Quality and Patient Safety Metrics: Developing a Structured Program for Improving Patient Care in the Department of Medicine at The Ottawa Hospital.

PROBLEM: Despite increasing recognition of the importance of quality and patient safety in academic medicine, challenges remain with ensuring physician participation in quality assurance and quality improvement efforts, such as lack of compensation and enabling resources. An organizational culture that includes physician leadership and a supportive infrastructure is needed to encourage physician backing of quality and patient safety initiatives. APPROACH: The authors describe the development of a robust quality and patient safety program in the Department of Medicine at The Ottawa Hospital over the past 7 years and highlight how the department changed its organizational culture by prioritizing quality and patient safety and establishing the necessary infrastructure to support this program. Program development was characterized by 4 overarching themes: incentives, administrative structure and physician leadership, training and support, and system enhancements. OUTCOMES: As a result of the program, the department broadly implemented a standardized framework for conducting quality committee meetings and morbidity and mortality rounds and reviewing patient safety incidents and patient experience across its 16 divisions. This has led to 100% departmental compliance on corporate quality assurance metrics each year (e.g., regular multidisciplinary divisional quality committee meetings), along with physician participation in formal quality improvement initiatives that align with larger corporate goals. NEXT STEPS: The authors reflect on lessons learned during the implementation of the program and the essential elements that contributed to its success. Next steps for the program include using a centralized repository of quality and patient safety data, including patient safety incident dashboards, to encourage greater divisional collaboration on quality improvement initiatives and continuous institutional learning over time. Another important avenue will be to create an academic hub for excellence in quality and a formal approach to reward and promote physicians for their quality work.

Intervention to reduce unnecessary urinary catheter use in a large academic health science centre: A one-group, pretest, posttest study with a theory-based process evaluation.

AIM: To evaluate an intervention to reduce unnecessary urinary catheter use and prevent catheter-associated urinary-tract infections (CAUTI) in hospitalized patients across an academic health science centre. METHODS: We conducted a one-group, pretest, posttest study with a theory-based process evaluation. Phase 1 consisted of a pre/postintervention to test the impact of a CAUTI protocol. Audits on four units were conducted, and data were analysed descriptively. Phase 2 consisted of a theory-based process evaluation to understand the barriers/enablers to the implementation. Semistructured interviews were conducted and then analysed using a systematic approach. RESULTS: In Phase 1, all inpatients with urinary catheters admitted to the units (N = 4) during the study period (N = 99, pre) and (N = 99, post) were included. CAUTI prevalence rate was 18.2% pre versus 14.1% post (p = .563). In Phase 2, participants (N = 18) who worked on the units were interviewed, and a total of 13 barriers and 19 enablers were found.

Stereotactic Radiotherapy in the Treatment of Paraneoplastic Vasculitis in Oligometastatic Renal Cell Carcinoma.

Approximately 20% of renal cell carcinoma (RCC) is diagnosed because of paraneoplastic manifestations. RCC has been associated with a large variety of paraneoplastic syndromes (PNS), but it is rarely associated with PNS vasculitis. We present a case of a previously healthy male who presented with systemic vasculitis; bitemporal headaches, diplopia, polyarthritis, palpable purpura, tongue lesion, peri-orbital edema, scleritis, chondritis and constitutional symptoms. He was subsequently found to have oligometastatic RCC. Both his primary lesion and site of oligometastasis were treated with stereotactic radiotherapy (SBRT) and resulted in the resolution of his vasculitis, as well as sustained oncologic response. This is the first case to demonstrate that effective sustained treatment for PNS vasculitis due to oligometastatic RCC is possible with SBRT.

Improving Timeliness of Internal Medicine Consults in the Emergency Department: A Quality Improvement Initiative.

INTRODUCTION: Emergency department (ED) wait time is an important health system quality indicator. Prolonged consult to decision time (CTDT), the time it takes to reach a disposition decision after receiving a specialty consultation request, can contribute to increased overall length of stay in the ED. OBJECTIVE: To identify delays in the consultation process for general internal medicine (GIM) and trial interventions to reduce CTDT. METHODS: The study was conducted at a large tertiary teaching hospital with GIM inpatient wards at two campuses. Four interventions were trialed over sequential Plan-Do-Study-Act cycles: (1) process mapping, (2) resident education sessions, (3) audit and feedback of CTDT, and (4) adding a swing shift during peak consult volume. MEASUREMENTS: The primary outcome measures were mean CTDT for patients admitted to GIM and the proportion of admitted patients with CTDT of less than 3 hours. RESULTS: Mean CTDT decreased from 4.61 hours before intervention to 4.18 hours after intervention (p < .0001). The proportion of GIM patients with CTDT less than 3 hours increased from 25% to 33% (p < .0001). CONCLUSIONS: The interventions trialed led to a sustained reduction in CTDT over a 12-month period and demonstrated the effectiveness of education in influencing physician performance.

A pre and post intervention study to reduce unnecessary urinary catheter use on general internal medicine wards of a large academic health science center.

BACKGROUND: Urinary catheters are a common medical intervention, yet they can also be associated with harmful adverse events such as infection, urinary tract trauma, delirium and patient discomfort. The purpose of this study was to describe the use of the SafetyLEAP program to drive improvement efforts, and specifically to reduce the use of urinary catheters on general internal medicine wards. METHODS: A pre and post intervention study using the SafetyLEAP program was performed with urinary catheter prevalence as the primary outcome on two general internal medicine wards in a large academic health sciences center. RESULTS: A total of n = 534 patients (n = 283 from ward #1; and n = 252 from ward #2) were included in the initial audit and feedback portion of the study and 1601 patients (n = 824 pre-intervention and n = 777 post-intervention were included in the planned quality improvement portion of the study). A total of 379 patients during the quality improvement intervention had a urinary catheter. Overall, the adherence to the SafetyLEAP program was 97.4% on both general internal medicine wards. The daily catheter point prevalence decreased from 22 to 13%. After the implementation of the program, the urinary catheter utilization ratio (defined as urinary catheter days/patient days) declined from 0.14 to 0.12. Catheter-associated urinary tract infections (CAUTI) were unchanged. CONCLUSION: The SafetyLEAP program can help provide a systematic approach to the detection, and reduction of safety incidents. Future studies should aim at refining and implementing this intervention broadly.