IV iron therapy and anemia management in patients on hemodialysis: benefits of a revised CQI strategy

Intravenous iron therapy is widely used in the management of anemia in patients on hemodialysis, and anemia management protocols provide a standardized approach to IV iron therapy. The author's hemodialysis center implemented an initial anemia management protocol in 2004 based on the principles of a continuous quality improvement (CQI) program, detailed by Bowe and Ammel in the Nephrology Nursing Journal in 2005. Successive revision using the CQI process has resulted in additional benefits regarding patient outcomes, which are reported here. This article illustrates the value of a CQI program for maintaining and improving clinical outcomes in patients who have anemia and are undergoing hemodialysis.     

E FFECTS OF A C ONTINUOUS Q UALITY I MPROVEMENT P ROGRAM ON H ELICOPTER L IFTOFF T IMES

Background. The continuous quality improvement (CQI) process addresses concerns from a systems approach, employing committees of employees rather than selected management personnel to identify and solve problems, improve patient care and efficiency, and enhance customer satisfaction. Little is known about the effects of the CQI process on an aeromedical program. Objectives. To create a CQI program within an aeromedical program and to investigate its effect on helicopter liftoff times for scene responses. Methods. A CQI program was established at a busy aeromedical service that completed 897 missions in the previous year. A concern identified by the CQI committee was delays in helicopter liftoff time after receipt of mission requests for scene responses. Each component necessary for liftoff (dispatch, pilot weather check, and crew response) was identified, time limits were set for each, new procedures were developed, and all staff received training on the new procedures. Computer tracking of each of the identified component times allowed comparison of data pre and post procedure implementation of the CQI-developed procedures. Results. After CQI changes in procedures were implemented, there were a total of 30 delays out of 323 calls (9% of liftoffs for on-scene flights). This represents a 6% reduction in total delays. The largest drop in component times was observed in crew response (2.6%). An unanticipated 10% drop in response times for interhospital liftoffs also occurred, presumably due to heightened awareness of the service to response times in general. Conclusions. These findings suggest that employing a program utilizing CQI concepts can shorten helicopter liftoff times and improve response times in aeromedical programs.     

Industrial models of continuous quality improvement. Implications for emergency medicine.

CQI or TQM programs were developed from industrial models dating back to the 1930s. The original philosophic underpinnings guiding CQI included SPC, in which rigorous statistical methods were used to study industrial flow processes. As originally adopted by the Japanese, CQI is credited, to a significant degree, with the emergence of the Japanese economy as a major world leader. Nonetheless, the original CQI concepts were developed and implemented by American researchers, including Deming and Juran. The application of industrial models of quality improvement to service businesses in general and the health care industry in particular have met with substantial success in a number of different settings. Far from representing a management fad, CQI represents a solid management philosophy with a strong statistical background that stands in sharp contrast to traditional management in this country. CQI recognizes that the majority of defects result from a failure of the processes through which the product or service is generated, as opposed to the workers themselves. To a significant degree, CQI empowers service providers (through the strong commitment of top management) to participate in improving the processes through which products and services are delivered. As efforts unfold to contain health care costs and maintain quality in the face of declining resources, CQI programs are likely to be essential to success. Nonetheless, adopting CQI requires a significant commitment on the part of top management to the training and retraining of health care providers and the recognition that traditional management philosophies and techniques have largely failed to produce the quantum leaps in quality that will be required in the coming years.     

Student faculty committee: A quality improvement and engagement strategy in nursing education

BackgroundThe purpose of this initiative was to address limitations of established continuous quality improvement (CQI) strategies in a nursing program, engage students in the process, and implement real time change.MethodsThe Plan Do Study Act (PDSA) process was utilized by an ad hoc student faculty CQI committee. After two years of activity, several collaborative changes were implemented, and a survey was presented to stakeholders.ResultsA thematic analysis revealed several themes regarding the perceived impacts the committee has had on the nursing program: personal and professional impacts (program improvement, improved communication, student empowerment, and improved student satisfaction), facilitators to participation (relationships, desire to participate in CQI, and desire to improve communication), and barriers to participation (no barriers, lack of awareness, competing priorities, closed membership, and fear of retaliation).ConclusionsStudent involvement in a CQI program can have a positive impact on the teaching and learning experience.     

持续质量改进在预防维持性血液透析患者中心静脉导管相关感染中的应用

目的探讨应用持续质量改进（CQI）的方法降低血液透析患者静脉导管相关血流感染（CRBSI）的效果。方法选择北京大学人民医院CQI前维持性透析患者（68例）分析导管相关的血流感染发生情况，采用PDCA四步法，设计并实施改善留置导管血液透析患者导管相关血流感染的防治措施，与CQI后次年同期76例中心静脉留置导管的患者导管相关血流感染发生情况比较。结果持续质量改进后，无论是非隧道式或隧道式中心静脉导管的CRBSI发生率均有不同程度降低。非隧道式中心静脉导管总体CRBSI发生率降低68％（8．1例次／1000导管日VS2．6例次／1000导管日，其中股静脉置管的CRBSI发生率由14．8例次／1000导管日降至4．1例次／1000导管日，颈内静脉置管CRBSI发生率2．6例次／1000导管日降至0．7例次／1000导管日。隧道式中心静脉置管CRBSI发生率降低了77％（5．2例／1000导管日VS0．7例／1000导管日），其中颈内静脉置管CRBSI发生率由CQI前的2．6例次／1000导管日下降至0．7例次／1000导管日。结论持续质量改进的方法可以降低维持性血液透析患者的中心静脉导管相关血流感染。     

Effectiveness of a continuous quality improvement program aiming to reduce unplanned extubation: A prospective study

Objective To evaluate the effectiveness of a continuous quality improvement (CQI) program in reducing the incidence of unplanned endotracheal extubation.Design Prospective study over a 9-month period.Setting Adult intensive care units (ICUs including coronary care unit, medical ICU, surgical ICU, and cardiovascular surgical ICU) in a university-affiliated medical center.Patients 831 consecutive mechanically ventilated patients.Interventions CQI program focusing on standardization of procedures, improvement of communication, and identification and management of high-risk patients.Measurements and results With the implementation of this CQI program, the overall incidence density of unplanned extubation (defined as number of new unplanned extubations per mechanical ventilation patient-days) significantly decreased from 2.6% in the first trimester to 1.5% in the second trimester and 1.2% in the third trimester (p=0.01). This reduction was essentially the result of a decrease in unplanned extubation in orally intubated patients (incidence density 4.6, 1.7 and 1.0% for three trimesters, respectively;p<0.0001). Unplanned extubation in nasally intubated patients remained largely unaffected (1.2, 1.4, and 1.4% for three trimesters, respectively;p=0.92).Conclusions The implementation of a concerted CQI program is effective in reducing the overall incidence of unplanned endotracheal extubation. Mailing address: Maria Parham Hospital, 1801 Ruin Creek Rd, Suite 002, Henderson, NC 27536, USA FAX: +1(919) 431-2088     

双肺移植患者肺康复方案的构建及应用

目的 构建双肺移植患者肺康复方案并评价其应用效果.方法 采用便利抽样法,选取2020年1月—2021年3月杭州市某三级甲等医院行双肺移植术的46例患者为研究对象,采用随机数字表法分为试验组和对照组,每组各23例.试验组在对照组方案的基础上接受肺康复方案的干预,由呼吸治疗专科护士主导的肺康复小组全程指导,包括术前预康复训...     

A Decentralized Admission Screening Protocol for a Geriatric Rehabilitation Program: Does It Make a Difference?

The purpose of this retrospective evaluation study was to compare outcomes related to two distinct processes for screening people referred for admission to a geriatric rehabilitation program at a chronic care hospital in southern Ontario. Data were collected through chart review and focus group methods. The results were unexpected in that the projected outcomes associated with the newer referral screening process did not materialize. For both referral screening processes, findings are discussed in terms of the percentage of achieved patient rehabilitation goals. The average lengths of patient stay associated with both screening processes were also compared. No statistically significant differences between the two processes were found in terms of either the percentage of goals achieved or the length of patient stay. Focus group sessions were held to elicit team members' perceptions of the effectiveness of each of the referral processes. Participants in the focus groups were supportive of the newer referral screening and admission process although the evidence gathered from the chart review did not demonstrate improvements in patients' length of stay or an increase in the percentage of rehabilitation goals achieved.     

Data-driven quality improvement in the Emergency Department at a level one trauma and tertiary care hospital

To demonstrate how a comprehensive and internally driven Continuous Quality Improvement (CQI) program was designed and implemented in our Emergency Department (ED) in 1999. This program involved monthly data collection and analysis, data-driven process change, staff education in the core concepts of quality, and data reanalysis. Data components collected during the program included census data, physician profiling, and focused clinical audits. CQI measures collected at the beginning of the program and quarterly included: (1) CQI metric data (turnaround times [TAT] and rates of left against medical advice [AMA] or left without being seen [LWOBS]), (2) rates and nature of patient complaints, and (3) results of patient satisfaction surveys performed by an outside consulting firm contracted by hospital administration. During the 4 years since its implementation the program demonstrated improvement in all measured areas. Despite an increase in patient volume of 32% to nearly 37,000 visits/year, and only minimal staffing adjustments, the mean quarterly TAT decreased from 183 min to 165 min (9.8% decrease), the rate of complaints dropped by 56.1% (2.1 per 1000 patients to 0.92), and patients leaving AMA or LWOBS decreased 66.7% from 2.7% to 0.9%. Overall, 44.8% of ED patients rated their care as "excellent." In summary, we demonstrate how a comprehensive quality improvement program was structured and implemented at a tertiary care center and how such a program demonstrated improvement in specific CQI parameters.     

Substantiation of patients' length stay in hospital after acute myocardial infarct

AIM: To study and validate the duration of optimal hospital stay for postmyocardial infarction patients and to specify indications for their discharge. MATERIALS AND METHODS: The trial enrolled 187 patients with large- and small-focal acute myocardial infarction. The patients were divided into two groups by different speed of activization and hospital stay. RESULTS: There were no significant differences between the groups with different duration of hospital stay by working ability and invalidism. Temporary disability in patients who have undergone standard rehabilitation was longer than in patients on the shorter-program rehabilitation. Performance of exercise tests on day 14 distinguished patients with a favourable long-term prognosis who were candidates for shorter rehabilitation program. CONCLUSION: The program of quicker rehabilitation (a two-times decrease in the hospital stay) can be applied to patients with uncomplicated myocardial infarction without damage to their health.     

The physiatrist as primary physician for patients on an inpatient rehabilitation unit

Eighty-two patients admitted to a predominantly geriatric inpatient rehabilitation unit were followed throughout their stay in order to document their need for medical management. Their average age was 74.1 years and mean length of stay was 27.9 days. A total of 302 indications for medical intervention (3.7/patient) were found. In addition there were 2.8 medication changes/patient found when comparing admission to discharge medications, and 0.7 medications/patient prescribed for intercurrent illnesses. Actual documented loss of planned therapy time was found 21 times, involving 19 patients but exceeded 1 day in only six patients. Fifty-eight patients were ultimately discharged home, 14 were discharged to nursing homes (7 for social reasons), and 10 were transferred to an acute general hospital. Adverse drug reactions occurred in 27% of the patients and incidence rate paralleled the number of medications prescribed for the patient. This study indicates that the physiatrist on an inpatient rehabilitation unit must function as team manager or program director, and as the patient's primary physician. By managing medical problems effectively, the physician limits the loss of therapy time, thus shortening the length of stay and enabling the patient to continue to participate in his rehabilitation program.     

持续质量改进在动脉粥样硬化性肾动脉狭窄患者随访中的作用

目的通过护士积极参与的持续质量改进措施(CQI),来提高动脉粥样硬化性肾动脉狭窄(ARAS)患者随访的依从性,以改善患者预后。方法应用PDCA四步法:即设计(plan)-实施(do)-检验(check)-应用(act),对患者进行随访。对实施质量改进前后患者横断面的指标进行比较。结果患者的随访率显著提高(46.9%~83.8%),绝大多数患者愿意接受随访检查,如测血压、监测肾功能、定期复查彩超等。血压控制率明显改善,由45.6%提高到93.1%。结论CQI对于改善ARAS患者依从性及预后非常有益,在这一措施计划、实施的过程中护士起了不可替代的作用。     

重症康复医学的意义及发展

现代医学发展模式从“治病的科学”逐渐转变为“维护健康的科学”,即强调身体功能、日常生活能力及社会参与能力在疾病救治中的重要作用。重症康复医学通过早期康复介入,能促进重症患者身体功能恢复及早日回归家庭和社会。因此,加强危急重症和疑难复杂疾病患者的早期临床康复是康复医学发展的重要方向。重症康复应与临床其他学科紧密结合,实现“叠加”,而不仅仅是“时间的延续”。重症康复技术不断更新和发展,重症康复病房-普通康复病房-社区康复三级康复网络的形成,康复相关人员知识和技能提高,以及新医疗管理模式的建立等都能促进重症康复医学的发展。     

Continuous Quality Improvement Reduces Length of Stay for Fast-track Patients in an Emergency Department

Objective: To demonstrate how continuous quality improvement (CQI) can identify rational and effective means to reduce length of stay for minor illness/injury in an ED.
Methods: A CQI team documented the process of fast-track (FT) patient flow and prioritized the causes of delay. In Phase I, two solutions were implemented. In this Phase II of the study, three changes were implemented, including expansion of the FT area, realignment to provide a full-time FT nurse, and a detailed, stricter triage classification. The outcome was assessed by examining the interval from presentation to release from the ED (length of stay; LOS). Differences were ascertained by analysis of variance for consecutive FT patients not requiring radiography, ECG, or blood testing. Intervals from three pre-Phase II intervention 48-hour periods and one post-Phase II intervention 48-hour period were analyzed.
Results: Before the Phase I changes, the mean ± SD LOS was 92 ± 46 min. After the Phase I changes, the LOS was 67 ± 31 min. After the Phase II changes, this was reduced to 57 ± 34 min (p < 0. 05).
Conclusion: The formal application of CQI techniques in the ED can change patient flow and reduce LOS for FT patients.     

“It is about taking grips and not let myself be ravaged by my body”: A qualitative study of outcomes from in-patient multidisciplinary rehabilitation for patients with chronic rheumatic diseases

Purpose: To explore how patients experience the process and personal impact of deriving outcomes from a rheumatological rehabilitation program. Methods: Semi-structured interviews were conducted with 23 patients with inflammatory rheumatic diseases approximately 2 months after a 4-week hospital based multidisciplinary rehabilitation program. A thematic analysis was applied. Results: Overarching themes were increased dignity and self-respect. Initial uncertainty regarding illness management was exchanged with confident coping and of becoming an active agent in ones own life. Strategies and coping tools tried out during the rehabilitation stay, do by their experienced effect become primary sources of gained insight into illness and symptom manifestation. Both elements give a sense of control and influence self-confidence and motivation to engage in self-management. The process from gained insight and experienced effect of coping tools, to active self management, is however, not automatic. Psychological factors play a key role, and there is a need to take individual psychological themes into account and tailor interventions accordingly. Conclusions: Specialized multidisciplinary rehabilitation is an ongoing active process, in which psychological factors play a key role and must be accounted for. Well targeted rehabilitation has the potential to create outcomes of major personal impact.

Implications for Rehabilitation

• Well targeted multidisciplinary rehabilitation has the potential to create outcomes of major personal impact

• Rehabilitation interventions should be tailored according to the patient’s subjective perception of challenges.

• A secure and supportive environment where patients are met with respect and interest represents a crucial element in rehabilitation.

     

Benefits of an inpatient pulmonary rehabilitation program: a prospective analysis

OBJECTIVE: To examine the effect of an inpatient pulmonary rehabilitation program on functional outcome, supplemental oxygen use, quality of life (QOL), and rehospitalization. DESIGN: A prospective study. SETTING: Inpatient pulmonary rehabilitation unit. PATIENTS: One hundred fifty-seven patients with moderate to severe chronic obstructive pulmonary disease (COPD) admitted to an inpatient pulmonary rehabilitation program over a 3-year period. INTERVENTION: Comprehensive interdisciplinary inpatient pulmonary rehabilitation program with an average length of stay of 21 days. MAIN OUTCOME MEASURES: Improvements in QOL questionnaire scores, COPD knowledge questionnaire scores, 6-minute walking test (with 3 ambulation categories: bed-bound, household ambulators, community ambulators), and supplemental oxygen use. Rehospitalization 1 year after completion of the program was also assessed and compared with hospital days for the year before the program. RESULTS: On discharge from the program, 88% of individuals walked farther (p <.0001), and community ambulators doubled their walking distance, whereas bed-bound patients decreased 10-fold; supplemental oxygen use dropped 33% during the day (p <.0001) and 57% during the night (p <.0001); 82% showed improved QOL (p <.0001); 67% showed improved knowledge of COPD (p <.0001); and 67% of the sample spent less time in the hospital during the 12 months after program completion compared with the 12 months before admission (p <.001). CONCLUSIONS: An inpatient pulmonary rehabilitation program leads to improved endurance and functional ambulation, decreased supplemental oxygen use, and fewer hospitalizations 1 year after discharge for patients with COPD.     

持续质量改进管理方法在抗肿瘤药物临床试验血标本采集中的应用

目的 探讨持续质量改进（CQI）理论在抗肿瘤药物临床试验血标本采集的应用及效果.方法 对2011年3-12月送往中心实验室的1896份临床试验血标本中94份不合格血样原因进行分析,针对血标本采集存在的问题,于2012年2月开始运用持续质量改进的方法,对采血者、患者依从性及采血流程从管理上进行改进,评价持续质量改进后的效果.结果 实施CQI后,血标本不合格率由4.92％下降至1.42％,患者对护士采血技术满意度由85.6％上升至97.2％,服务态度满意度由90.5％上升至99.5％,实施前后比较差异均有统计学意义（x2值分别为42.93,15.57,14.97;P ＜0.01）.结论 实施持续质量改进提高了临床试验血标本合格率及患者满意度.     

Full-time integrated treatment program, a new system for stroke rehabilitation in Japan: comparison with conventional rehabilitation

OBJECTIVE: To validate the effectiveness of the Full-time Integrated Treatment (FIT) program that is characterized by rehabilitation 7 days/wk, encouragement of daytime activity, and enhanced communication between staff in stroke rehabilitation. DESIGN: Since our facility changed from the conventional rehabilitation system of 5 days of treatment to the FIT program in December 2000, we compared the conventional rehabilitation program with the FIT program at our hospital. The conventional treatment group and the FIT group consisted of 48 and 58 first-stroke hemiplegics, respectively. RESULTS: The motor subscore of the FIM instrument at admission and at discharge was 64.3 and 77.0 in the conventional group and 60.6 and 80.9 in the FIT group, respectively. The length of stay and efficiency of the FIM instrument were 80.0 days and 0.16 in the conventional group and 69.8 days and 0.30 in the FIT group, respectively. These differences between groups were statistically significant, with the exception of admission FIM data. CONCLUSIONS: Because the FIT program attained a higher discharge FIM level with a shorter length of stay, the FIT program was concluded to be an efficient and effective method of stroke rehabilitation.     

3049 例脑卒中患者康复住院日的影响因素分析

目的分析脑卒中患者康复住院日趋势及其影响因素。方法连续选取北京博爱医院2002 年1 月~2011 年12 月住院康复脑卒中患者共3049 例,进行回顾性分析。采用秩和检验、二分类Logistic 回归模型进行统计学分析,探讨住院日的影响因素。结果脑卒中患者康复住院日中位数为82 d,2010 年、2011 年住院日有明显下降趋势。Logistic 回归共筛选出13 个变量,手术、肌肉痉挛、日常生活活动能力评分增加值、发病时间、院内感染、并发症、言语障碍、卒中类型、住院次数、付费方式为住院日的危险因素,年龄段、步行功能分级、Fugl-Meyer 评分为保护因素。结论降低住院日要以康复效果为参照指标,通过改善医院管理流程,加强并发症预防和院感控制,早期康复介入,从而降低住院日。