The incidence, root-causes, and outcomes of adverse events in surgical units: implication for potential prevention strategies

<p>Abstract</p> <p>Background</p> <p>We need to know the scale and underlying causes of surgical adverse events (AEs) in order to improve the safety of care in surgical units. However, there is little recent data. Previous record review studies that reported on surgical AEs in detail are now more than ten years old. Since then surgical technology and quality assurance have changed rapidly. The objective of this study was to provide more recent data on the incidence, consequences, preventability, causes and potential strategies to prevent AEs among hospitalized patients in surgical units.</p> <p>Methods</p> <p>A structured record review study of 7,926 patient records was carried out by trained nurses and medical specialist reviewers in 21 Dutch hospitals. The aim was to determine the presence of AEs during hospitalizations in 2004 and to consider how far they could be prevented. Of all AEs, the consequences, responsible medical specialty, causes and potential prevention strategies were identified. Surgical AEs were defined as AEs attributable to surgical treatment and care processes and were selected for analysis in detail.</p> <p>Results</p> <p>Surgical AEs occurred in 3.6% of hospital admissions and represented 65% of all AEs. Forty-one percent of the surgical AEs was considered to be preventable. The consequences of surgical AEs were more severe than for other types of AEs, resulting in more permanent disability, extra treatment, prolonged hospital stay, unplanned readmissions and extra outpatient visits. Almost 40% of the surgical AEs were infections, 23% bleeding, and 22% injury by mechanical, physical or chemical cause. Human factors were involved in the causation of 65% of surgical AEs and were considered to be preventable through quality assurance and training.</p> <p>Conclusions</p> <p>Surgical AEs occur more often than other types of AEs, are more often preventable and their consequences are more severe. Therefore, surgical AEs have a major impact on the burden of AEs during hospitalizations. These findings concur with the results from previous studies. However, evidence-based solutions to reduce surgical AEs are increasingly available. Interventions directed at human causes are recommended to improve the safety of surgical care. Examples are team training and the surgical safety checklist. In addition, specific strategies are needed to improve appropriate use of antibiotic prophylaxis and sustainable implementation of hygiene guidelines to reduce infections.</p

What are the perceived added values and barriers of regulating long-term care in the home environment using a care network perspective

__Background:__ Changes in Dutch policy towards long-term care led to the Dutch Health and Youth Care Inspectorate testing a regulatory framework focusing on care networks around older adults living independently. This regulatory activity involved all care providers and the older adults themselves. __Methods:__ Semi-structured interviews with the older adults, and focus groups with care providers and inspectors were used to assess the perceived added value of, and barriers to the framework. __Results:__ The positive elements of this framework were the involvement of the older adults in the regulatory activity, the focus of the framework on care networks and the open character of the conversations with the inspectors. However, applying the framework requires a substantial investment of time. Care providers often did not perceive themselves as being part of a care network around one person and they expressed concerns about financial and privacy issues when thinking in terms of care networks. __Conclusions:__ The experiences of the client were seen as important in regulating long-term care. Regulating care networks as a whole puts cooperation between care providers involved around one person on the agenda. However, barriers for this form of regulation were also perceived and, therefore, careful consideration when and how to regulate care networks is recommended

Can vital signs recorded in patients' homes aid decision making in emergency care? A Scoping Review

Aim: Use of tele-health programs and wearable sensors that allow patients to monitor their own vital signs have been expanded in response to COVID-19. We aimed to explore the utility of patient-held data during presentation as medical emergencies. Methods: We undertook a systematic scoping review of two groups of studies: studies using non-invasive vital sign monitoring in patients with chronic diseases aimed at preventing unscheduled reviews in primary care, hospitalization or emergency department visits and studies using vital sign measurements from wearable sensors for decision making by clinicians on presentation of these patients as emergencies. Only studies that described a comparator or control group were included. Studies limited to inpatient use of devices were excluded. Results: The initial search resulted in 896 references for screening, nine more studies were identified through searches of references. 26 studies fulfilled inclusion and exclusion criteria and were further analyzed. The majority of studies were from telehealth programs of patients with congestive heart failure or Chronic Obstructive Pulmonary Disease. There was limited evidence that patient held data is currently used to risk-stratify the admission or discharge process for medical emergencies. Studies that showed impact on mortality or hospital admission rates measured vital signs at least daily. We identified no interventional study using commercially available sensors in watches or smart phones. Conclusions: Further research is needed to determine utility of patient held monitoring devices to guide management of acute medical emergencies at the patients’ home, on presentation to hospital and after discharge back to the community

Patient safety in elderly hip fracture patients: design of a randomised controlled trial

<p>Abstract</p> <p>Background</p> <p>The clinical environment in which health care providers have to work everyday is highly complex; this increases the risk for the occurrence of unintended events. The aim of this randomised controlled trial is to improve patient safety for a vulnerable group of patients that have to go through a complex care chain, namely elderly hip fracture patients.</p> <p>Methods/design</p> <p>A randomised controlled trial that consists of three interventions; these will be implemented in three surgical wards in Dutch hospitals. One surgical ward in another hospital will be the control group. The first intervention is aimed at improving communication between care providers using the SBAR communication tool. The second intervention is directed at stimulating the role of the patient within the care process with a patient safety card. The third intervention consists of a leaflet for patients with information on the most common complications for the period after discharge. The primary outcome measures in this study are the incidence of complications and adverse events, mortality rate within six months after discharge and functional mobility six months after discharge. Secondary outcome measures are length of hospital stay, quality and completeness of information transfer and patient satisfaction with the instruments.</p> <p>Discussion</p> <p>The results will give insight into the nature and scale of complications and adverse events that occur in elderly hip fracture patients. Also, the implementation of three interventions aimed at improving the communication and information transfer provides valuable possibilities for improving patient safety in this increasing patient group. This study combines the use of three interventions, which is an innovative aspect of the study.</p> <p>Trial registration</p> <p>The Netherlands National Trial Register <a href="http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=1562">NTR1562</a></p

Care and support for older adults in The Netherlands living independently

The growth in the numbers of older adults needing long-term care has resulted in rising costs which have forced the Dutch government to change its long-term care system. Now, the local authorities have greater responsibility for supporting older adults and in prolonging independent living with increased support provided by the social network. However, it is unclear whether these older adults have such a network to rely upon. The objective of this study was to gain insight into the providers of formal and informal care to older adults, and to assess possible differences between older adults who are frail and those who are not. In addition, we investigated their care and support needs. We used data from a quantitative survey using a cross-sectional design in different regions of the Netherlands from July until September 2014 (n = 181). Frailty was measured using the Tilburg Frailty indicator. To analyse the data chi-square tests, crosstabs and odds ratios were used for dichotomous data and the Mann–Whitney U-Test for nominal data. The number of formal care providers involved was significantly higher (median = 2) for those deemed frail than for those not deemed frail (median = 1), U = 2,130, p <.005. However, more than one-third of the respondents deemed frail did not get the care or support they needed (33.7%). There was a significant positive association between being frail and having an informal care provider (χ2 = 18.78, df = 1, p <.005). However, more than one-third of those deemed frail did not have an informal care provider (36.8%). One-third of older adults deemed to be frail did not have their needs sufficiently addressed by their care network. For a substantial part of this group of older adults, the informal network seems to be unable to support them sufficiently. Additional attention for their needs and wishes is required to implement the policy reforms successfully

Perspectives on the risks for older adults living independently

Insight into risks concerning older adults living independently from their own perspective and their care provider’s perspective is essential to address issues that may threaten their independent living. The most often mentioned perceived risks by older adults and their care providers in different regions in the Netherlands were: loneliness, falls, budget cuts in Dutch long-term care and not being able to call for help. The different perspectives of the respondents show a wide variety in risks, but also some similarities. The perspective of the frail older adults is required to gain insight into the priority of their perceived risks. An additional finding was the reluctance shown by the older adults to ask others in their social network for help. Results imply that possible preventive measures should not only focus on the medical or physical domain because older adults are likely to have other priorities to maintain self-reliance and live independently

A cross sectional study on the different domains of frailty for independent living older adults

Abstract Background With the ageing population, there is a stronger focus on supporting older people to live independently as long as possible. One of the important factors to take into consideration for independent living older adults is frailty. This manuscript aims to provide insight into the relation between the different domains of frailty (physical, social and psychological or a combination), health outcomes and wellbeing aspects for independent living older adults. Methods This cross sectional community-based study included independent living older adults of 65 years and over who are member of a welfare organisation. The questionnaire contained items on background characteristics, health, quality of life, frailty (Tilburg Frailty Indicator), activities and loneliness. A multivariate analysis, one Way ANOVA’s and chi-square tests with post-hoc analyses were used to identify significant differences between the following outcomes: Age, gender, marital status, living situation, income, health perception, number of conditions, activities of daily living, home care and informal care, Quality of life, loneliness, going outside, meeting people and the different domains of frailty. Results 1768 (35.1%) participants completed the questionnaire. 68.9% of the respondents was frail on one or multiple domains and 51.6% of the respondents was frail based on the total score on the TFI. Social frailty (18.4%) was most often present followed by 10.3% for frailty on all three domains of the TFI. All variables tested, except for income, showed significant differences between the different domains of frailty. Conclusion Distinguishing the different domains of frailty provides information about the older adult’s needs which is valuable for policymakers and care providers, to anticipate to the increasing number of independent living older adults and deliver them tailored care and support to contribute to their independent living situation and wellbeing

High risk of adverse events in hospitalised hip fracture patients of 65 years and older: results of a retrospective record review study

Objectives Hip fracture patients of 65 years and older are a complex patient group who often suffer from complications and difficult rehabilitation with disappointing results. It is unknown to what extent suboptimal hospital care contributes to these poor outcomes. This study reports on the scale, preventability, causes and prevention strategies of adverse events in patients, aged 65 years and older, admitted to the hospital with a primary diagnosis of hip fracture. Design, setting and outcome measures A retrospective record review study was conducted of 616 hip fracture patients (≥65 years) admitted to surgical or orthopaedic departments in four Dutch hospitals in 2007. Experienced physician reviewers determined the presence and preventability of adverse events, causes and prevention strategies using a structured review form. The main outcome measures were frequency of adverse events and preventable adverse events in hospitalised hip fracture patients of 65 years and older, and strategies to prevent them in the future. Results 114 (19%) of the 616 patients in the study experienced one or more adverse events; 49 of these were preventable. The majority of the adverse events (70%) was related to the surgical procedure and many resulted in an intervention or additional treatment (67%). Human causes contributed to 53% of the adverse events, followed by patient-related factors (39%). Training and close monitoring of quality of care and the health professional's performance were the most often selected strategies to prevent these adverse events in the future. Conclusions The high percentage of preventable adverse events found in this study shows that care for older hospitalised hip fracture patients should be improved. More training and quality assurance is required to provide safer care and to reduce the number of preventable adverse events in this vulnerable patient group