Incidence of complications after nonoperating room anesthesia in children in a low- and middle-income country: A prospective and observational study.

INTRODUCTION: Nonoperating room anesthesia is a growing field of medicine that can have an increased risk of complications, particularly in low- and middle-income countries. AIMS: The aim of this study was to describe the incidence of complications after pediatric nonoperating room anesthesia and investigate its risk factors. METHODS: In this prospective observational study, we included all children aged less than 5 years who were sedated or anesthetized in the radiology setting of a university hospital in a low- and middle-income country. Patients were divided into two groups: complications or no-complications groups. Then, we compared both groups, and univariable and multivariable logistic regression models were used to investigate the main risk factors for complications. RESULTS: We included 256 children, and the incidence of complications was 8.6%. The main predictors of nonoperating room anesthesia-related morbidity were: critically-ill children (aOR = 2.490; 95% CI: 1.55-11.21), predicted difficult airway (aOR = 5.704; 95% CI: 1.017-31.98), and organization insufficiencies (aOR = 52.6; 95% CI:4.55-613). The preanesthetic consultation few days before NORA protected against complications (aOR = 0.263; 95%CI: 0.080-0.867). CONCLUSIONS: The incidence of complications during NORA among children in our radiology setting remains high. Investigating predictors for morbidity allowed high-risk patient selection, which allowed taking precautions. Several improvement measures were taken to address the organization's insufficiencies.

Generalizable Approach to Quantifying Guideline-Directed Medical Therapy.

BACKGROUND: Quantifying guideline-directed medical therapy (GDMT) intensity is foundational for improving heart failure (HF) care. Existing measures discount dose intensity or use inconsistent weighting. METHODS: The Kansas City Medical Optimization (KCMO) score is the average of total daily to target dose percentages for eligible GDMT, reflecting the percentage of optimal GDMT prescribed (range, 0-100). In Change the Management of Patients With HF, we computed KCMO, HF collaboratory (0-7), and modified HF Collaboratory (0-100) scores for each patient at baseline and for 1-year change in established GDMT at the time (mineralocorticoid receptor antagonist, ß-blocker, ACE [angiotensin-converting enzyme] inhibitor/angiotensin receptor blocker/angiotensin receptor neprilysin inhibitor). We compared baseline and 1-year change distributions and the coefficient of variation (SD/mean) across scores. RESULTS: Among 4532 patients at baseline, mean KCMO, HF collaboratory, and modified HF Collaboratory scores were 38.8 (SD, 25.7), 3.4 (1.7), and 42.2 (22.2), respectively. The mean 1-year change (n=4061) for KCMO was -1.94 (17.8); HF collaborator, -0.11 (1.32); and modified HF Collaboratory, -1.35 (19.8). KCMO had the highest coefficient of variation (0.66), indicating greater variability around the mean than the HF collaboratory (0.49) and modified HF Collaboratory (0.53) scores, reflecting higher resolution of the variability in GDMT intensity across patients. CONCLUSIONS: KCMO measures GDMT intensity by incorporating dosing and treatment eligibility, provides more granularity than existing methods, is easily interpretable (percentage of ideal GDMT), and can be adapted as performance measures evolve. Further study of its association with outcomes and its usefulness for quality assessment and improvement is needed.

[Synthetic indicator of compliance with standards for Quality Units of health centers and multicenter prospective pilot study]. / Indicador sintético de cumplimiento de estándares para Unidades de Calidad de centros sanitarios y estudio de pilotaje prospectivo multicéntrico.

BACKGROUND AND OBJECTIVE: In Spain, Quality Units play a key and unique role in advising healthcare centers on the methodology of healthcare quality. The objectives of the study were to develop computer algorithms to obtain a synthetic indicator of standard compliance for Quality Units and to pilot its functioning in these units. MATERIALS AND METHODS: The Excel program was used to establish evaluation algorithms, and quantitatively interrelate and weight various categories of standards, as a computer evaluation tool, to build a continuous improvement cycle system, and offer a global synthetic indicator of compliance. The tool was tested in a prospective multicenter pilot study, in which coordinators of Quality Units from different health centers and care settings participated, to evaluate the usefulness of the tool and compliance with the standards, in addition to analyzing the content validity of each standard. RESULTS: The formulas for the structured computer algorithms were developed, consecutively, in a «PLAN-DO-CHECK-ACT¼ improvement cycle for the 9 categories of standards, resulting in a single synthetic indicator of compliance. Twenty-one Quality Units participated in the piloting. The overall average compliance rate for the synthetic indicator was 55.63% with differences between centers (P=.002) and between categories (P<.0001), but not by autonomous communities (P=.86) or by areas (P=.97). Content validity was ensured through the variable of «understanding¼ of the standards (P<.001), and through their «justification¼ with documentary evidence (P<.001). CONCLUSIONS: The computer tool with the synthetic indicator have allowed for the evaluation of standard compliance in Quality Units of healthcare centers.

Tendências na qualidade da atenção à saúde da criança na primeira semana de vida na Atenção Primária no Brasil / Trends in the quality of child health care in the first week of life in primary care services in Brazil

Resumo O objetivo deste estudo foi avaliar a tendência temporal da qualidade da atenção à saúde da criança na consulta da primeira semana de vida no nível da Atenção Primária à Saúde, segundo características dos municípios, do processo de trabalho das equipes e das usuárias responsáveis pelas crianças. Foram realizadas análises transversais com dados dos três ciclos do Programa Nacional de Melhoria do Acesso e da Qualidade (PMAQ) (2012, 2014 e 2018). Usuá­rias adultas com filhos de até dois anos foram entrevistadas. O desfecho foi a "boa qualidade da atenção à saúde na primeira semana de vida". Foram realizadas análises descritivas e de tendência temporal por meio de regressão de mínimos quadrados ponderados por variância. A frequên­cia de boa qualidade na consulta da primeira semana de vida foi 47,9% (IC95% 46,6-49,3) em 2012, 52,5% (IC95% 51,3-53,7) em 2014 e 53,3% (IC95% 52,2-54,4) em 2018, com um aumento anual de 0,73 ponto percentual (p<0,001). O aumento anual foi maior na região Nordeste (2,06 pp) e com IDH muito baixo/baixo (1,48 pp) e com 100% de cobertura de ESF (0,98 pp). Ao longo dos três ciclos do PMAQ-AB houve uma evolução favorável na frequência da boa qualidade na atenção à saúde na primeira semana de vida.

Abstract The aim of this study was to assess temporal trends in the quality of health care during the first-week child check-up in primary care services stratified by municipal, health team and maternal characteristics. We conducted a cross-sectional study using data from the three cycles of the National Program for the Improvement of Access and Quality (PMAQ) (2012, 2014 and 2018). Adult service users with children aged up to 2 were interviewed. The outcome was "good quality health care in the first week of life". Descriptive and time trend analyses were performed using variance-weighted least squares regression. The frequency of good quality care during the first-week check-up was 47.9% (95%CI 46.6-49.3) in 2012, 52.5% (95%CI 51.3-53.7) in 2014 and 53.3% (95%CI 52.2-54.4) in 2018, with an annual increase of 0.73 pp (p<0.001). The annual increase was greater in the Northeast (2.06 pp) and in municipalities with very low/low HDI (1.48 pp) and 100% family health strategy coverage (0.98 pp). Trends in the frequency of good quality health care during the first-week child check-up were favorable.

The relationship between Quality and Outcomes Framework scores and socioeconomic deprivation: a longitudinal study.

BACKGROUND: The Quality Outcomes Framework (QOF) is a pay incentive scheme in England designed to improve and standardise general practice. QOF attainment has been used as a proxy for primary care quality in previous research. AIM: To investigate whether there is a relationship between socioeconomic deprivation and QOF attainment in primary care in England. DESIGN & SETTING: Retrospective longitudinal study of primary care providers in England. METHOD: QOF scores were obtained for individual general practices in England from between 2007-2019 and linked to practice-level Indices of Multiple Deprivation (IMD) scores derived from census data. Beta regression analyses were used to analyse the relationship with either percentage of total QOF attainment or of domain-specific attainment with multivariate analyses, adjusting for additional practice-level demographics. QOF attainment in the most affluent quintile was used as the reference group. RESULTS: General practices in less deprived areas have consistently outperformed those in more deprived areas in terms of QOF achievement. Initially, the gap between least and most deprived practices decreased, however since 2015 there has been relatively little change in comparative performance. The magnitude of inequality was reduced after adjusting for demographic factors. Of the independent variables analysed, the proportion of patients aged >65 years ('over 65s') had the strongest relationship with QOF attainment. CONCLUSION: There remains an inequality in primary care quality by socioeconomic deprivation in England, even after accounting for demographic differences.

Clinicians' perceptions and practices of diagnostic assessment in psychiatric services.

BACKGROUND: Diagnostic assessment in psychiatric services typically involves applying clinical judgment to information collected from patients using multiple sources, including anamnesis and structured diagnostic interviews. Research shows that clinicians' perceptions of diagnostic assessment are associated with their diagnostic practices, and that perceptions and practices may vary according to clinician characteristics. Examining clinicians' perceptions and practices of diagnostic assessment is important for quality improvement in psychiatric services, including implementation of evidence-based practice procedures. The purpose of the present study was to evaluate clinicians' perceptions and practices of diagnostic assessment in psychiatric services and examine whether these perceptions and practices varied according to profession and age, with the aim of providing a basis for quality improvement. METHODS: A total of 183 (53.2%) clinicians in community-based adult psychiatric services in Stockholm, Sweden participated in an online survey. Differences between professions were analyzed using Kruskal-Wallis tests and effect sizes were calculated. Associations of clinicians' perceptions with their age were examined using Spearman correlations. RESULTS: Overall, clinicians had positive attitudes toward diagnostic assessment, and they considered themselves as competent. Differences were as most pronounced between nurses and other professions. Nursed had conducted fewer assessments, perceived themselves as less competent, and reported to a smaller extent to be able to determine which diagnosis should be the target for treatment in patients with multiple diagnoses. There were no associations of clinicians' perceptions with their age. Some potential areas of improvement were identified, including clinician qualifications, education in diagnostic assessment, and contents of diagnostic assessment. CONCLUSIONS: The results of the present study may provide a basis for quality improvement in psychiatric services. For example, it may be important to pay attention to potential differences in perceptions and practices between professions in efforts to improve quality of assessment and care.

Quality appraisal of clinical nutrition practice guidelines for critically ill adult patients: a systematic review using the Advancing Guideline Development, Reporting and Evaluation in Health Care instrument II (AGREE-II) and AGREE-Recommendation Excellence (AGREE-REX).

Nutritional therapy should follow evidence-based practice, thus several societies regarding nutrition and critical care have developed specific Clinical Practice Guidelines (CPG). However, to be regarded as trustworthy, the quality of the CPG for critically ill patients and its recommendations need to be high. This systematic review aimed to appraise the methodology and recommendations of nutrition CPG for critically ill patients. We performed a systematic review (protocol number CRD42020184199) with literature search conducted on PubMed, Embase, Cochrane Library and other four specific databases of guidelines up to October 2021. Two reviewers, independently, assessed titles and abstracts and potentially eligible full-text reports to determine eligibility and subsequently four reviewers appraised the guidelines quality using the Advancing Guideline Development, Reporting and Evaluation in Health Care instrument II (AGREE-II) and AGREE-Recommendation Excellence (AGREE-REX). Ten CPG for nutrition in critically ill patients were identified. Only Academy of Nutrition and Dietetics and European Society of Intensive Care Medicine had a total acceptable quality and were recommended for daily practice according AGREE-II. None of the CPG recommendations had an overall quality score above 70 %, thus being classified as moderate quality according AGREE-REX. The methodological evaluation of the critically ill adult patient CPG revealed significant discrepancies and showed a need for improvement in its development and/or reporting. In addition, recommendations about nutrition care process presented a moderate quality.

Effects of Diabetes Quality Assessment on Diabetes Management Behaviors Based on a Nationwide Survey.

Improved diabetes management in primary care is essential for reducing the public health burden of diabetes, and various programs are being implemented in Korea for this purpose. Although the Health Insurance Review and Assessment (HIRA) evaluates the quality of type 2 diabetes management in primary care clinics and hospitals, it is unclear whether the implementation of these evaluations is related to the adequate management of complications in diabetic patients. We evaluated the association between the proportion of clinics managing diabetes well and lifestyles and uptake of screening for complications in 24,620 diabetic participants of the 2019 Korean Community Health Survey (KCHS). Multivariate multilevel logistic regression was performed to evaluate the fixed effect of the district-level variable and the heterogeneity among districts. The proportion of clinics with good diabetes management per 10,000 inhabitants was positively related to screening for diabetes complications. Furthermore, this district variable was significantly related to engaging in walking activity (Odds ratio: 1.39, 95% CI: 1.10-1.76) and sufficiently explained the heterogeneity among districts. However, current smoking and weight control were not associated with the proportion of clinics with good diabetes management. The financial incentives to primary care clinics would improve the primary prevention of diabetic complications.

[How to prepare for the V2020 certification visit by the French Health Authority in a maternity ward?] / Comment préparer la visite de certification V2020 de la Haute Autorité de santé dans sa maternité ?

Although certification in France is at the health establishment level, maternity wards are directly and indirectly concerned by the certification of their establishment. The purpose of this article is to help perinatal caregivers in maternity wards to prepare, as well as possible, for the certification visit of their establishment. The 7 stages of preparation for the visit are explained with concrete examples from the Haute Autorité de santé (HAS) certification guide. With good organization, the certification visit can go stress-free and professionals will be ready to meet HAS experts.

Use of 90-day mortality does not change assessment of hospital quality after coronary artery bypass grafting in New York State.

OBJECTIVES: Publicly reported postoperative 30-day mortality rates are commonly used to compare hospital quality after coronary artery bypass grafting. We sought to determine whether 90-day mortality rates, which are not publicly reported but better capture postdischarge mortality, are a better determinant of hospital performance. METHODS: We performed a retrospective cohort analysis of 30- versus 90-day risk-standardized mortality rates at adult cardiac surgical centers in New York State from 2008 to 2014. Hospitals were classified as good or poor performing outliers at each time point based on the bounds of the 95% confidence interval around each hospital's predicted risk-standardized mortality rates determined via hierarchical models. The primary outcome was change in institutional performance via outlier classification from 30 to 90 days. RESULTS: During the study period, 72,398 adults underwent a coronary artery bypass grafting procedure at 1 of 42 institutions. The risk-standardized mortality rates increased from 30 to 90 days at all institutions, with a median 30-day risk-standardized mortality rate of 2.16% (interquartile range, 0.69%) and median 90-day risk-standardized mortality rate of 3.69% (interquartile range, 1.00%). In using a 90-day instead of a 30-day metric, 3 hospitals changed outlier status. One hospital improved to a good from as expected performer, and 2 worsened to as expected from good performers. CONCLUSIONS: In a cohort of patients who underwent coronary artery bypass grafting surgery from 2008 to 2014 in New York State, use of a 90-day mortality metric resulted in a change in hospital quality assessment for a minority of hospitals. The use of 90-day mortality may not provide additional value when evaluating institutional performance for this population.

Development and validation of risk-adjusted quality indicators for the long-term outcome of acute sepsis care in German hospitals based on health claims data.

Background: Methods for assessing long-term outcome quality of acute care for sepsis are lacking. We investigated a method for measuring long-term outcome quality based on health claims data in Germany. Materials and methods: Analyses were based on data of the largest German health insurer, covering 32% of the population. Cases (aged 15 years and older) with ICD-10-codes for severe sepsis or septic shock according to sepsis-1-definitions hospitalized in 2014 were included. Short-term outcome was assessed by 90-day mortality; long-term outcome was assessed by a composite endpoint defined by 1-year mortality or increased dependency on chronic care. Risk factors were identified by logistic regressions with backward selection. Hierarchical generalized linear models were used to correct for clustering of cases in hospitals. Predictive validity of the models was assessed by internal validation using bootstrap-sampling. Risk-standardized mortality rates (RSMR) were calculated with and without reliability adjustment and their univariate and bivariate distributions were described. Results: Among 35,552 included patients, 53.2% died within 90 days after admission; 39.8% of 90-day survivors died within the first year or had an increased dependency on chronic care. Both risk-models showed a sufficient predictive validity regarding discrimination [AUC = 0.748 (95% CI: 0.742; 0.752) for 90-day mortality; AUC = 0.675 (95% CI: 0.665; 0.685) for the 1-year composite outcome, respectively], calibration (Brier Score of 0.203 and 0.220; calibration slope of 1.094 and 0.978), and explained variance (R 2 = 0.242 and R 2 = 0.111). Because of a small case-volume per hospital, applying reliability adjustment to the RSMR led to a great decrease in variability across hospitals [from median (1st quartile, 3rd quartile) 54.2% (44.3%, 65.5%) to 53.2% (50.7%, 55.9%) for 90-day mortality; from 39.2% (27.8%, 51.1%) to 39.9% (39.5%, 40.4%) for the 1-year composite endpoint]. There was no substantial correlation between the two endpoints at hospital level (observed rates: ρ = 0, p = 0.99; RSMR: ρ = 0.017, p = 0.56; reliability-adjusted RSMR: ρ = 0.067; p = 0.026). Conclusion: Quality assurance and epidemiological surveillance of sepsis care should include indicators of long-term mortality and morbidity. Claims-based risk-adjustment models for quality indicators of acute sepsis care showed satisfactory predictive validity. To increase reliability of measurement, data sources should cover the full population and hospitals need to improve ICD-10-coding of sepsis.

Regional lithium prescription rates and recurrence in bipolar disorder.

BACKGROUND: Lithium is the best documented maintenance treatment in bipolar disorder, but its use varies considerably across and within countries. It is not known whether regional differences in lithium prescription rates translate to differing regional outcomes. AIMS: To estimate associations between county specific lithium prescription rates and county specific recurrence odds of bipolar disorder in Sweden. METHOD: Data from 14,616 patients with bipolar I disorder, bipolar II disorder, or bipolar disorder not otherwise specified were extracted from the Swedish national quality assurance register for bipolar disorders (BipoläR). Lithium prescription frequencies were calculated for 21 counties. Logistic regression analyses were run adjusted for confounders, with any type of recurrence as primary outcome, and incident elated and depressive episodes as secondary outcomes. Subsets of patients with bipolar I, II and not otherwise specified disorder were also analysed separately. RESULTS: Lithium prescription rates for populations with all bipolar subtypes ranged across counties from 37.7 to 84.9% (mean 52.4%). Higher regional prescription rates were significantly associated with lower rate of any type of recurrence. The association was stronger when bipolar I disorder was analysed separately. CONCLUSIONS: The advantages for lithium use long acknowledged for bipolar I disorder are also seen for the rest of the bipolar spectrum. Results suggest that population level outcomes of bipolar disorder could be improved by increasing the number of patients using lithium.

Evaluation of dialysis centres: values and criteria of the stakeholders.

BACKGROUND: Evaluation of renal replacement therapy with haemodialysis is essential for its improvement. Remarkably, outcomes vary across centres. In addition, the methods used have important epistemological limitations, such as ignoring significant features (e.g., quality of life) or no relevance given to the patient's perspective in the indicator's selection. The present study aimed to determine the opinions and preferences of stakeholders (patients, clinicians, and managers) and establish their relative importance, considering the complexity of their interactions, to facilitate a comprehensive evaluation of haemodialysis centres. METHODS: Successive working groups (WGs) were established using a multicriteria methodology. WG1 created a draft of criteria and sub-criteria, WG2 agreed, using a qualitative structured analysis with pre-established criteria, and WG3 was composed of three face-to-face subgroups (WG3-A, WG3-B, and WG3-C) that weighted them using two methodologies: weighted sum (WS) and analytic hierarchy process (AHP). Subsequently, they determined a preference for the WS or AHP results. Finally, via the Internet, WG4 weighted the criteria and sub-criteria by the method preferred by WG3, and WG5 analysed the results. RESULTS: WG1 and WG2 identified and agreed on the following evaluation criteria: evidence-based variables (EBVs), annual morbidity, annual mortality, patient-reported outcome measures (PROMs), and patient-reported experience measures (PREMs). The EBVs consisted of five sub-criteria: type of vascular access, dialysis dose, haemoglobin concentration, ratio of catheter bacteraemia, and bone mineral disease. The patients rated the PROMs with greater weight than the other stakeholders in both face-to-face WG3 (WS and AHP) and WG4 via the Internet. The type of vascular access was the most valued sub-criterion. A performance matrix of each criterion and sub-criterion is presented as a reference for assessing the results based on the preferences of the stakeholders. CONCLUSIONS: The use of a multicriteria methodology allows the relative importance of the indicators to be determined, reflecting the values of the different stakeholders. In a performance matrix, the inclusion of values and intangible aspects in the evaluation could help in making clinical and organizational decisions.

Support offered to newborns parents by the nursing team / Apoio oferecido aos pais de neonatos pela equipe de enfermagem

Abstract Objectives: to know the perception of parents of newborns regarding the support received from the nursing team during their child's hospitalization. Methods: prospective study. Sample of 127 mothers and fathers of newborns hospitalized for at least 72 hours in neonatal units of a hospital in the southern region of Brazil. Data collected from May to September 2018 through application of a proposed questionnaire and consultation of medical records. Descriptive and analytical statistics were used. Results: participants were aged 28.2 (SD = 6.8) years, mostly composed of mothers (76.4%), primiparous (51.2%). Full support was declared by 66.0% of participants in the appreciative domain and 65.5% in the instrumental, 51.7% in the informational and 46.2% in the emotional domains. Mothers declared they felt supported mainly in the instrumental (p=0.009) and informational (p=0.039) domains. There was a positive correlation between the emotional, appreciative and informational domains (p<0.001). Conclusion: for most participants, in the informational domain, there was a demand for knowledge provided by the team, inclusion in decisions and encouragement to ask questions; in the emotional, there was concern for wellbeing and attention to anguish. Greater support for parents in the informational and emotional domains must be reinforced with the use of training strategies for the nursing team.

Resumo Objetivos: conhecer a percepção dos pais de neonatos quanto ao apoio que recebem da equipe de Enfermagem durante a hospitalização do seu filho. Métodos: estudo prospectivo. Amostra de 127 mães e pais de neonatos internados por, no mínimo, 72 horas em unidades de neonatologia de um hospital da região Sul do Brasil. Dados coletados de maio a setembro de 2018, por meio da aplicação de questionário proposto e consulta a prontuários. Estatísticas descritiva e analítica foram utilizadas. Resultados: participantes com idade de 28,2 (DP=6,8) anos, maioria composta por mães (76,4%), primíparas (51,2%). Participantes declararam pleno apoio em 66,0% no domínio apreciativo, 65,5% no instrumental, 51,7% no informativo e 46,2% no emocional. Mães declararam-se apoiadas principalmente nos domínios instrumental (p=0,009) e informativo (p=0,039). Houve correlação positiva entre os domínios emocional, apreciativo e informativo (p<0,001). Conclusão: para a maioria dos participantes, no domínio informativo, houve demanda de conhecimento fornecido pela equipe, inclusão nas decisões e estímulo em realizar perguntas; no emocional, preocupação com bem-estar e atenção para angústias. Maior apoio aos pais nos domínios informativo e emocional deve ser reforçado com estratégias de capacitação para equipe de Enfermagem.

Assessing the performance of indicators during their life cycle: the mixed QUID method.

BACKGROUND: Quality indicators (QI) are mandatory in French hospitals. After a decade of use, the Ministry of Health set up an expert workgroup to enhance informed decision-making regarding currently used national QI, i.e. to propose a decision of withdrawing, revising or continuing their use. We report the development of an integrated method for a comprehensive appraisal of quality/safety indicators (QI) during their life cycle, for three purposes, quality improvement, public disclosure and regulation purposes. The method was tested on 10 national QI on use for up to 10 years to identify operational issues. METHODS: A modified Delphi technique to select relevant criteria and a development of a mixed evaluation method by the workgroup. A 'real-life' test on 10 national QI. RESULTS: Twelve criteria were selected for the appraisal of QI used for regulation goals, 11 were selected for hospital improvement and seven for public disclosure. The perceived feasibility and relevance were studied including hospital workers, patients and health authorities professionals; the scientific soundness of the indicator development phase was reviewed by analyzing reference documents; the metrological performance (limited to the discriminatory power and dynamics of change during the life cycle dimensions) was analyzed on the national datasets.Applied to the 10 QI, the workgroup proposed to withdraw four of them and to modify or suspend the six others. CONCLUSIONS: The value of the method was supported by the clear-cut conclusions and endorsement of the proposed decisions by the health authorities.

Assessing the quality of medication documentation: development and feasibility of the MediDocQ instrument for retrospective chart review in the hospital setting.

OBJECTIVE: The medication process requires clear and transparent documentation in patient records. Incomplete or incorrect medication documentation may contribute to inappropriate clinical decision-making and adverse events. To comprehensively assess the quality of in-hospital medication documentation, we developed a retrospective chart review (RCR) instrument. We report on the development process, the feasibility of the instrument and describe our application of the instrument to a sample of patient records. DESIGN: Cross-sectional study using an RCR instrument to evaluate paper-based, non-standardised prescription and medication administration charts (MediDocQ). SETTING: Two German university hospitals. PARTICIPANTS: Records from 1361 patients admitted between April and July 2015 were evaluated. METHODS: The MediDocQ development process comprised six consecutive stages: focused literature review, web-based search, initial patient record screening, review by project advisory board, focus groups with professionals and pilot testing. The final 54-item RCR instrument covers three key components of medication documentation: (1) completeness of documented information (including prescription, medication administration and pro re nata (PRN) medication), (2) quality of transcriptions and (3) compliance with chart structure, legibility, handling of deletions and chart corrections. Descriptive statistics are presented as mean values, SD, median and interquartile ranges for individual items. RESULTS: Overall, 33 out of 54 items resulted in mean values above 0.75, indicating high-quality medication documentation. Documentation quality was particularly compromised for verbal and PRN orders (which involve more steps than standard orders) and when documentation was not completed at the same time as medication administration. CONCLUSIONS: MediDocQ is a patient safety instrument that can be used to evaluate the quality of medication documentation and identify components of the process where intervention is required. In our setting, standardisation of medication documentation, particularly regarding medication administration and PRN medication is a priority.

Implementation of health care quality indicators for out-of-hospital emergencies: a systematic review. / Utilización e implementación de indicadores de calidad para evaluar la atención en las emergencias extrahospitalarias: revisión sistemática.

ABSTRACT: Although many health care quality indicators have been defined for establishing a common, homogeneous, and reliable system for assessing emergency department care, less information is available on the use of indicators of quality in attending emergencies outside the hospital. We aimed to identify and analyze quality indicators that have appeared in the literature on out-of-hospital emergencies. This systematic review of the literature followed the ations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). We developed protocols for searching 5 databases to locate studies using quality indicators to evaluate care in out-of-hospital emergencies. Studies were published between July 2017 and July 2018 in either English or Spanish. We identified 22 studies naming 333 quality indicators in out-of-hospital emergencies. The indicators were classified as clinical or nonclinical; within each of these 2 sets, we also identified domains, or subcategories. As nonclinical quality identifiers were more numerous in the literature, it seems that they are the ones most often used to assess out-of-hospital emergency care at this time. This finding leaves the door open to designing and implementing new indicators able to measure quality of care in this clinical setting.

RESUMEN: Aunque son muchos los indicadores de calidad (IC) definidos para establecer un sistema común, homogéneo y fiable de evaluación sobre la actividad en los servicios de urgencias, es escasa la información acerca de los IC relacionados con las emergencias atendidas en el ámbito extrahospitalario. El objetivo de este trabajo es identificar y analizar, a través de la literatura científica publicada, los IC específicos de dicha atención ante emergencias fuera del contexto hospitalario. Se realizó una revisión sistemática de la literatura según las recomendaciones PRISMA. Se exploraron 5 bases de datos y se elaboraron protocolos de búsqueda para localizar estudios que aportasen información sobre IC para evaluar la atención en emergencias extrahospitalarias, entre noviembre de 2017 y julio de 2018, tanto en inglés como en español. Se analizaron un total de 22 estudios y se identificaron un total de 333 IC en emergencias extrahospitalarias que fueron clasificados en clínicos y no clínicos, con sus subdominios correspondientes para cada grupo. El número de IC no clínicos identificados en la búsqueda fue superior, pudiendo concluir que son los más utilizados para evaluar la atención en las emergencias extrahospitalarias en la actualidad y dejando la puerta abierta para el diseño e implementación de nuevos IC capaces de evaluar la actividad fuera del contexto hospitalario.

Development and Assessment of RecosDoc-MTeV to Improve the Quality of Direct Oral Anticoagulant Prescription for Venous Thromboembolic Disease.

Potentially inappropriate prescribing of direct oral anticoagulants is frequent with the most common errors being dosage, administration, and duration of therapy. We developed RecosDoc-MTeV, a documentary-based clinical decision support system (CDSS) for the management of direct oral anticoagulant prescription to prevent and treat venous thromboembolism. Simultaneously, the network of Parisian public hospitals (AP-HP, France) developed narrative clinical practice guidelines (CPGs) and a companion smartphone application to enhance medication and patient safety related to direct oral anticoagulant prescription. To assess the effectiveness of these CDS tools, we performed a retrospective review of 274 random patients hospitalized in 2017, which were either at risk of venous thromboembolism or actually treated for the disease. Consistency between the two CDS tools was measured at 96.7%. Administered treatments were compliant in 67.2% and 72.3% of the cases, with AP-HP CPGs and RecosDoc-MTeV, respectively. These results support that implementing CDSSs for the prescription of direct oral anticoagulants may ensure safe prescribing of high-risk medications.

Alternative approach to pediatric cardiac quality assessment for low-volume centers.

BACKGROUND: In pediatric cardiac care, many centers participate in multiple, national, domain-specific registries, as a major component of their quality assessment and improvement efforts. Small cardiac programs, whose clinical activities and scale may not be well-suited to this approach, need alternative methods to assess and track quality. METHODS: We conceived of and piloted a rapid-approach cardiac quality assessment, intended to encompass multiple aspects of the service line, in a low-volume program. The assessment incorporated previously identified measures, drawn from multiple sources, and ultimately relied on retrospective chart review. RESULTS: A collaborative, multidisciplinary team formed and came to consensus on quality metrics pertaining to 3 chosen areas of clinical activity in the program. Despite the use of multiple different data sources and the need for manual chart review in data collection, a rich assessment of these program components was completed for presentation in 6 weeks. CONCLUSIONS: While small programs may not participate in the spectrum of cardiac care registries available, these same centers can benefit from them by adapting some of their validated metrics for use in internal, self-maintained quality reports. Our pilot of this alternative approach revealed opportunities for improved quality assessment practices; the product can serve as a baseline for future prospective assessment and reporting, as well as longitudinal internal benchmarking.