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Postoperative Opiate Use in Urological Patients: A Quality Improvement Study Aimed at Improving Opiate Disposal Practices.
Cabo J, Hsi RS, Scarpato KR
(2019) J Urol 201: 371-376
MeSH Terms: Analgesics, Opioid, Humans, Pain Management, Pain, Postoperative, Patient Education as Topic, Postoperative Period, Prescription Drug Misuse, Quality Improvement, Retrospective Studies, Tennessee, Urologic Surgical Procedures
Show Abstract · Added February 26, 2019
PURPOSE - We aimed to determine trends in postoperative opiate management among urological patients, identify associations with opiate keeping and foster appropriate opiate disposal after surgery via introduction of an educational handout.
MATERIALS AND METHODS - We retrospectively analyzed opiate practices in 68 patients who had undergone urological surgery. In a separate consecutive cohort of 59 patients we distributed a handout detailing FDA (Food and Drug Administration) approved disposal methods. Patient opiate obtainment, use and disposal were assessed via telephone interviews with prescription filling data verified using the Tennessee CSMD (Controlled Substances Monitoring Database). Opiate keeping was defined as possessing any opiates more than 3 weeks after surgery or more than 4 times the duration of the postoperative prescription, whichever was longer.
RESULTS - Opiate keeping was observed in 41 patients (72%) in our initial cohort. Of these patients 68% left the medication unsecured at home. Major barriers to opiate disposal included concern for return of disease specific pain in 44% of patients and unrelated pain in 29%. As assessed on a short test, opiate keepers were less knowledgeable about safe disposal practices compared to nonkeepers (72% vs 85%, p = 0.005). Among opiate keepers there was an improvement in knowledge scores after the intervention (66% to 77%, p = 0.03). When comparing pre-education to post-education, there was no detectable improvement in the rate of opiate keeping (72% vs 68%, p = 0.66) or proper disposal (9% vs 8%, p = 1.0).
CONCLUSIONS - Opiate keeping is common following urological surgery and a major barrier to disposal is concern for the return of disease specific pain. Future interventions aimed at limiting opiate keeping should combine evidence-based prescription practices and targeted patient education.
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11 MeSH Terms
Differentiating Research, Quality Improvement, and Case Studies to Ethically Incorporate Pregnant Women.
Phillippi JC, Hartmann KE
(2018) J Midwifery Womens Health 63: 104-114
MeSH Terms: Delivery of Health Care, Female, Humans, Information Dissemination, Patient Participation, Perinatal Care, Pregnancy, Pregnancy Outcome, Pregnant Women, Publishing, Quality Improvement, Research
Show Abstract · Added February 21, 2019
Pregnant women have been called therapeutic orphans because data supporting common interventions, medications, health teaching, and models of care are meager. The generation of quality evidence benefits from proactive approaches that ensure ethical standards are met to protect participants. The purpose of this article is to differentiate among health care, quality improvement, and research and to discuss ethical involvement of women who are pregnant and potentially childbearing in these initiatives. Health care is provided to protect and improve individual health. Quality improvement aims to enhance delivery of care for all those receiving care in particular settings. Research, whether retrospective or prospective, is designed to contribute to generalizable knowledge. This review includes vignettes to distinguish between research, quality improvement, and case study dissemination and to highlight the value of publication of information with applicability beyond a single site. As a community, perinatal care providers will be able to contribute more evidence to guide care if they err on the side of seeking institutional review board approval for activities that examine the care and outcomes of pregnant women and the fetus. Traditional research activities, including clinical trials, remain crucial. However, to fill gaps in knowledge, we must expedite our ability to report informative cases, examine clinical data, share lessons learned during quality improvement campaigns, and publish and disseminate these findings. Accelerating improvements in care demands expansion of the evidence base.
© 2017 by the American College of Nurse-Midwives.
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12 MeSH Terms
Rheumatologists' perception of systemic lupus erythematosus quality indicators: significant interest and perceived barriers.
Casey C, Chung CP, Crofford LJ, Barnado A
(2017) Clin Rheumatol 36: 97-102
MeSH Terms: Adult, Attitude of Health Personnel, Cross-Sectional Studies, Female, Health Knowledge, Attitudes, Practice, Humans, Internet, Lupus Erythematosus, Systemic, Male, Middle Aged, Quality Improvement, Quality Indicators, Health Care, Rheumatologists, Rheumatology, Southeastern United States, Surveys and Questionnaires
Show Abstract · Added March 25, 2020
Differences in quality of care may contribute to health disparities in systemic lupus erythematosus (SLE). Studies show low physician adherence rates to the SLE quality indicators but do not assess physician perception of SLE quality indicators or quality improvement. Using a cross-sectional survey of rheumatologists in the southeastern USA, we assessed the perception and involvement of rheumatologists in quality improvement and the SLE quality indicators. Using electronic mail, an online survey of 32 questions was delivered to 568 rheumatologists. With a response rate of 19% (n = 106), the majority of participants were male, Caucasian, with over 20 years of experience, and seeing adult patients in an academic setting. Participants had a positive perception toward quality improvement (81%) with a majority responding that the SLE quality indicators would significantly impact quality of care (54%). While 66% of respondents were familiar with the SLE quality indicators, only 18% of respondents reported using them in everyday practice. The most commonly reported barrier to involvement in quality improvement and the SLE quality indicators was time. Rheumatologists had a positive perception of the SLE quality indicators and agreed that use of the quality indicators could improve quality of care in SLE; however, they identified time as a barrier to implementation. Future studies should investigate methods to increase use of the SLE quality indicators.
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Enhancing Literacy in Cardiovascular Genetics: A Scientific Statement From the American Heart Association.
Mital S, Musunuru K, Garg V, Russell MW, Lanfear DE, Gupta RM, Hickey KT, Ackerman MJ, Perez MV, Roden DM, Woo D, Fox CS, Ware S, American Heart Association Council on Functional Genomics and Translational Biology; Council on Cardiovascular Disease in the Young; Council on Cardiovascular and Stroke Nursing; Stroke Council; Council on Lifestyle and Cardiometabolic Health; and Council on Quality of Care and Outcomes Research
(2016) Circ Cardiovasc Genet 9: 448-467
MeSH Terms: American Heart Association, Cardiovascular Diseases, Clinical Competence, Delivery of Health Care, Integrated, Diffusion of Innovation, Education, Medical, Continuing, Genetic Predisposition to Disease, Genetic Testing, Genomics, Humans, Pharmacogenetics, Phenotype, Predictive Value of Tests, Prognosis, Quality Improvement, Quality Indicators, Health Care, Risk Assessment, Risk Factors, United States
Show Abstract · Added March 24, 2020
Advances in genomics are enhancing our understanding of the genetic basis of cardiovascular diseases, both congenital and acquired, and stroke. These advances include finding genes that cause or increase the risk for childhood and adult-onset diseases, finding genes that influence how patients respond to medications, and the development of genetics-guided therapies for diseases. However, the ability of cardiovascular and stroke clinicians to fully understand and apply this knowledge to the care of their patients has lagged. This statement addresses what the specialist caring for patients with cardiovascular diseases and stroke should know about genetics; how they can gain this knowledge; how they can keep up-to-date with advances in genetics, genomics, and pharmacogenetics; and how they can apply this knowledge to improve the care of patients and families with cardiovascular diseases and stroke.
© 2016 American Heart Association, Inc.
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Major and minor complications in extraoperative electrocorticography: A review of a national database.
Rolston JD, Englot DJ, Cornes S, Chang EF
(2016) Epilepsy Res 122: 26-9
MeSH Terms: Adult, Databases, Factual, Electrocorticography, Female, General Surgery, Humans, Male, Postoperative Complications, Quality Improvement, Societies, Medical, United States
Show Abstract · Added August 12, 2016
The risk profile of extraoperative electrocorticography (ECoG) is documented almost exclusively by case series from a limited number of academic medical centers. These studies tend to underreport minor complications, like urinary tract infections (UTIs) and deep venous thromboses (DVTs), that nevertheless affect hospital cost, length of stay, and the patient's quality of life. Herein, we used data from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) to estimate the rate of adverse events in extraoperative ECoG surgeries. NSQIP is a validated dataset containing nearly 3 million procedures from over 600 North American hospitals, and uses strict criteria for the documentation of complications. Major complications occurred in 3.4% of 177 extraoperative ECoG cases, while minor complications occurred in 9.6%. The most common minor complication was bleeding requiring a transfusion in 3.4% of cases, followed by sepsis, DVT, and UTI each in 2.3% of cases. No mortality was reported. Overall, in a national database containing a heterogeneous population of hospitals, major complications of extraoperative ECoG were rare (3.4%). Complications such as UTI and DVT tend to be underreported in retrospective case series, yet make up a majority of minor complications for ECoG patients in this dataset.
Copyright © 2016 Elsevier B.V. All rights reserved.
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11 MeSH Terms
Catheter Insertion and Perioperative Practices Within the ISPD North American Research Consortium.
Wallace EL, Fissell RB, Golper TA, Blake PG, Lewin AM, Oliver MJ, Quinn RR
(2016) Perit Dial Int 36: 382-6
MeSH Terms: Canada, Catheterization, Catheters, Indwelling, Humans, Kidney Failure, Chronic, Laparoscopy, Peritoneal Dialysis, Practice Patterns, Physicians', Quality Improvement, United States
Show Abstract · Added November 5, 2015
UNLABELLED - ♦
BACKGROUND - In general, efforts to standardize care based on group consensus practice guidelines have resulted in lower morbidity and mortality. Although there are published guidelines regarding insertion and perioperative management of peritoneal dialysis (PD) catheters, variation in practice patterns between centers may exist. The objective of this study is to understand variation in PD catheter insertion practices in preparation for conducting future studies. ♦
METHODS - An electronic survey was developed by the research committee of the International Society for Peritoneal Dialysis - North American Research Consortium (ISPD-NARC) to be completed by physicians and nurses involved in PD programs across North America. It consisted of 45 questions related to 1) organizational characteristics; 2) PD catheter insertion practices; 3) current quality-improvement initiatives; and 4) interest in participation in PD studies. Invitation to participate in the survey was given to nephrologists and nurses in centers across Canada and the United States (US) identified by participation in the inaugural meeting of the ISPD-NARC. Descriptive statistics were applied to analyze the data. ♦
RESULTS - Fifty-one ISPD-NARC sites were identified (45% in Canada and 55% in the US) of which 42 responded (82%). Center size varied significantly, with prevalent PD population ranging from 6 - 300 (median: 60) and incident PD patients in the year prior to survey administration ranging from 3 - 180 (median: 20). The majority of centers placed fewer than 19 PD catheters/year, with a range of 0 - 50. Availability of insertion techniques varied significantly, with 83% of centers employing more than 1 insertion technique. Seventy-one percent performed laparoscopic insertion with advanced techniques (omentectomy, omentopexy, and lysis of adhesions), 62% of sites performed open surgical dissection, 10% performed blind insertion via trocar, and 29% performed blind placement with the Seldinger technique. Use of double-cuff catheters was nearly universal, with a near even distribution of catheters with pre-formed bend versus straight inter-cuff segments. There was also variation in the choice of perioperative antibiotics and perioperative flushing practices. Although 86% of centers had quality-improvement initiatives, there was little consensus as to appropriate targets. ♦
CONCLUSIONS - There is marked variability in PD catheter insertion techniques and perioperative management. Large multicenter studies are needed to determine associations between these practices and catheter and patient outcomes. This research could inform future trials and guidelines and improve practice. The ISPD-NARC is a network of PD units that has been formed to conduct multicenter studies in PD.
Copyright © 2016 International Society for Peritoneal Dialysis.
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10 MeSH Terms
Parenteral Prostanoid Use at a Tertiary Referral Center: A Retrospective Cohort Study.
Hay BR, Pugh ME, Robbins IM, Hemnes AR
(2016) Chest 149: 660-6
MeSH Terms: Adult, Cause of Death, Cohort Studies, Comorbidity, Connective Tissue Diseases, Death, Sudden, Endothelin Receptor Antagonists, Familial Primary Pulmonary Hypertension, Female, Guideline Adherence, HIV Infections, Heart Defects, Congenital, Heart Failure, Humans, Hypertension, Pulmonary, Infusions, Parenteral, Male, Middle Aged, Patient Selection, Phosphodiesterase 5 Inhibitors, Practice Guidelines as Topic, Prostaglandins, Quality Improvement, Retrospective Studies, Severity of Illness Index, Tertiary Care Centers
Show Abstract · Added March 8, 2020
BACKGROUND - Evidence-based guidelines recommend the use of parenteral prostaglandin (PP) therapy in patients with advanced pulmonary arterial hypertension (PAH). Despite this, many patients with PAH die without PP therapy. We sought to examine the frequency of PP use at a large referral center and characterize patients with PAH who died without receiving PP.
METHODS - We conducted a single-center retrospective cohort analysis of consecutive patients with PAH between 2008 and 2012. Clinical data and cause of death were compared between patients with PAH treated with PP (PAH-PP) and those who were not but were not documented as poor PP candidates (PAH-nonPP).
RESULTS - Of the 101 patients who received a diagnosis of PAH and died, 61 received PP therapy. Of the 40 patients not treated with PP, 10 did not have documented evaluations for PP therapy (PAH-nonPP) whereas 30 were not considered candidates or refused PP therapy. Compared with PAH-PP, PAH-nonPP had a longer 6-min walk distance, had a longer duration between time of diagnosis and date of worse functional class visit, were less likely to be diagnosed as functional class IV, and had significantly lower right atrial pressure. None of the PAH-nonPP died of progressive PAH.
CONCLUSIONS - We found that most patients who die with PAH are evaluated for PP therapy at a large referral center and the small minority of PAH-nonPP tended to have less severe disease and die of non-PAH-related causes. Our data suggest that at large pulmonary hypertension (PH) centers, the vast majority of patients who are appropriate candidates receive PP therapy.
Copyright © 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
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Peer kidney care initiative 2014 report: dialysis care and outcomes in the United States.
Weinhandl E, Constantini E, Everson S, Gilbertson D, Li S, Solid C, Anger M, Bhat JG, DeOreo P, Krishnan M, Nissenson A, Johnson D, Ikizler TA, Maddux F, Sadler J, Tyshler L, Parker T, Schiller B, Smith B, Lindenfeld S, Collins AJ
(2015) Am J Kidney Dis 65: Svi, S1-140
MeSH Terms: Catheterization, Central Venous, Health Status Disparities, Hospitalization, Humans, Infections, Kidney Failure, Chronic, Mortality, Outcome Assessment, Health Care, Quality Improvement, Renal Dialysis, United States
Added August 5, 2015
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11 MeSH Terms
Pharmacist leadership in ICU quality improvement: coordinating spontaneous awakening and breathing trials.
Stollings JL, Foss JJ, Ely EW, Ambrose AM, Rice TW, Girard TD, Wheeler AP
(2015) Ann Pharmacother 49: 883-91
MeSH Terms: Critical Care, Humans, Intensive Care Units, Leadership, Pharmacists, Pharmacy Service, Hospital, Prospective Studies, Quality Improvement, Respiration, Artificial, Ventilator Weaning
Show Abstract · Added September 23, 2015
BACKGROUND - Coordinating efforts across disciplines in the intensive care unit is a key component of quality improvement (QI) efforts. Spontaneous awakening trials (SATs) and spontaneous breathing trials (SBTs) are considered key components of guidelines, yet unfortunately are often not done or coordinated properly.
OBJECTIVE - To determine if a pharmacist-driven awakening and breathing coordination (ABC) QI program would improve compliance (ie, process measures) as compared with the previous protocol, which did not involve pharmacists.
METHODS - The QI program included pharmacist-led education, daily discussion on rounds, and weekly performance reports to staff. Using a pre-QI versus during-QI versus post-QI intervention design, we compared data from 500 control ventilator-days (pre-QI period) versus 580 prospective ventilator-days (during-QI period). We then evaluated the sustainability of the QI program in 216 ventilator-days in the post-QI period.
RESULTS - SAT safety screens were performed on only 20% pre-QI patient-days versus 97% of during-QI patient-days (P < 0.001) and 100% of post-QI patient-days (P = 0.25). The rates of passing the SAT safety screen in pre-QI and during-QI periods were 63% versus 78% (P = 0.03) and 81% in the post-QI period (P = 0.86). The rates of SATs among eligible patients on continuous infusions were only 53% in the pre-QI versus 85% in the during-QI (P = 0.0001) and 87% in the post-QI (P = 1) periods.
CONCLUSIONS - In this QI initiative, a pharmacist-driven, interdisciplinary ABC protocol significantly improved process measures compliance, comparing the pre-QI versus during-QI rates of screening, performing, and coordinating SAT and SBTs, and these results were sustained in the 8-month follow-up period post-QI program.
© The Author(s) 2015.
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10 MeSH Terms
Use of Six Sigma for eliminating missed opportunities for prevention services.
Gittner LS, Husaini BA, Hull PC, Emerson JS, Tropez-Sims S, Reece MC, Zoorob R, Levine RS
(2015) J Nurs Care Qual 30: 254-60
MeSH Terms: Ambulatory Care Facilities, Evidence-Based Nursing, Female, Humans, Male, Medical Staff, Minority Groups, Nurse Administrators, Organizational Case Studies, Preventive Health Services, Primary Health Care, Quality Improvement, Total Quality Management
Show Abstract · Added February 21, 2017
Delivery of primary care preventative services can be significantly increased utilizing Six Sigma methods. Missed preventative service opportunities were compared in the study clinic with the community clinic in the same practice. The study clinic had 100% preventative services, compared with only 16.3% in the community clinic. Preventative services can be enhanced to Six Sigma quality when the nurse executive and medical staff agree on a single standard of nursing care executed via standing orders.
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13 MeSH Terms