A Quality Improvement Intervention to Improve the Efficiency of Arteriovenous Access Placement for Pre-Dialysis Inpatients.

The authors aimed to improve the rate of pre-dialysis arteriovenous (AV) access placement for hospitalized patients with advanced chronic kidney disease. The authors developed and implemented a protocol for hospitalized adult patients with an estimated glomerular filtration rate <20 mL/min to streamline the workflow for obtaining AV access. The protocol was piloted on 5 inpatient medical services over 3 months at 1 institution. Specific-Measurable-Achievable-Realistic-Timely (SMART) aims, Fishbone diagrams, Plan-Do-Study-Act cycles, and run charts were used to assess the process and outcomes of the intervention. There were 22 patients in the baseline group and 27 patients in the intervention group. Pre-dialysis AV access increased from 23% to 46%. Length of stay did not differ significantly between the baseline group (8.31 days) and the intervention group (8.4 days). Pathways can improve pre-dialysis AV access without significantly increasing length of stay.

Physicians-in-training attitudes on patient safety: 2003 to 2008.

OBJECTIVE: : Physician trainees will embody medicine's future culture. We assess whether trainees' patient safety attitudes have evolved over time. METHODS: : We anonymously surveyed more than 800 house staff and fourth-year medical students (MS 4) in 2008, at 1 academic institution, with a 19-item questionnaire and compared their responses to the 2003 responses at the same institution on the same questionnaire. RESULTS: : A total of 463 trainees (53%) completed the 2008 survey, with a mean overall safety score of 3.54, which significantly improved from the 2003 overall score of 3.41 (P < 0.001). Compared with those from 2003, respondents in 2008 more strongly agree that physician-nurse teamwork (P = 0.001), attending supervision (P = 0.017), 80-hour workweek (P < 0.001), computer order entry (P < 0.001), and improved resident sign-out (P < 0.001) help reduce adverse events. The 2008 trainees feel more prepared to prevent adverse events (P = 0.030) and more acknowledge the ethical responsibility to disclose adverse events to patients (P = 0.002). However, compared with 2003, fewer 2008 respondents felt that reducing nurses' patient load would reduce adverse events (P = 0.015); on 8 questionnaire items, there were no significant attitudinal changes between 2003 and 2008. CONCLUSIONS: : Physician trainee safety attitudes at 1 institution improved between 2003 and 2008, and these trainees support many system-based solutions to adverse events. The changes seem incremental and responses do not fully align with all aspects of a safety culture. Cultural change in health care must involve trainees and address their attitudes.

Effectiveness of a clinical-decision-support system in improving compliance with cardiac-care quality measures and supporting resident training.

Many of the quality measures for patients with heart failure (HF) or acute myocardial infarction (AMI) require the completion of comprehensive discharge instructions, including instructions about medications to be taken after discharge. To improve compliance in a tertiary care teaching hospital with these evidence-based quality measures, a clinical-decision-support system (CDSS) that uses an electronic checklist was developed. The CDSS prompts clinicians at every training level to consistently create comprehensive discharge instructions addressing quality measures. The authors compared compliance during the 15-month preintervention and postintervention periods. Compliance with discharge measures for AMI (i.e., aspirin, beta-blocker, angiotensin-converting enzyme inhibitor [ACEI], or angiotensin receptor blocker [ARB] use) and for HF (i.e., discharge instructions, left ventricular systolic function [LVSF] evaluation, and ACEI/ARB use) was assessed. The delivery of discharge instructions showed significant improvement from the preintervention period to the postintervention period (37.2% to 93.0%; P < .001). Compliance with prescription of ACEI or ARB also improved significantly for HF (80.7% to 96.4%; P < .001) and AMI (88.1% to 100%; P = .014) patients. Compliance with the remaining measures was higher before intervention, and, thus, the modest improvement in the postintervention period was not statistically significant (AMI patients: aspirin, 97.5% to 98.8%; P = .43; and beta-blocker, 97.9% to 98.7%; P = .78; HF patients: LVSF, 99.3% to 99.1%; P = .78). Implementation of a CDSS with computerized electronic prompts improved compliance with selected cardiac-care quality measures. The design of quality-improvement decision-support tools should incorporate educational missions in their message and design.

Hypoglycemia in hospitalized patients treated with antihyperglycemic agents.

OBJECTIVE: To determine the incidence and manifestations of hypoglycemia in hospitalized patients receiving antihyperglycemic therapy. RESEARCH DESIGN AND METHODS: The study was a 3-month prospective review of consecutive medical records of all adult, nonpregnant hospitalized patients at a 675-bed university hospital who experienced at least 1 blood glucose (BG)

Enhancing patient safety during feeding-tube insertion: a review of more than 2,000 insertions.

BACKGROUND: An intervention to reduce complications from insertion of small-bore nasogastric feeding tubes was performed. METHODS: This was a Performance Improvement project with the Plan, Do, Study, Act (PDSA) format; interventions occurred in July 2003. Electronic searches of risk management and radiology databases identified feeding-tube malpositions and complications from January 1, 2001, through December 31, 2004. Chart abstraction and a pre- and postintervention comparison were performed. Interventions were adoption of a more compliant feeding tube, direct supervision of residents, technology-guided insertion, and implementation of explicit policies and procedures. RESULTS: Of all small-bore nasogastric feeding-tube placements, 1.3%-2.4% resulted in 50 documented cases of feeding-tube malpositions during 4 years. Over half of the 50 patients were mechanically ventilated, and only 2 had a normal mental status. There were 13 complications (26% of malpositions), including 2 deaths, which were directly attributed to the feeding-tube malposition. Only 2 of the 13 complications and none of the misplacements had been recorded in the risk management database; most cases were identified from the search of radiology reports. In the 15-month postintervention period, no complications were identified. The control chart showed that after the intervention, there was a significant increase in the "number between" tube insertions without complications, confirming the effectiveness of the performance improvement (PI) project. CONCLUSIONS: Unassisted feeding tube insertion carries significant risk in vulnerable patients, which can be mitigated. Voluntary reporting appears inadequate to capture complications from feeding tube insertion.

Attitudes about patient safety: a survey of physicians-in-training.

Little is known about the attitudes of physicians-in-training on patient safety, although success in error reduction strategies requires their support. We surveyed house staff and fourth-year medical students from 1 academic institution about their perceptions of adverse patient events. Three hundred twenty-one trainees (41%) completed the survey. Most believe adverse events are preventable (61%) and think improved teamwork (88%), better procedural training (74%), and improved sign-out (70%) would reduce medical mishaps. Forty-seven percent of trainees agree computerized order entry and restricted work hours would prevent adverse events. Although 60% feel malpractice fears inhibit discussion, 80% of trainees agreed physicians must disclose adverse events to patients and grow more comfortable with disclosure as training progresses (P for trend<.01). In conclusion, trainees believe adverse events are preventable and are poised to respond to many components of the patient safety movement.