S(2−) m(−3) s(−1) or 2 × 10(−9) mmol s(−1) per aggregate) was located in a surface layer of 50 to 100 μm thick. The sulfidogenic aggregates contained a wider sulfate-reducing zone (the first 200 to 300 μm from the aggregate surface) with a higher activity (1 to 6 mmol of S(2−) m(−3) s(−1) or 7 × 10(−9) mol s(−1) per aggregate). The methanogenic aggregates did not show significant sulfate-reducing activity. Methanogenic activity in the methanogenic-sulfidogenic aggregates (1 to 2 mmol of CH(4) m(−3) s(−1) or 10(−9) mmol s(−1) per aggregate) and the methanogenic aggregates (2 to 4 mmol of CH(4) m(−3) s(−1) or 5 × 10(−9) mmol s(−1) per aggregate) was located more inward, starting at ca. 100 μm from the aggregate surface. The methanogenic activity was not affected by 10 mM sulfate during a 1-day incubation. The sulfidogenic and methanogenic activities were independent of the type of electron donor (acetate, propionate, ethanol, or H(2)), but the substrates were metabolized in different zones. The localization of the populations corresponded to the microsensor data. A distinct layered structure was found in the methanogenic-sulfidogenic aggregates, with sulfate-reducing bacteria in the outer 50 to 100 μm, methanogens in the inner part, and Eubacteria spp. (partly syntrophic bacteria) filling the gap between sulfate-reducing and methanogenic bacteria. In methanogenic aggregates, few sulfate-reducing bacteria were detected, while methanogens were found in the core. In the sulfidogenic aggregates, sulfate-reducing bacteria were present in the outer 300 μm, and methanogens were distributed over the inner part in clusters with syntrophic bacteria

Skeletal muscle lipase content and activity in obesity and type 2 diabetes.

International audienceCONTEXT: The obese insulin-resistant state is characterized by elevated lipid storage in skeletal muscle tissue. OBJECTIVE: We tested whether differences in muscle triacylglycerol (TAG) and diacylglycerol (DAG) lipase content and activity are associated with incomplete in vivo lipolysis and lipid accumulation. DESIGN AND PATIENTS: Two case-control studies were conducted on skeletal muscle biopsies from lean (n=13) and obese (n=10) men (study 1) and from 11 nonobese type 2 diabetic (T2D), obese T2D, and healthy normoglycemic men (study 2). MAIN OUTCOME MEASURES: Skeletal muscle lipase protein content and activity and muscle lipid content (TAG and DAG) were determined. RESULTS: Skeletal muscle hormone-sensitive lipase protein content was lower (0.39±0.07 vs. 1.00±0.19 arbitrary units; P=0.004) and adipose triglyceride lipase protein content was higher in obese men compared with lean controls (2.17±0.40 vs. 0.42±0.23 arbitrary units; P=0.008). This apparent difference in lipase content was accompanied by a 60% lower ratio of DAG to TAG hydrolase activity in the obese men (11.4±2.3 vs. 26.5±7.3 nmol/h*mg; P=0.045), implying incomplete lipolysis. Lower hormone-sensitive lipase and higher adipose triglyceride lipase content was confined to obesity per se, because it was observed solely in obese T2D men but not in healthy normoglycemic controls and nonobese T2D men. Muscle total DAG content was not higher in obese men but was even lower (6.2±0.7 vs. 9.4±0.9 μmol/mg dry weight; P=0.017). TAG content did not differ between groups (84.7±18.9 vs. 70.4±12.4 μmol/mg dry weight; P=0.543). CONCLUSIONS: Our data do not support an important role of total muscle DAG content in the development of insulin resistance in obese men

The key actor: a qualitative study of patient participation in the handover process in Europe

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An international comparison of factors affecting quality of life among patients with congestive heart failure: A cross-sectional study

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