Importancia de la resiliencia individual y organizacional para la salud laboral del personal sanitario / Importance of individual and organizational resilience for the occupational health of healthcare workers

La resiliencia individual se refiere a las cualidades personales que permiten prosperar frente a la adversidad. La resiliencia organizacional es la capacidad de una organización para adaptarse en tiempos de crisis. Ambas variables pueden desempeñar un papel positivo en la salud de los empleados del sector sanitario, especialmente en el contexto actual de pandemia. El objetivo principal es explorar el impacto de la resiliencia individual y organizacional en la salud laboral. Se llevó a cabo un estudio transversal con cuestionarios validados, en una muestra de 311 profesionales de dos hospitales de Barcelona. Los resultados indican que una mayor resiliencia individual influye en menor fatiga, menor presencia de enfermedad y mayor satisfacción laboral. A su vez, una mayor percepción de resiliencia organizacional tiene un impacto significativo en la satisfacción laboral. Se destaca la importancia de considerar la resiliencia en los planes de intervención para la mejora de la salud laboral en el ámbito hospitalario (AU)

Individual resilience refers to the personal qualities that allow to thrive in the face of adversity. Organizational resilience is the ability of an organization to survive and grow stronger in times of crisis. Both variables can play a positive role in the health of healthcare employees, especially in the current context of a pandemic. The main objective is to explore the impact of individual and organizational resilience on occupational health. A cross-sectional study was carried out with validated questionnaires. The sample consisted of 311 professionals from two hospitals in the Barcelona region. The results indicate that higher individual resilience is related to less fatigue, less disease and greater job satisfaction. In turn, a higher perception of organizational resilience has a significant impact on job satisfaction. These results confirm the importance of considering resilience in intervention plans to improve occupational health in the health field (AU)

Segurança do paciente em hospitais de grande porte / Patient safety in large hospitals

Objetivo: analisar a implementação da política nacional de segurança do paciente. Método: trata-se de um estudo quantitativo, descritivo e avaliativo de casos múltiplos em hospitais de grande porte. Informa-se que a coleta de dados constou de uma entrevista com o profissional responsável pelos Núcleos de Segurança do Paciente por meio de um formulário semiestruturado. Analisaram-se os dados pela estatística simples. Resultados: detalha-se que, dos 20 hospitais elegíveis, 12 (60%) participaram do estudo; todos os hospitais (100%) possuem núcleos constituídos, (91,7%) com Plano de Segurança do Paciente e (50%) contam com profissional com dedicação exclusiva. Implementaram-se, por mais da metade dos núcleos (58,3%), todos os protocolos obrigatórios, sendo identificação do paciente (83,3%) e higienização das mãos (83,3%) os mais frequentes. Revela-se que os percentuais de eventos adversos notificados foram: lesão por pressão (88,9%); queda do leito (77,8%) e erros de medicamentos (75%). Conclusão: conclui-se que os núcleos estudados não atendem totalmente às políticas regulatórias vigentes no país, merecendo, portanto, de adequações e de controle sanitário efetivo.(AU)

Objective: to analyze the implementation of the national patient safety policy. Method: this is a quantitative, descriptive and evaluative study of multiple cases in large hospitals. Please be informed that the data collection consisted of an interview with the professional responsible for the Patient Safety Centers using a semi-structured form. Data were analyzed using simple statistics. Results: it is detailed that, of the 20 eligible hospitals, 12 (60%) participated in the study; all hospitals (100%) have centers, (91.7%) have a Patient Safety Plan and (50%) have a professional with exclusive dedication. All mandatory protocols were implemented in more than half of the centers (58.3%), with patient identification (83.3%) and hand hygiene (83.3%) being the most frequent. It is revealed that the percentages of adverse events reported were: pressure injury (88.9%); bed falls (77.8%) and medication errors (75%). Conclusion: it is concluded that the centers studied do not fully comply with the regulatory policies in force in the country, therefore deserving adjustments and effective sanitary control.(AU)

Objetivo: analizar la implementación de la política nacional de seguridad del paciente. Método: se trata de un estudio cuantitativo, descriptivo y evaluativo de casos múltiples en grandes hospitales. Tenga en cuenta que la recopilación de datos consistió en una entrevista con el profesional responsable de los Centros de Seguridad del Paciente utilizando un formulario semiestructurado. Los datos se analizaron mediante estadísticas simples. Resultados: se observa que de los 20 hospitales elegibles, 12 (60%) participaron en el estudio. Se dice que todos los hospitales (100%) tienen centros constituidos, (91.7%) con un Plan de Seguridad del Paciente y (50%) tienen un profesional con dedicación exclusiva. Es de destacar que más de la mitad de los centros (58.3%) implementan todos los protocolos obligatorios, siendo la identificación del paciente (83.3%) y la higiene de manos (83.3%) las más frecuentes. Se observa que los porcentajes de eventos adversos informados fueron: lesión por presión (88,9%), caída de la cama (77,8%) y errores de medicación (75%). Conclusión: se informa que los centros estudiados no cumplen plenamente con las políticas regulatorias vigentes en el país, por lo que merecen ajustes y un control sanitario efectivo.(AU)

Racial and Ethnic Differences in 30-Day Hospital Readmissions Among US Adults With Diabetes.

Importance: Differences in readmission rates among racial and ethnic minorities have been reported, but data among people with diabetes are lacking despite the high burden of diabetes and its complications in these populations. Objectives: To examine racial/ethnic differences in all-cause readmission among US adults with diabetes and categorize patient- and system-level factors associated with these differences. Design, Setting, and Participants: This retrospective cohort study includes 272 758 adult patients with diabetes, discharged alive from the hospital between January 1, 2009, and December 31, 2014, and stratified by race/ethnicity. An administrative claims data set of commercially insured and Medicare Advantage beneficiaries across the United States was used. Data analysis took place between October 2016 and February 2019. Main Outcomes and Measures: Unplanned all-cause readmission within 30 days of discharge and individual-, clinical-, economic-, index hospitalization-, and hospital-level risk factors for readmission. Results: A total of 467 324 index hospitalizations among 272 758 adults with diabetes (mean [SD] age, 67.7 [12.7]; 143 498 [52.6%] women) were examined. The rates of 30-day all-cause readmission were 10.2% (33 683 of 329 264) among white individuals, 12.2% (11 014 of 89 989) among black individuals, 10.9% (4151 of 38 137) among Hispanic individuals, and 9.9% (980 of 9934) among Asian individuals (P < .001). After adjustment for all factors, only black patients had a higher risk of readmission compared with white patients (odds ratio, 1.05; 95% CI, 1.02-1.08). This increased readmission risk among black patients was sequentially attenuated, but not entirely explained, by other demographic factors, comorbidities, income, reason for index hospitalization, or place of hospitalization. Compared with white patients, both black and Hispanic patients had the highest observed-to-expected (OE) readmission rate ratio when their income was low (annual household income <$40 000 among black patients: OE ratio, 1.11; 95% CI, 1.09-1.14; among Hispanic patients: OE ratio, 1.11; 95% CI, 1.07-1.16) and when they were hospitalized in nonprofit hospitals (black patients: OE ratio, 1.10; 95% CI, 1.08-1.12; among Hispanic patients: OE ratio, 1.08; 95% CI, 1.05-1.12), academic hospitals (black patients: OE ratio, 1.16; 95% CI, 1.13-1.20; Hispanic patients: OE ratio, 1.12; 95% CI, 1.06-1.19), or large hospitals (ie, with ≥400 beds; black patients: OE ratio, 1.11; 95% CI, 1.09-1.14; Hispanic patients: OE ratio, 1.09; 95% CI, 1.04-1.14). Conclusions and Relevance: In this study, black patients with diabetes had a significantly higher risk of readmission than members of other racial/ethnic groups. This increased risk was most pronounced among lower-income patients hospitalized in nonprofit, academic, or large hospitals. These findings reinforce the importance of identifying and addressing the many reasons for persistent racial/ethnic differences in health care quality and outcomes.

Prevalence and characteristics of hospital inpatients with reported fluoroquinolone allergy.

Background Fluoroquinolone (quinolones) antibiotics are commonly prescribed worldwide. Hypersensitivity reactions to these agents have been reported, but little systematic data exists concerning prevalence, types of reactions, or associated factors. Objective To identify the prevalence of patients reporting an allergy to quinolones, types of reactions claimed, and patient information associated with allergy. Setting A tertiary 370 bed level 1 trauma center, located in a Midwestern City in the United States. Method A retrospective cohort study was conducted. Included in the study were all unique patients 18 years or older admitted to our hospital in 2016 with a length of stay ≥ 24 h. Collected data elements included types of reaction, other drug allergies claimed, and patient characteristics. As a comparator group, an equal sized random sample of patients admitted during the same period reporting penicillin allergy was identified. Main Outcome Measure prevalence and descriptors of quinolone allergy. Results There were 327 patients with a quinolone allergy and 317 patients with a penicillin allergy used as the study sample. Hospital prevalence rate for quinolone allergy was 2%. Hives, rash, and nausea/vomiting were the most common reported reactions. These patients tended to be older than penicillin allergy patients and had an association with concomitant intravenous contrast allergy. Tendonitis or tendon rupture was reported in quinolone patients. Conclusion The prevalence of patients claiming a quinolone allergy in the study hospital was 2%. Common hypersensitivity reactions were reported. Data tended to support a possible association between intravenous contrast allergy and quinolone allergy.

Mortality of hospitalised internal medicine patients bedspaced to non-internal medicine inpatient units: retrospective cohort study.

OBJECTIVE: To compare inhospital mortality of general internal medicine (GIM) patients bedspaced to off-service wards with GIM inpatients admitted to assigned GIM wards. METHOD: A retrospective cohort study of consecutive GIM admissions between 1 January 2015 and 1 January 2016 was conducted at a large tertiary care hospital in Canada.Inhospital mortality was compared between patients admitted to off-service wards (bedspaced) and assigned GIM wards using a Cox proportional hazards model and a competing risk model. Sensitivity analyses included propensity score and pair matching based on GIM service team, workload, demographics, time of admission, reasons for admission and comorbidities. RESULTS: Among 3243 consecutive GIM admissions, more than a third (1125, 35%) were bedspaced to off-service wards with the rest (2118, 65%) admitted to assigned GIM wards. In hospital, 176 (5%) patients died: 88/1125 (8%) bedspaced patients and 88/2118 (4%) assigned GIM ward patients. Compared with assigned GIM wards patients, bedspaced patients had an HR of 3.42 (95% CI 2.23 to 5.26; P<0.0001) for inhospital mortality at admission, which then decreased by HR of 0.97 (95% CI 0.94 to 0.99; P=0.0133) per day in hospital. Competing risk models and sensitivity analyses using propensity scores and pair matching yielded similar results. CONCLUSIONS: Bedspaced patients had significantly higher inhospital mortality than patients admitted to assigned GIM wards. The risk was highest at admission and subsequently declined. The results of this single centre study may not be generalisable to other hospitals and may be influenced by residual confounding. Despite these limitations, the relationship between bedspacing and patient outcomes requires investigation at other institutions to determine if this common practice represents a modifiable patient safety indicator.

Using scores to identify patients at risk of short term mortality at arrival to the acute medical unit: A validation study of six existing scores.

INTRODUCTION: "Early warning scores" (EWS) have been developed to quantify levels of vital sign abnormality. However, many scores have not been validated. The aim of this study was to validate six scores that all rely on vital signs: Rapid Acute Physiology Score (RAPS), Rapid Emergency Medicine Score (REMS) and the National Early Warning Score (NEWS) and the Goodacre, Groarke and Worthing physiological scores. METHODS: A posthoc single-center observational cohort study of prospectively collected vital signs on acutely admitted medical patients to a Danish hospital. All adult patients arriving at an acute medical unit at a 450-bed regional teaching hospital were included. Upon arrival, we registered initial vital signs and only the first presentation in the study period was included. Patients were included from 1 June to 31 October 2012. All-cause 24-h mortality and overall in-hospital mortality were used as endpoints. A discriminatory power above 0.8 was considered acceptable. RESULTS: 5784 patients were included with a median age of 67 (49-78) years, 32 (0.6%) died within 24h and 161 (2.8%) while admitted. Discriminatory power for 24h mortality was above 0.8 for all scores (except the Groarke score (0.587)) and highest for the Worthing score (0.847). The discriminatory power for predicting overall in-hospital mortality was highest for the Goodacre and Worthing scores (0.810 and 0.800 respectively) but below 0.8 for the remaining scores. CONCLUSION: The Goodacre score and the Worthing physiological score have good discriminatory power at identifying patients at increased risk of 24-h and in-hospital mortality in our setting.

Hospital occupancy and discharge strategies: a simulation-based study.

BACKGROUND: Increasing demand for hospital services has resulted in more arrivals to emergency department (ED), increased admissions, and, quite often, access block and ED congestion, along with patients' dissatisfaction. Cost constraints limit an increase in the number of hospital beds, so alternative solutions need to be explored. AIMS: To propose and test different discharge strategies, which, potentially, could reduce occupancy rates in the hospital, thereby improving patient flow and minimising frequency and duration of congestion episodes. METHODS: We used a simulation approach using HESMAD (Hospital Event Simulation Model: Arrivals to Discharge) - a sophisticated simulation model capturing patient flow through a large Australian hospital from arrival at ED to discharge. A set of simulation experiments with a range of proposed discharge strategies was carried out. The results were tabulated, analysed and compared using common hospital occupancy indicators. RESULTS: Simulation results demonstrated that it is possible to reduce significantly the number of days when a hospital runs above its base bed capacity. In our case study, this reduction was from 281.5 to 22.8 days in the best scenario, and reductions within the above range under other scenarios considered. CONCLUSION: Some relatively simple strategies, such as 24-h discharge or discharge/relocation of long-staying patients, can significantly reduce overcrowding and improve hospital occupancy rates. Shortening administrative and/or some treatment processes have a smaller effect, although the latter could be easier to implement.

Organizational Perspectives of Nurse Executives in 15 Hospitals on the Impact and Effectiveness of Rapid Response Teams.

BACKGROUND: Many hospitals use rapid response teams (RRTs) to respond to deteriorating patients, but it remains unclear what organizations actually monitor. Understanding what organizations value in an RRT may help clarify measurement choices. Interviews were conducted to determine how organizational leaders perceived and evaluated their hospitals' RRTs. METHODS: The study used a descriptive, qualitative design. Participants were nurse executives and key informants in 300- to 500-bed hospitals in the south-central United States and were recruited using purposive and snowball sampling. Sample size was determined by data saturation. Semistructured face-to-face interviews were audio-recorded and transcribed. Interview data were analyzed using the techniques of conventional content analysis and constant comparison and descriptive statistics for demographics. RESULTS: From November 2014 through April 2015, 27 participants were interviewed from 15 hospitals. Global themes emerged: value of and monitoring the RRT. All participants valued positive patient outcomes from use of the RRT, such as decreased code rates and transfers to the ICU. They also valued positive influences of the RRT on the health care team such as education, relationships, and promotion of a culture of safety, including providing consistency of care and evidence-based care. Formal and informal RRT evaluations were usually conducted, resulting in subsequent actions. CONCLUSION: Participants emphasized the impact of the RRT on professional staff relationships and the organizational culture, suggesting that the actual value of the RRT stretches beyond patient outcomes. Evaluations of the RRTs were largely informal. Hospitals placed high value on health care team and organizational outcomes but generally did not capture data to support them.

Pharmacy-Driven Dexmedetomidine Stewardship and Appropriate Use Guidelines in a Community Hospital Setting.

BACKGROUND: Dexmedetomidine is a widely utilized agent in the intensive care unit (ICU) because it does not suppress respiratory drive and may be associated with less delirium than midazolam or propofol. Cost of dexmedetomidine therapy and debate as to the proper duration of use has brought its use to the forefront of discussion. OBJECTIVE: To validate the efficacy and cost savings associated with pharmacy-driven dexmedetomidine appropriate use guidelines and stewardship in mechanically ventilated patients. METHODS: This was a retrospective cohort study of adult patients who received dexmedetomidine for ICU sedation while on mechanical ventilation at a 433-bed not-for-profit community hospital. Included patients were divided into pre-enactment (PRE) and postenactment (POST) of dexmedetomidine guideline groups. RESULTS: A total of 100 patients (50 PRE and 50 POST) were included in the analysis. A significant difference in duration of mechanical ventilation (11.1 vs 6.2 days, P = 0.006) and incidence of reintubation (36% vs 18% of patients, P = 0.043) was seen in the POST group. Aggregate use of dexmedetomidine 200-µg vials (37.1 vs 18.4 vials, P = 0.010) and infusion days (5.4 vs 2.5 days, P = 0.006) were significantly lower in the POST group. Dexmedetomidine acquisition cost savings were calculated at $374 456.15 in the POST group. There was no difference between the PRE and POST groups with regard to ICU length of stay, expected mortality, and observed mortality. CONCLUSIONS: Pharmacy-driven dexmedetomidine appropriate use guidelines decreased the use of dexmedetomidine and increased cost savings at a community hospital without adversely affecting clinical outcomes.

Predictors of a Desire to be Helpful to Professional Nurses Among Japanese Nursing Assistants in Small- to Medium-Sized Hospitals.

Registered nurses and licensed practical nurses have been educated as professional nurses. Professional nurses can concentrate on their jobs requiring a high degree of expertise with help they get from nursing assistants.If professional nurses have improper attitudes toward nursing assistants, it is most likely that the nursing assistants will not help them to the best of their ability. We investigated nursing assistants' impressions regarding professional nurses' attitudes, and what effects nursing assistants' impressions have on their "desire to be helpful to professional nurses." The study design was a cross sectional study. Twenty-five small- to medium-sized hospitals with 55 to 458 beds were included in this study. The analyzed subjects were 642 nursing assistants (96 males, 546 females). Factor analyses were conducted to extract the factors of nursing assistants' impressions regarding professional nurses' attitudes. Multiple linear regression analysis was conducted to investigate the predictors of "desire to be helpful to professional nurses." We discovered 5 factors: 1. professional nurses' model behavior, 2. manner dealing with nursing assistants, 3. respect for nursing assistants' passion for their work, 4. respect for nursing assistants' work, and 5. enhancing the ability of nursing assistants to do their work. The "desire to be helpful to professional nurses" was significantly associated with "professional nurses' model behavior," "manner dealing with nursing assistants" and "respect for nursing assistants' passion for their work." Factors 1 to 3 are fundamental principles when people establish appropriate relationships. Professional nurses must consider these fundamentals in their daily work in order to get complete cooperation from nursing assistants.

Clinical Weighting of Drug-Drug Interactions in Hospitalized Elderly.

Adverse drug reactions impact on patient health, effectiveness of pharmacological therapy and increased health care costs. This investigation intended to detect the most critical drug-drug interactions in hospitalized elderly patients, weighting clinical risk. We conducted a cross-sectional study between January and April 2014; all patients 70 years or older, hospitalized for >24 hr and prescribed at least one medication were included in the study. Drug-drug interactions were estimated by combining Stockley's, Hansten and Tatro drug interactions. Drug-drug interactions were weighted using a risk-analysis method based on failure modes, effects and criticality analysis. We calculated a criticality index for each drug involved in the drug-drug interactions based on the severity of the interaction mechanism, the frequency the drug was involved in drug-drug interactions and the risk of drug-drug interactions in patients with impaired renal function. The average number of drugs consumed in the hospital was 6 ± 2.69, involving 160 active ingredients. The most frequent were as follows: Furosemide, followed by Enalapril. Of drug-drug interactions, 2% were classified as contraindicated, 14% advised against and 83% advised caution during the hospital stay. Thirty-four drug-drug interactions were assessed, of which 23 were pharmacodynamic drug-drug interactions and 12 were pharmacokinetic drug-drug interactions (1 was both). The clinical risk calculated for each drug-drug interaction included heparins + non-steroidal anti-inflammatory drugs (NSAIDs) or Digoxin + Calcium Gluconate, cases which are pharmacodynamic drug-drug interactions with agonist effect and clinical risk of bleeding, one of the most common clinical risks in the hospital. An index of clinical risk for drug-drug interactions can be calculated based on severity by the interaction mechanism, the frequency that the drug is involved in drug-drug interactions and the risk of drug-drug interactions in an elderly patient with impaired renal function.

Proper use of carbapenems: Role of the infectious disease specialist.

OBJECTIVE: One of the objectives of the French national plan on antibiotics is to preserve antibiotic effectiveness. A group of infectious disease specialists of the University hospital of Bordeaux aimed to monitor the prescriptions of broad-spectrum antibiotics. Particular attention was paid to carbapenem (CBP) prescriptions given the increase in betalactamase- and carbapenemase-producing bacteria. PATIENTS AND METHODS: We carried out a three-step Professional Practice Evaluation (PPE): evaluation of CBP prescriptions made at the hospital between January and June 2013; CBP prescription training for prescribers; and another evaluation of CBP prescriptions between January and June 2014. RESULTS: Although the number of admissions remained stable between the two evaluation periods, CBP prescriptions decreased by 16%. The mean treatment duration was stable (9.6 days). Physicians asked for the infectious disease specialist's advice for 82% of CBP prescriptions in 2013 and for 83% in 2014. The number of case patients discussed at the multidisciplinary staff meetings for approval of CBP prescriptions increased from 16% in 2013 to 39% in 2014. Antibiotic de-escalation increased by 61% between the two periods. CONCLUSION: Professional Practice Evaluation, supervised by an infectious disease specialist, is a useful addition to weekly multidisciplinary staff meetings to improve CBP prescription.

Off-label and unlicensed utilisation of medicines in a French paediatric hospital.

BACKGROUND: Off-label or unlicensed medicine use is very common in paediatric practice, ranging from 11 to 80 %, and is one of the predisposing factors for adverse events (23-60 %). Medicine indications are the third leading reason for doctors to perform off-label prescriptions. OBJECTIVE: The aim of our study was to determine the prevalence and nature of off-label and unlicensed medicine prescriptions in children and propose methods for risk reduction and management. SETTING: 475 bed maternity-paediatric university hospital. METHOD: Retrospective cross-sectional study lasting 1 day on new prescriptions issued over the previous 24 h by departments using electronic prescribing. Age and indication were compared to those in the French independent formulary Thériaque(®) database. MAIN OUTCOME MEASURE: Number of off-label/unlicensed prescriptions, number of patients, proportion of off-label/unlicensed prescriptions by age group, treatment class and International Non proprietary Name (INN), using the established classification. RESULTS: A total of 315 prescription medicines were analysed for 120 patients, of average age 5.1 years old. For the classification of medicine utilisation, the majority of the medicines were prescribed as licensed (190/60.3 %), followed by off-label (115/36.5 %) and unlicensed (10/3.2 %) medicines. Alimentary tract, metabolic and nervous system medicines constituted the most widely prescribed ATC classes. At least 54 % of patients received an off-label/unlicensed medicine. The indications for these were mainly for off-label prescriptions (80/25.4 %) followed by medicines not evaluated for safety and regarding safety and efficacy in children (14/4.5 %). Pantoprazole was the most widely prescribed off-label INN for stress ulcer prevention (62 %). For risk reduction, we found esomeprazole being prescribed instead of pantoprazole; esomeprazole is indicated for children under a year old. CONCLUSION: This study reflects one given day: 36.5 % of off-label prescriptions and 3.2 % of unlicensed prescriptions in a paediatric setting. Few risk reductions for off-label number prescriptions have been found. This work confirmed the necessity of carrying out further studies in children.

Demonstrating the clinical pharmacist's activity: validation of an intervention oriented classification system.

BACKGROUND: Clinical pharmacists are increasingly involved in detecting and solving drug-related problems. To document their performance, a convenient tool to code pharmaceutical interventions in daily practice is desirable. The Swiss Society of Public Health Administration and Hospital Pharmacists (GSASA) proposed to implement a new classification system for pharmaceutical interventions. OBJECTIVES: To develop and validate a classification system for pharmaceutical interventions and to compare it with the well-established Pharmaceutical Care Network Europe (PCNE) system. SETTING: Rehabilitation clinic, geriatric and orthopaedic wards of a 427-bed teaching hospital. METHODS: Development of the GSASA classification started with expert panel discussions and the validation of the first version (GSASA V1). To assess appropriateness, interpretability, and validity, clinical pharmacists documented during a 6-week period all interventions using GSASA V1 and PCNE version 6.2 (V6.2). Acceptability and feasibility were tested by an 8-item questionnaire with 5-point Likert scale (1 = strongly disagree, 5 = strongly agree), and inter-rater reliability (Fleiss-Kappa coefficients κ) was determined. After revision, the second version (V2) was assessed again for reliability. MEAN OUTCOME MEASURES: User's agreement/satisfaction, comprehensiveness/reliability of the classification system. RESULTS: The GSASA V1 includes 4 categories and 35 subcategories. Of 115 interventions classified with GSASA V1, 93 (80.9 %) could be completely classified in all categories. This explains that 3 of 6 users could be not satisfied with the comprehensiveness of GSASA V1 (mean user agreement 2.7 ± 0.8). The questionnaire showed that all users could find GSASA V1 (4.0 ± 0.0) easier to use than PCNE V6.2 (3.0 ± 0.9). Users were generally satisfied with the GSASA V1 (3.5 ± 0.8), especially with the adequate time expenditure (4.0 ± 0.7). Inter-rater reliability and acceptability of GSASA V1 were comparable to those of the PCNE V6.2. The agreement among the GSASA V1 users was substantial for the categories 'problem' (κ = 0.66), 'intervention' (κ = 0.74), and 'outcome' (κ = 0.63), while moderate agreement for the category 'cause' was obtained (κ = 0.53). The final system GSASA V2 includes 5 categories (addition of 'type of problem') and 41 subcategories. Total inter-rater reliability was moderate (κ = 0.52). CONCLUSION: The GSASA classification system appeared to be reliable and promising for documentation of pharmaceutical interventions in daily practice (practical and less time-consuming). The system is validated in terms of appropriateness, interpretability, validity, acceptability, feasibility, and reliability.

A multidisciplinary care pathway significantly increases the number of early morning discharges in a large academic medical center.

In an environment where there is increased demand for hospital beds, it is important that inpatient flow from admission to treatment to discharge is optimized. Among the many drivers that impact efficient patient throughput is an effective and timely discharge process. Early morning discharge helps align inpatient capacity with clinical demand, thereby avoiding gridlock that adversely affects scheduled surgical procedures, diagnostic procedures, and therapies. At our large, academic medical center, we hypothesized that an interdisciplinary approach to scheduled discharge order entry would increase the percentage of discharges occurring before 11:00 AM and improve overall discharge time. The pilot study involved moving rate-limiting steps to earlier in the discharge process, specifically medication reconciliation to the night before discharge and "discharge to home" order entry before 9:00 AM the morning of discharge. The baseline rate of discharges before 11:00 AM was 8% and significantly increased to 11% after the intervention (P = .02). Moreover, in the subset of patients (21%) for whom early medication reconciliation and discharge to home order entry were both executed, the percentage of patient discharges occurring before 11:00 AM increased to 29.7%, with an associated average discharge time of more than 3 hours earlier. No patient harm events were associated with this pilot project. There was no significant change in length of stay, and 30-day readmission rate improved significantly from 13.8% to 10.3% (P = .002). Our study demonstrates that a multidisciplinary approach using prescribed order entry and medication reconciliation is a low cost, safe, and effective way to increase early morning discharges and improve patient flow for large hospitals with high volumes of scheduled patient admissions.

Clinical and economic impact of a quality improvement initiative to enhance early recognition and treatment of sepsis.

BACKGROUND: Studies evaluating the clinical effectiveness of sepsis screening tools and methods to improve the time from diagnosis to antibiotic administration are needed to improve sepsis-related outcomes. OBJECTIVE: To evaluate the clinical and economic impact of a sepsis quality improvement initiative to improve early recognition and treatment of sepsis. METHODS: A retrospective observational study of adults with sepsis was performed in a 433-bed tertiary medical center. Baseline data were collected for 181 patients with sepsis diagnosis-related group (DRG) coding assignments from July through September 2013. The intervnetion group included 216 patients from October through December 2013. A First-Dose STAT Antibiotic policy was developed, and nurses were instructed to complete an electronic sepsis screening tool once per shift. Primary outcomes included in-hospital mortality and intensive care unit (ICU) length of stay (LOS). Secondary outcomes included overall LOS and cost per case. RESULTS: Nonsignificant decreases in overall LOS (7.43 ± 5.68 days vs 6.77 ± 5 days; P = 0.138) and in-hospital mortality (13.8% vs 8.8%; P = 0.113) were observed in patients with sepsis DRGs. Early recognition and treatment contributed to significant reductions in ICU LOS (5.85 ± 4.38 days vs 4.21 ± 3.64 days; P = 0.003) and total cost per case ($14 378 vs $12 311; P = 0.033). The percentage of highest disease-severity DRG coding assignments decreased from 7.9% to 0%. CONCLUSIONS: Strategies to improve early recognition and treatment of sepsis, including routine use of an electronic sepsis screening tool and implementation of a First-Dose STAT Antibiotic policy, contributed to significant reductions in ICU LOS and cost per case.

The return on investment of implementing a continuous monitoring system in general medical-surgical units.

OBJECTIVES: To evaluate the cost savings attributable to the implementation of a continuous monitoring system in a medical-surgical unit and to determine the return on investment associated with its implementation. DESIGN: Return on investment analysis. SETTING: A 316-bed community hospital. PATIENTS: Medicine, surgery, or trauma patients admitted or transferred to a 33-bed medical-surgical unit. INTERVENTIONS: Each bed was equipped with a monitoring unit, with data collected and compared in a 9-month preimplementation period to a 9-month postimplementation period. MEASUREMENTS AND MAIN RESULTS: Two models were constructed: a base case model (A) in which we estimated the total cost savings of intervention effects and a conservative model (B) in which we only included the direct variable cost component for the final day of length of stay and treatment of pressure ulcers. In the 5-year return on investment model, the monitoring system saved between $3,268,000 (conservative model B) and $9,089,000 (base model A), given an 80% prospective reimbursement rate. A net benefit of between $2,687,000 ($658,000 annualized) and $8,508,000 ($2,085,000 annualized) was reported, with the hospital breaking even on the investment after 0.5 and 0.75 of a year, respectively. The average net benefit of implementing the system ranged from $224 per patient (model B) to $710 per patient (model A) per year. A multiway sensitivity analyses was performed using the most and least favorable conditions for all variables. In the case of the most favorable conditions, the analysis yielded a net benefit of $3,823,000 (model B) and $10,599,000 (model A), and for the least favorable conditions, a net benefit of $715,000 (model B) and $3,386,000 (model A). The return on investment for the sensitivity analysis ranged from 127.1% (25.4% annualized) (model B) to 601.7% (120.3% annualized) (model A) for the least favorable conditions and from 627.5% (125.5% annualized) (model B) to 1739.7% (347.9% annualized) (model A) for the most favorable conditions. CONCLUSIONS: Implementation of this monitoring system was associated with a highly positive return on investment. The magnitude and timing of these expected gains to the investment costs may justify the accelerated adoption of this system across remaining inpatient non-ICU wards of the community hospital.

Sustainable, effective implementation of a surgical preprocedural checklist: an "attestation" format for all operating team members.

BACKGROUND: Adoption ofa preprocedural pause (PPP) associated with a checklist and a team briefing has been shown to improve teamwork function in operating rooms (ORs) and has resulted in improved outcomes. The format of the World Health Organization Safe Surgery Saves Lives checklist has been used as a template for a PPP. Performing a PPP, described as a "time-out," is one of the three principal components, along with a preprocedure verification process and marking the procedure site, of the Joint Commission's Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery. However, if the surgeon alone leads the pause, its effectiveness may be decreased by lack of input from other operating team members. METHODS: In this study, the PPP was assessed to measure participation and input from operating team members. On the basis of low participation levels, the pause was modified to include an attestation from each member of the team. RESULTS: Preliminary analysis of our surgeon-led pause revealed only 54% completion of all items, which increased to 97% after the intervention. With the new format, operating team members stopped for the pause in 96% of cases, compared with 78% before the change. Operating team members introduced themselves in 94% of cases, compared with 44% before the change. Follow-up analysis showed sustained performance at 18 months after implementation. CONCLUSIONS: A preprocedural checklist format in which each member of the operating team provides a personal attestation can improve pause compliance and may contribute to improvements in the culture of teamwork within an OR. Successful online implementation of a PPP, which includes participation by all operating team members, requires little or no additional expense and only minimal formal coaching outside working situations.

Performance of the adverse drug event trigger tool and the global trigger tool for identifying adverse drug events: experience in a Belgian hospital.

BACKGROUND: Medication-related harm can be detected using the adverse drug event (ADE) trigger tool and the medication module of the Global Trigger Tool (GTT) developed by the Institute for Healthcare Improvement (IHI). In recent years, there has been some controversy on the performance of this method. In addition, there are limited data on the performance of the medication module of the GTT as compared with the ADE trigger tool. OBJECTIVES: To evaluate the performance of the ADE trigger tool and of the medication module of the GTT for identifying ADEs. METHODS: The methodology of the IHI was used. A random sample of 20 adult admissions per month was selected over a 12-month period in a teaching hospital in Belgium. The ADE trigger tool was adapted to the Belgian setting and included 20 triggers. The positive predictive value (PPV) of each trigger was calculated, as well as the proportion of ADEs that would have been identified with the medication module of the GTT as compared with the ADE trigger tool. RESULTS: A total of 200 triggers and 62 ADEs were found, representing 26 ADEs/100 admissions. Nineteen ADEs (31%) were found spontaneously without the presence of a trigger. Three triggers never occurred. The PPVs of other triggers varied from 0 to 0.67, with half of them having PPVs less than 0.20. If we had used the medication triggers included in the GTT (n = 11), we would have identified 77% of total ADEs and 67% of preventable ADEs. CONCLUSIONS: Applying the trigger tool method proposed by the IHI to a Belgian hospital led to the identification of one ADE out of 4 admissions. To increase performance, refining the list of triggers in the ADE trigger tool and in the medication module of the GTT would be needed. Recording nontriggered events should be encouraged.