Quality indicators for out-of-hospital emergency medical services: The paramedics' perspective

Objective. Out-of-hospital emergency medical services (EMS) need relevant and measurable indicators of quality. Those front-line workers who provide service directly to the customer are integral to the process of defining quality. The authors' objective was to obtain from paramedics, the front-line workers in the EMS system, their perspective on quality of care.

Methods. During regularly scheduled education sessions, 102 of the 140 field paramedics from a large municipal EMS system attended a presentation on total quality management. The paramedics were then assigned to focus groups and asked to identify quality indicators and provide recommendations for how they should be measured.

Results. Eighteen different quality indicators were identified. In addition, the paramedics suggested 17 ways to measure these proposed quality indicators.

Conclusions. From the perspective of the study participants, indicators of the quality of out-of-hospital care differ from many used in traditional EMS quality assurance programs. Future studies should investigate the applicability of these indicators to the total quality management of EMS systems.     

Quality assurance programme for nursing*

This article describes a conceptual and methodological framework for evaluating nursing care quality. The conceptual framework is based on Orem's theory of self-care which emphasizes the importance of decisions in the selection of nursing process based on patient status and problems. The primary outcome criteria is self-care. The methodological framework is based on Greenfield's criteria maps methodology for linking patient status (problems or diagnoses) to decisions about nursing interventions and linking these specific nursing intervention criteria to desired outcomes for self-care. The article further describes a multiagency quality assurance programme for nursing. The programme includes: a definition of criteria and standards across agencies; nursing care management protocols that define standards of care; continuing education courses for nursing based on management protocols; the maps method of auditing actual and recorded nursing process and patient outcomes as defined in the management protocol.     

The Acute Complications After Surgery for Penile Carcinoma and Strategies for Their Management: A Systematic Review of the Literature

ObjectivesTo investigate the contemporary rates of 30-day complications after surgery for penile cancer and to discuss the currently used preventative and therapeutic practices aimed at mitigation of these postoperative adverse events.Data SourcesA systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was performed, and studies reporting on the contemporary rates, nature, or management of acute complications following primary penile surgery or inguinal lymph node dissection for penile cancer were abstracted. Medline (PubMed) and EMBASE libraries were used to retrieve the articles published between January 1984 and December 2021 (n = 170 articles). Ultimately, 38 articles were included. The primary outcome of interest was 30-day (acute) postoperative complications, stratified by those associated with treatment of the primary penile lesion and those with inguinal lymph node dissection. Risk of bias assessment was undertaken. Special attention was paid to studies reporting management strategies for these complications.ConclusionThis comprehensive review revealed that the quality of existing studies reporting on complications is poor and the risk of bias is high. Within these studies, the rates of acute complications following primary penile surgery and inguinal lymph node dissection ranged between 0% and 29.4% and 6% and 90%, respectively. More than 50% of these complications were wound related. Over the past two decades, several studies have reported on improved surgical techniques and protocolized postsurgical care pathways. Although the newer techniques have been associated with improved outcomes, the absolute rates of complications have remained high even in the most contemporary series. Therefore, there is an urgent need for health care providers and stakeholders to reach consensus regarding preoperative workup and medical optimization goals, stage appropriate therapies, and postoperative care pathways, as has been done for other malignancies associated with high morbidity.Implications for Nursing PracticePenile cancer is a disease of the elderly, and surgical management of the primary lesion or the groins is associated with a high rate of complications. Most complications are wound related. Meticulous surgical technique and careful postoperative monitoring with early intervention are keys to mitigating surgery-related morbidity. However, equally important is dissemination and adoption of these principles by all health care workers universally.     

Protocol for an embedded pragmatic clinical trial to test the effectiveness of Aliviado Dementia Care in improving quality of life for persons living with dementia and their informal caregivers

IntroductionPersons living with Alzheimer's disease and related dementias (ADRD) frequently experience pain and behavioral and psychological symptoms of dementia (BPSD) which decrease quality of life (QOL) and influence caregiver burden. Home healthcare professionals however may underrecognize or lack the ability to manage BPSD.InterventionThis protocol describes an ADRD palliative quality assurance performance improvement program for home healthcare, Aliviado Dementia Care-Home Health Edition. It includes training, mentoring, and a toolbox containing intervention strategies.MethodsThis embedded pragmatic clinical trial will utilize a multi-site, cluster randomized control design. Recruitment will occur from three home healthcare agencies located in New Jersey, Utah, and Florida. At each agency, care teams will be randomized as clusters and assigned to either the Aliviado Dementia Care program or usual care. We plan to enroll 345 persons living with ADRD and their informal caregiver dyads. The primary outcome will be to measure QOL in both the person living with ADRD and their informal caregiver, and emergency department visits and hospital admissions. Secondary outcomes in the person living with ADRD will include the examination of pain, BPSD, antipsychotic and analgesic use. Secondary outcomes in caregivers include burden, depressive symptoms, functional health and wellbeing, and healthcare utilization.ConclusionThis study will be the first large-scale embedded pragmatic clinical trial in home healthcare focused on care quality and outcomes in addressing QOL in ADRD. If proven successful, the intervention can then be disseminated to agencies throughout the country to improve the quality of care for this vulnerable, underserved population.Trial registrationClinical Trials.gov: NCT03255967.     

Surgical perspectives of symptomatic omphalomesenteric duct remnants: Differences between infancy and beyond

BACKGROUNDThe clinical manifestations of omphalomesenteric duct remnant (OMDR) can vary with the age at diagnosis, from asymptomatic incidental findings to symptoms related to gastrointestinal complications. The lifelong complication rates are reported as 4%-34%, and complications are more common in patients younger than 2 years of age. The authors attempted to identify different clinical features and management for the various pediatric age groups.AIMTo find surgical perspectives for the pediatric age-related variants of OMDR and make recommendations for optimal management.METHODSThe medical records of pediatric patients diagnosed with OMDR were reviewed retrospectively. Fifteen patients diagnosed based on incidental findings during other surgeries were excluded. The patients were divided into two groups based on age: < 12 mo (infants) and > 12 mo (beyond infancy). We analyzed the demographic characteristics, clinical manifestations, diagnostic tools, surgical procedures, and clinical outcomes of the patients and compared them for the age groups. Chi-squared and Fisher''s exact tests were used for nominal scales and a Mann-Whitney test was used for ratio scales.RESULTSA total of 35 patients (7 infants, 28 children beyond infancy) were finally included. In both groups, Meckel''s diverticulum (MD) was the most common type of OMDR, while umbilical lesions were more common in the infant group (P = 0.006). Hematochezia and abdominal pain were common in the beyond infancy group, while umbilical lesions were the most frequent symptoms in the infant group. Several diagnostic tools were used, but Meckel''s scan was most useful in diagnosing OMDR in patients with painless rectal bleeding. Minimally invasive surgery was more commonly performed for children than for infants (P = 0.016). Single-incision laparoscopic surgery (SILS) was performed for fifteen patients who underwent laparoscopic surgery. There were only three cases of postoperative complications, and all patients survived in good condition.CONCLUSIONThe clinical type of OMDR varies with age, umbilical lesions in infants, and MD beyond infancy. SILS is effective for managing children with MD regardless of age.     

Perioperative Management in Reverse Total Shoulder Arthroplasty

Purpose of ReviewA successful reverse total shoulder arthroplasty requires careful preoperative planning and perioperative management. Preoperative comorbidity risks, perioperative pain management, and postoperative rehabilitation are all critical components of this arthroplasty. The current review examines available literature to guide the perioperative care of the reverse total shoulder arthroplasty patient.Recent FindingsOne of the most important advances for shoulder arthroplasty in recent years has been heightened awareness of various modalities for perioperative pain management. A number of recent studies have focused on the options for regional blockade as a critical tool for postoperative pain relief and the use of either continuous interscalene blocks or single shot blocks are supported. Additional studies are necessary to define the best local anesthetic agent and delivery mechanism to provide appropriate pain relief with a low side effect profile.SummaryManagement of the patient throughout the perioperative course is a critical component in achieving better patient outcomes delivering high quality patient care. An orthopedic surgery team focused on perioperative management is better positioned to decrease adverse events and improve patient outcomes after reverse total shoulder arthroplasty.     

A cluster randomized trial of a primary palliative care intervention (CONNECT) for patients with advanced cancer: Protocol and key design considerations

BackgroundThe addition of specialty palliative care to standard oncology care improves outcomes for patients with advanced cancer and their caregivers, but many lack access to specialty care services. Primary palliative care—meaning basic palliative care services provided by clinicians who are not palliative care specialists—is an alternative approach that has not been rigorously evaluated.MethodsA cluster randomized, controlled trial of the CONNECT (Care management by Oncology Nurses to address supportive care needs) intervention, an oncology nurse-led care management approach to providing primary palliative care for patients with advanced cancer and their family caregivers, is currently underway at 16 oncology practices in Western Pennsylvania. Existing oncology nurses are trained to provide symptom management and emotional support, engage patients and families in advance care planning, and coordinate appropriate care using evidence-based care management strategies. The trial will assess the impact of CONNECT versus standard oncology care on patient quality of life (primary outcome), symptom burden, and mood; caregiver burden and mood; and healthcare resource use.DiscussionThis trial addresses the need for more accessible models of palliative care by evaluating an intervention led by oncology nurses that can be widely disseminated in community oncology settings. The design confronts potential biases in palliative care research by randomizing at the practice level to avoid contamination, enrolling patients prior to informing them of group allocation, and conducting blinded outcome assessments. By collecting patient, caregiver, and healthcare utilization outcomes, the trial will enable understanding of the full range of a primary palliative care intervention's impact.     

Quality Indicators (QI) of Acute Pain after Surgery in European Countries

ObjectivesIt is common practice to use pain quality indicators (QI) to accurately assess the medical care situation of patients. This literature review identifies the status quo of acute pain QI among adult inpatients.Data SourcesStudies published in English or German were identified using a systematic search on CINAHL, Cochrane Library, PubMed, Web of Science, and Google Scholar from 01/2007 to 02/2018. Additional pain management journals, conference proceedings, and websites of health organizations and pain societies were manually screened. Studies about postoperative pain in adults (≥18 years) during inpatient stay after all types of surgery in Europe were included in this review.Review/Analysis MethodsThe identified study results were categorized into structural, process, and outcome indicators based on Donabedian's framework of evaluating care quality.ResultsThe search identified 319 citations, of which 20 studies used structure, process, and outcome data including 180,988 patients and 1,970 health care professionals to gain insight into the quality of acute pain management. Overall, 80% used patient surveys to collect data. National data on pain management are reported in five European studies (France [2], the Netherlands, Spain, and Austria).ConclusionsEuropean studies comprehensively comparing acute pain management results are currently missing. Thus, this report highlights the need to develop consensus-based quality indicators in management of acute pain, which take into account both the methodologic quality and the relevance to clinical practice.     

Associations between socioeconomic status,atrial fibrillation,and outcomes: a systematic review

ABSTRACT

Background: Atrial fibrillation (AF) is a growing epidemic and evidence of a relationship to socioeconomic status (SES) is inconsistent. We aimed to summarize the literature about SES and AF and defined two objectives: (1) To examine the association between SES and the risk of AF; (2) To examine the association between SES and AF-related outcomes in an AF-population.

Methods: We performed a separate search for each objective in Ovid-MEDLINE and Ovid-Embase. For objective 1, the population included was healthy participants and outcome of interest was AF. For objective 2, the population included were patients with AF and outcome of interest was mortality, treatment, ablation for AF, knowledge about AF, and morbidity.

Results: For objective 1, 12 studies were included. No consistent pattern for an association between SES and the risk of AF was discovered. For objective 2, 39 studies comprising 42 outcomes were included. The majority of studies showed an association between low SES and increased mortality and morbidity.

Conclusion: Low SES was associated with poorer outcomes when AF was present. These findings may imply that health-care professionals and policy interventions should focus on the promotion of AF-education and management among patients with AF and low SES.     

Gait quality assessed by trunk accelerometry after total knee arthroplasty and its association with patient related outcome measures

BackgroundWith an increasingly younger population and more active patients, assessment of functional outcome is more important than ever in patients undergoing total knee arthroplasty. Accelerometers have been used successfully to objectively evaluate gait quality in other fields. The aim of this study was to assess gait quality with accelerometers before and after surgery, and to assess added value of resulting parameters to patient reported outcome measures scores.MethodsSixty-five patients (mean age 65 years (range 41–75)) who underwent primary total knee arthroplasty were evaluated using a tri-axial trunk accelerometer preoperatively and 1 year after surgery. Gait quality parameters derived from the accelerometry data were evaluated in three dimensions at both time points. Factor analysis was performed on all outcome variables and changes from before to 1 year after surgery in the most representative variable for each factor were studied.FindingsFactor analysis identified three separate gait quality factors, with questionnaire and gait quality parameters loading on different factors. Both gait quality factor scores and questionnaire factor scores improved significantly 1 year after surgery. As expected based on the factor analysis, only weak to moderate associations were found between patient reported outcome measures and gait quality before surgery, after surgery and in change scores.InterpretationThe independence of patient reported outcome measures and gait quality parameters measured with trunk accelerometry indicates that gait quality parameters provide additional information on functional outcome after total knee arthroplasty. Providing caretakers with objectively measurable targets using accelerometry could help improve outcome of these patients.     

Public health nurses’ views on quality measures: A cross-sectional study

BackgroundThe quality indicators program has intended and unintended consequences that may affect nurses’ professional performance and organisational outcomes.AimsTo explore public health nurses’ knowledge, attitudes, and perceptions of the nursing-sensitive quality indicators applied in mother–child health clinics and their associations with organisational quality outcomes: quality of care, burnout, and communication.MethodsA cross-sectional study with a convenience sample. In total, 177 public health nurses completed a self-administered questionnaire measuring their knowledge, attitudes, and perceptions of the quality indicators regarding their performance and organisational outcomes. A structural equation modelling analysis was performed to describe the associations between the variables and to identify the mediating variables.FindingsThe structural equation modelling analysis revealed that the intended (positive) impact on the nurse's professional level was the mediating variable between the nurses’ knowledge and attitudes towards the National Health Quality Measure program, their seniority, and the unintended (negative) impact on the nurse's professional level, and the organisational outcomes.Discussion and conclusionPublic health nurses perceive quality indicators as contributing to and improving their professional work, with a positive impact on organisational outcomes. Nursing leaders and policymakers may promote good organisational outcomes by developing methods that will emphasise the importance of quality indicators in nursing practice.     

Severe complications of chronic cholelithiasis treatment

BackgroundGallstone disease is a burden affecting about 15% percent of the population around the world. The complications of gallstone disease are numerous and many require emergency care. Severe complications are not uncommon and require special attention, as lethal outcome is possible.Case presentationWe present a retrospective analysis of eight cases describing severe complications of gallstones in patients undergoing endoscopic treatment of chronic gallstones conditions. All patients were admitted to our emergency care department following symptoms onset. The diagnostic difficulties, treatment strategies and outcomes are presented. The associated risk factors and preventative measures are discussed. Two patients developed profuse bleeding, two developed acute pancreatitis, two patients had perforation related complications. One rare case of bilioma and one case of iatrogenic injury are presented. All patients had severe condition, in two cases lethal outcome was a result of co-morbidity and difficulties in management.ConclusionSpecial care should be taken in patients with risk factors of severe complications in order to improve outcome and prevent the development of life-threatening conditions.     

Prepare,a randomized trial to promote and evaluate weight loss among overweight and obese women planning pregnancy: Study design and rationale

BackgroundWomen who are overweight or have obesity at pregnancy onset, and those who gain excessive weight during pregnancy, are at increased risk of pregnancy-related complications and large for gestational age infants.ObjectiveThis report describes methodology for the Prepare study, a randomized, controlled clinical trial testing a preconception and pregnancy weight management program for women who are overweight or have obesity (BMI ≥ 27 kg/m²).OutcomesThis trial examines multiple pregnancy and neonatal outcomes, with the primary outcome being gestational weight gain (GWG). Secondary outcomes include change in weight before conception, offspring birth weight adjusted for gestational age, offspring weight for length, and pregnancy diet quality and physical activity level.MethodsNonpregnant women who anticipate becoming pregnant in the next 2 years are randomly assigned to an intervention program or a usual care control condition. Intervention participants receive weight management counseling by telephone before and during pregnancy, with weekly contacts during the first 6 months and monthly contacts for the next 18 months. Intervention participants also have unlimited access to a study website that provides self-management tools. All participants who become pregnant are contacted at 20 weeks' gestation to assess physical activity levels and dietary habits. All other outcome data are obtained from medical records. Intervention satisfaction is assessed via questionnaire.SummaryThis clinical trial tests the efficacy of an intervention program designed to help overweight and obese women achieve healthy lifestyle changes that will result in a healthy weight prior to pregnancy and appropriate weight gain during pregnancy.     

Can bystanders' gender affect the clinical outcome of out-of-hospital cardiac arrest: A prospective,multicentre observational study

Background and purposeOut-of-hospital cardiac arrest (OHCA) is one of the most common causes of death in many countries. For OHCA patients to have a good clinical outcome, bystander cardiopulmonary resuscitation (CPR) is extremely significant. It is necessary to study the various characteristics of bystanders to improve bystander CPR quality. We aimed to evaluate the correlation between bystanders' gender and clinical outcomes of patients with OHCA.MethodsWe conducted an observational study by using a prospective, multicenter registry of OHCA resuscitation, provided by the Korean Cardiac Arrest Research Consortium registry from October 2015 to June 2017. The following data were collected: patient's age, patient's gender, witnessed by a layperson, characteristics of the bystanders (age grouped by decade, gender, CPR education, compression method, and perception of automated external defibrillators), arrest place, emergency medical services arrival time, and initial electrocardiogram rhythms. Outcome variables were prehospital return of spontaneous circulation, survival discharge, and cerebral performance category status at discharge.ResultsA total of 691 patients were included in the study. There were significant differences in the initial shockable rhythm and previous CPR training between bystander's gender. Characteristics such as age, patient's gender, witnessed by a layperson, bystander's gender, initial shockable rhythm, and arrest place were significantly associated with neurologic outcome at discharge, using univariable analysis. However, in the multivariate logistic model, there was no significant correlation between bystander's gender and neurologic outcome. In the subgroup analysis using the multivariate logistic model with 291 patients without missing values of CPR education and bystander’ age, there was a significant difference in neurologic outcome depending on bystander's CPR education status.ConclusionThere was no difference in the neurologic outcomes of OHCA patients based on bystanders' gender. However, according to subgroup analysis, there was a difference in the neurologic outcome depending on the status of bystanders' CPR education and females received less CPR education than males. Therefore, more active CPR education is required.     

Robotic-assisted laparoscopy is a feasible method for resection of deep infiltrating endometriosis,especially in the rectosigmoid area

ObjectiveThis study aimed to compare outcomes of mini-invasive surgical treatment of endometriosis, especially conventional laparoscopy with robotic-assisted laparoscopy, and to evaluate the quality of life.MethodsOne hundred three consecutive patients with endometriosis who had surgery from 2014 to 2017 owing to an indication of pain were enrolled in this retrospective study. The majority (n = 77, 75%) of patients underwent conventional laparoscopy and 18 (17%) had robotic-assisted laparoscopy. The quality of life was postoperatively assessed with a questionnaire.ResultsThe rates of parametrectomy (76% vs. 45%,) and rectovaginal resection (28% vs. 4%) were significantly higher in robotic-assisted laparoscopy than in laparoscopy. Additionally, the rate of bowel operations (50% vs. 17%), especially the shaving technique, was higher in robotic-assisted laparoscopy surgery than in laparoscopy (39% vs. 8%). There was no difference in the rate of postoperative complications between laparoscopy and robotic-assisted laparoscopy. Most (91%) of the patients who answered the questionnaire felt that surgical treatment had relieved their pain. In the laparoscopic and robotic-assisted groups, 88% of respondents felt that their quality of life had improved after surgery.ConclusionsThis study suggests that robotic-assisted laparoscopy is a feasible method to resect deep infiltrating endometriosis, especially in the rectosigmoid area.     

Translation of the Care of Persons with Dementia in their Environments (COPE) intervention in a publicly-funded home care context: Rationale and research design

BackgroundDementia is the leading cause of loss of independence in older adults worldwide. In the U.S., approximately 15 million family members provide care to relatives with dementia. This paper presents the rationale and design for a translational study in which an evidence-based, non-pharmacologic intervention for older adults with dementia and family caregivers (CGs) is incorporated into a publicly-funded home care program for older adults at risk for nursing home admission.MethodsThe 4-month Care of Persons with Dementia in their Environments (COPE) intervention is designed to optimize older adults' functional independence, and to improve CG dementia management skills and health-related outcomes. COPE features 10 in-home occupational therapy visits, and 1 in-home visit and 1 telephone contact by an advanced practice nurse. COPE was deemed efficacious in a published randomized clinical trial. In the present study, older adults with dementia enrolled in the Connecticut Home Care Program for Elders (CHCPE) and their CGs are randomly assigned to receive COPE plus their ongoing CHCPE services, or to continue receiving CHCPE services only.OutcomesThe primary outcome for older adults with dementia is functional independence; secondary outcomes are activity engagement, quality of life, and prevention or alleviation of neuropsychiatric symptoms. CG outcomes include perceived well-being and confidence in using activities to manage dementia symptoms. Translational outcomes include net financial benefit of COPE, and feasibility and acceptability of COPE implementation into the CHCPE. COPE has the potential to improve health-related outcomes while saving Medicaid waiver and state revenue-funded home care program costs nationwide.     

NAEMSE Abstracts 2006

Abstract

Objective. Early, high-quality, minimally interrupted bystander cardio-pulmonary resuscitation (BCPR) is essential for out-of-hospital cardiac arrest survival. However, rates of bystander intervention remain low in many geographic areas. Community CPR programs have been initiated to combat these low numbers by teaching compression-only CPR to laypersons. This study examined bystander CPR and the cost-effectiveness of a countywide CPR program to improve out-of-hospital cardiac arrest survival. Methods. A 2-year retrospective review of emergency medical services (EMS) run reports for adult nontraumatic cardiac arrests was performed using existing prehospital EMS quality assurance data. The incidence and success of bystander CPR to produce prehospital return of spontaneous circulation and favorable neurologic outcomes at hospital discharge were analyzed. The outcomes were paired with cost data for the jurisdiction's community CPR program to develop a cost-effectiveness model. Results. During the 23-month study period, a total of 371 nontraumatic adult out-of-hospital cardiac arrests occurred, with a 33.4% incidence of bystander CPR. Incremental cost-effectiveness analysis for the community CPR program demonstrated a total cost of $22,539 per quality-adjusted life-year (QALY). A significantly increased proportion of those who received BCPR also had an automated external defibrillator (AED) applied. There was no correlation between witnessed arrest and performance of BCPR. A significantly increased proportion of those who received BCPR were found to be in a shockable rhythm when the initial ECG was performed. In the home setting, the chances of receiving BCPR were significantly smaller, whereas in the public setting a nearly equal number of people received and did not receive BCPR. Witnessed arrest, AED application, public location, and shockable rhythm on initial ECG were all significantly associated with positive ROSC and neurologic outcomes. A home arrest was significantly associated with worse neurologic outcome. Conclusions. Cost-effectiveness analysis demonstrates that a community CPR outreach program is a cost-effective means for saving lives when compared to other healthcare-related interventions. Bystander CPR showed a clear trend toward improving the neurologic outcome of survivors. The findings of this study indicate a need for additional research into the economic effects of bystander CPR.     

The effect of goal setting in asthma self-management education: A systematic review

BackgroundAsthma self-management education combining with behavior therapy is considered to be more effective. Goal setting is a common behavior change technique used to help patients self-manage their symptoms. However, empirical evidence around its effectiveness on asthma management lacks clarity.AimsTo systematically integrate and appraise the evidence for effectiveness of goal setting interventions on asthma outcomes.MethodsDatabases included CENTRAL, PubMed, EMBASE, CINAHL and Proquest Psychology Database were systematically searched for relevant intervention studies employing goal setting technique as a method in asthma education program for self-management. Characteristic of studies and outcomes in clinical, psychosocial and healthcare utilization outcome were extracted.ResultsFrom a total of 2641 citations, 45 full-text articles were assessed for eligibility and 9 studies met the inclusion criteria. Eight studies were randomized controlled trial and one was before-after study. None studies have a high methodological quality. Goal-setting based intervention appeared to improve symptom control, quality of life and self-efficacy in adult patients with asthma.ConclusionThis systematic review highlighted the potential of a goal setting technique in the asthma self-management education. However, due to the limitations of the quality and quantity of the included literature, more rigorous studies are needed. In the future, better effective study protocol combining with goal setting approach and other behavior technique is needed to further investigate.