From guidelines to clinical practice in care for ischaemic stroke patients: A systematic review and expert opinion.

BACKGROUND AND PURPOSE: Guidelines help physicians to provide optimal care for stroke patients, but implementation is challenging due to the quantity of recommendations. Therefore a practical overview related to applicability of recommendations can be of assistance. METHODS: A systematic review was performed on ischaemic stroke guidelines published in scientific journals, covering the whole acute care process for patients with ischaemic stroke. After data extraction, experts rated the recommendations on dimensions of applicability, that is, actionability, feasibility and validity, on a 9-point Likert scale. Agreement was defined as a score of ≥8 by ≥80% of the experts. RESULTS: Eighteen articles were identified and 48 recommendations were ultimately extracted. Papers were included only if they described the whole acute care process for patients with ischaemic stroke. Data extraction and analysis revealed variation in terms of both content and comprehensiveness of this description. Experts reached agreement on 34 of 48 (70.8%) recommendations in the dimension actionability, for 16 (33.3%) in feasibility and for 15 (31.3%) in validity. Agreement on all three dimensions was reached for seven (14.6%) recommendations: use of a stroke unit, exclusion of intracerebral haemorrhage as differential diagnosis, administration of intravenous thrombolysis, performance of electrocardiography/cardiac evaluation, non-invasive vascular examination, deep venous thrombosis prophylaxis and administration of statins if needed. DISCUSSION AND CONCLUSION: Substantial variation in agreement was revealed on the three dimensions of the applicability of recommendations. This overview can guide stroke physicians in improving the care process and removing barriers where implementation may be hampered by validity and feasibility.

Quality indicators for ambulatory colectomy: literature search and expert consensus.

BACKGROUND: Care for patients undergoing elective colectomy has become increasingly standardized using Enhanced Recovery Programs (ERP). ERP, encorporating minimally invasive surgery (MIS), decreased postoperative morbidity and length of stay (LOS). However, disruptive changes are needed to safely introduce colectomy in an ambulatory or same-day discharge (SDD) setting. Few research groups showed the feasibility of ambulatory colectomy. So far, no minimum standards for the quality of care of this procedure have been defined. This study aims to identify quality indicators (QIs) that assess the quality of care for ambulatory colectomy. METHODS: A literature search was performed to identify recommendations for ambulatory colectomy. Based on that search, a set of QIs was identified and categorized into seven domains: preparation of the patient (pre-admission), anesthesia, surgery, in-hospital monitoring, home monitoring, feasibility, and clinical outcomes. This list was presented to a panel of international experts (surgeons and anesthesiologists) in a 1 round Delphi to assess the relevance of the proposed indicators. RESULTS: Based on the literature search (2010-2021), 3841 results were screened on title and abstract for relevant information. Nine papers were withheld to identify the first set of QIs (n = 155). After excluding duplicates and outdated QIs, this longlist was narrowed down to 88 indicators. Afterward, consensus was reached in a 1 round Delphi on a final list of 32 QIs, aiming to be a comprehensive set to evaluate the quality of ambulatory colectomy care. CONCLUSION: We propose a list of 32 QI to guide and evaluate the implementation of ambulatory colectomy.

The determinants of expert opinion in the development of care pathways: insights from an exploratory cluster analysis.

BACKGROUND: We performed a secondary exploratory cluster analysis on the data collected from the validation phase of the study leading to the development of the model care pathway (CP) for Myasthenia Gravis (MG), in which a panel of 85 international experts were asked some characteristics about themselves and their opinion about the model CP. Our aim was to identify which characteristics of the experts play a role in the genesis of their opinion. METHODS: We extracted the questions probing an opinion and those describing a characteristic of the expert from the original questionnaire. We performed a multiple correspondence analysis (MCA) and a subsequent hierarchical clustering on principal component (HCPC) on the opinion variables, integrating the characteristic variables as supplementary (predicted). RESULTS: After reducing the dimensionality of the questionnaire to three dimensions we noticed that the not-appropriateness judgement of the clinical activities may overlap with the completeness one. From the HCPC it seems that the working setting of the expert may play a crucial role in determining the opinion about the setting of the sub-processes of MG: shifting from a cluster where the experts do not work in sub-specialist settings to one where the experts are working in them, the opinion changes accordingly from a mono-disciplinary setting to a multi-disciplinary one. Another interesting result is that the experience in neuromuscular diseases (NMD) measured in years and the expert typology (whether general neurologist or NMD expert) seem not to contribute significantly to the opinions. CONCLUSIONS: These findings might indicate a poor ability of the expert to discriminate what is not appropriate from what is not complete. Also, the opinion of the expert might be influenced by the working setting, but not by the experience in NMD (as measured in years).

Variation in stroke care at the hospital level: A cross-sectional multicenter study.

Introduction: Stroke is one of the leading causes of mortality and disability. Improving patient outcomes can be achieved by improving stroke care and adherence to guidelines. Since wide variation in adherence rates for stroke guidelines still exists, we aimed to describe and compare stroke care variability within Belgian hospitals. Materials and methods: An observational, multicenter study was performed in 29 Belgian hospitals. We retrospectively collected patient characteristics, quality indicators, and time metrics from the last 30 consecutive patients per hospital, diagnosed with ischemic stroke in 2019 with structured questionnaires. Mean adherence ratios (%) ± SD (minimum - maximum) were calculated. Results: We analyzed 870 patient records from 29 hospitals. Results showed large inter- and intrahospitals variations in adherence for various indicators. Almost all the patients received brain imaging (99.7%) followed by admission at a stroke unit in 82.9% of patients. Of patients not receiving thrombolysis, 92.5% of patients were started on antithrombotic drugs. Indicators with moderate median adherence but large interhospital variability were glycemia monitoring [82.3 ± 16.7% (26.7-100.0%)], performing clinical neurological examination and documentation of stroke severity [63.1 ± 36.8% (0-100%)], and screening for activities of daily living [51.1 ± 40.3% (0.0-100.0%)]. Other indicators lacked adequate adherence: swallowing function screening [37.0 ± 30.4% (0.0-93.3%)], depression screening [20.2 ± 35.8% (0.0-100%)], and timely body temperature measurement [15.1 ± 17.0% (0.0-60%)]. Conclusion: We identified high adherence to guidelines for some indicators, but lower rates with large interhospital variability for other recommendations also based on robust evidence. Improvement strategies should be implemented to improve the latter.

A Breakthrough Improvement Collaborative Significantly Reduces Hospital Stay After Elective Colectomy for Cancer Across a Healthcare System.

OBJECTIVE: This multicenter study aimed to assess (1) the effect of an improvement collaborative on enhanced recovery after surgery (ERAS) protocol adherence after elective colectomy and (2) the association between adherence and patient outcomes. BACKGROUND: ERAS pathways provide a framework to standardize care processes and improve postoperative outcomes in patients after colon surgery. Despite growing evidence of its effectiveness, adherence to these guidelines remains a challenge. METHODS: This prospective, multicenter collaborative was initiated throughout 11 hospitals in Flanders, Belgium. A structured audit tool was used to study patient outcomes and adherence to 12 ERAS components, defined by the collaborative. Three retrospective audits (based on patient record analysis) were conducted in 2017, 2019, and 2021, respectively. RESULTS: Overall, 740 patients were included (45.4% female; mean±SD age, 71±12 years). The overall adherence increased from 42.8% in 2017 to 58.4% in 2019 and 69.2% in 2021. Compared with low adherence, length of stay was increasingly reduced by 1.3 days for medium [95% confidence interval (95% CI): -2.5; 0.0], 3.6 days for high (95% CI: -4.9; -2.2), and up to 4.4 days for very high adherence (95% CI: -6.1; -2.7). Corresponding odds ratios for postoperative complications were 0.62 (95% CI: 0.33; 1.17), 0.19 (95% CI: 0.09; 0.43), and 0.14 (95% CI: 0.05; 0.39), respectively. No increase in 30-day readmissions was observed. CONCLUSIONS: A peer-constructed improvement collaborative effectively increases adherence to an ERAS protocol in individual hospitals. Across time, length of stay and postoperative complications decreased significantly, and a dose-response relationship was observed.

Quality indicators in the treatment of geriatric hip fractures: literature review and expert consensus.

PURPOSE: Even though hip fracture care pathways have evolved, mortality rates have not improved during the last 20 years. This finding together with the increased frailty of hip fracture patients turned hip fractures into a major public health concern. The corresponding development of an indicator labyrinth for hip fractures and the ongoing practice variance in Europe call for a list of benchmarking indicators that allow for quality improvement initiatives for the rapid recovery of fragile hip fractures (RR-FHF). The purpose of this study was to identify quality indicators that assess the quality of in-hospital care for rapid recovery of fragile hip fracture (RR-FHF). METHODS: A literature search and guideline selection was conducted to identify recommendations for RR-FHF. Recommendations were categorized as potential structure, process, and outcome QIs and subdivided in-hospital care treatment topics. A list of structure and process recommendations that belongs to care treatment topics relevant for RR-FHF was used to facilitate extraction of recommendations during a 2-day consensus meeting with experts (n = 15) in hip fracture care across Europe. Participants were instructed to select 5 key recommendations relevant for RR-FHF for each part of the in-hospital care pathway: pre-, intra-, and postoperative care. RESULTS: In total, 37 potential QIs for RR-FHF were selected based on a methodology using the combination of high levels of evidence and expert opinion. The set consists of 14 process, 13 structure, and 10 outcome indicators that cover the whole perioperative process of fragile hip fracture care. CONCLUSION: We suggest the QIs for RR-FHF to be practice tested and adapted to allow for intra-hospital longitudinal follow-up of the quality of care and for inter-hospital and cross-country benchmarking and quality improvement initiatives.

Overview on the target population and methods used in care pathway projects: A narrative review.

BACKGROUND: There is evidence that the efficiency and effectiveness of care processes can be improved in all countries. Care pathways (CPs) are proposed as a method to improve the quality of care by reducing variation. During the last decades, CPs have been intensively used in practice. The objective of this study is to examine the study designs for investigating CPs, for which pathologies CPs are used and what the reported indicators to measure the impact of CPs are. METHODS: A narrative review of the literature published from 2015 to 2019 was performed. RESULTS: We identified 286 studies, of which 207 evaluated the impact of CPs, 33 were review articles, 29 studies described the development of a CP, 12 were study protocols and 5 opinion papers. The most frequently reported study design for studying the impact of a CP is pre-posttest (n = 82), followed by cross-sectional studies (n = 50). Oncology, cardiovascular disease and abdominal surgery are the domains with the highest numbers of studies evaluating the impact of CPs. Financial (n = 86), process (n = 76) and clinical indicators (n = 74) are the most frequently reported indicators while service (n = 12) and team indicators (n = 6) are less reported. CONCLUSIONS: Based on the relative low number of identified studies compared with the number of CP projects in organisations, we conclude that the CP knowledge is not only found in the literature. We, therefore, argue that (inter)national scientific societies should not only focus on searching and spreading evidence on the content of care but also enhance their knowledge sharing initiatives on the organisation of care processes.

Peer support by interprofessional health care providers in aftermath of patient safety incidents: A cross-sectional study.

AIM: To investigate the health care professionals' preferences pertaining to support in the aftermath of patient safety incidents and potential variation thereof depending on the degree of harm. BACKGROUND: Peer support systems are available to support health care professionals in the aftermath of patient safety incidents. It is unclear which type of support is best offered by whom. METHODS: A cross-sectional study in 32 Dutch hospitals. RESULTS: In total, 2,362 nurses and 1,404 doctors indicated they were involved in patient safety incidents at any time during their career (86%). Less than 10% of health care providers had spoken with professional support, and less than 20% admitted a need to do so. They used different support. A higher degree of harm related to higher odds of desiring support. Respondents mainly wanted to understand what happened and how it can be prevented. CONCLUSION: The desired support of health care professionals in the aftermath of patient safety incidents depends on the level of harm. IMPLICATION FOR NURSING MANAGEMENT: Health care professionals seem to mostly rely on persons they are close with, and they mainly desire information related to the aftermath of patient safety incidents. This should be taken into account when support programmes are set up.

A 15-Year Follow-up Retrospective Study on 959 Spine Surgeries: What Can We Learn From Real-world Data?

STUDY DESIGN: This was a retrospective study. OBJECTIVE: The aim of this study was to investigate the patient flow and need for additional surgery after first-time lower back surgery. Next, we analyzed the patients who developed chronic low back pain (LBP) and were treated with spinal cord stimulation. SUMMARY OF BACKGROUND DATA: LBP has a lifetime prevalence of 84% and imposes a high economic burden. Treatment is focused on preventing chronic pain. Research has shown the efficacy of treatment options. However, less is known about who benefits the most from which therapy and when they should be positioned in the treatment algorithm. METHODS: In this retrospective study, data of all patients who underwent first-time surgery from 2000 to 2004 were included. After 10-15 years, patients were contacted about their quality of life (QoL) (EuroQoL-5 Dimension) and life and heath perception (EuroQoL Visual Analogue Scale). RESULTS: In all, 959 patients underwent surgery at the lower back area. Follow-up time ranged from 13 to 17 years; 225 patients (23.5%) underwent a second surgery. In total, 20 patients (2.1%) developed chronic neuropathic back pain and received spinal cord stimulation therapy. Ten years postsurgery, 438 (45.7%) patients completed the QoL and LBP questionnaires. The health-related QoL and health situation were significantly lower in patients with multiple surgeries ( P <0.001). CONCLUSIONS: The study results indicate that large data sets, with multiple outcome measurements and long-term follow-up are necessary to improve our knowledge and to optimize the therapeutic pathway. In that way, we might learn how to select a patient for the right treatment or treatments at the right moment and shorten the circulation in our health care system.