Evidence-based performance and quality improvement in the acute cardiac care setting

This article was originally planned to appear in the October 2007 issue of Critical Care Clinics. The goal of this article is to summarize the indicators, processes, and dimensions of care that are linked to desired clinical outcomes of the most commonly encountered conditions in the acute cardiovascular care setting, and specifically, acute coronary syndromes and congestive heart failure. Additionally, it reinforces the concepts of best cardiovascular care practice and reviews some of the highly successful quality initiatives that have demonstrated a link between hospital process performance and outcomes. Particular attention is focused on the evidence-based treatments and diagnostic evaluation and processes of inpatient cardiovascular care, which lead to desired outcomes meaningful to patients and where available, provide physicians with the strategies and tools to be successful in translating scientific evidence into effective and rewarding care.     

Integrating quality and safety content into clinical teaching in the acute care setting

Teaching the highest quality and safest practice has long been a goal of faculty members in pre-licensure nursing education programs. This article will describe innovative approaches to integrating quality and safety content into existing clinical practica. The core competencies identified by the Quality and Safety Education for Nurses project--patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics--serve as the framework for the teaching/learning exercises. The strategies described require a shift in attention rather than changes in course content and can be included in any clinical rotation in an acute care setting.     

持续质量改进在护理质量管理中的应用

目的通过持续质量改进的实施与效果评价,全面提高护理质量.方法借鉴美国卫生保健组织鉴定联合委员会(JCAHO)10步持续质量改进流程模式,定义出11个重要的护理方面:特一级基础护理、皮肤护理、护理记录、急救药品管理等.按照医院评审要求,结合医院实际情况,制定测量标准,建立阈值,评价护理质量.结果医院护理质量管理在推行持续质量改进模式的4年中,护理质量始终呈平稳上升趋势.结论持续质量改进是护理质量管理的一个永恒目标.     

Applying the diabetes quality improvement project indicators in the Indian Health Service primary care setting

OBJECTIVE: With publication of the Diabetes Quality Improvement Project (DQIP) measures, the Indian Health Service National Diabetes Program applied the DQIP format to its IHS Diabetes Care and Outcomes Audit for comparison and benchmarks. RESEARCH DESIGN AND METHODS: Since 1986 the IHS Diabetes Care and Outcomes Audit has been conducted by medical record review in >75% of IHS and tribal facilities. Each year systematic random sample of charts is drawn from local diabetes registries. Chart reviews are conducted by, trained professionals according to standard definitions and instructions. Abstracted data are entered into a microcomputer-based epidemiologic software package. Local, regional, and national rates are constructed for each item. During the period 1995-1997, 150 facilities submitted data for compilation, representing participation from all 12 IHS administrative regions. The IHS Diabetes Care and Outcomes Audit collected virtually all of the DQIP measures, with the exception of LDL cholesterol (which was added to the record review in 1998). RESULTS: In 1995, 1996, and 1997, a total of 9,557, 9,985, and 9,626 individuals, respectively, were included in the total IHS audit sample. The reviews for 1995, 1996, and 1997 revealed that of all subjects: 55, 65, and 80%, respectively, had more than one HbA1c test during the year (P < 0.001); 42, 38, and 34%, respectively; had a high-risk HbA1c (>9.5%) (P < 0.001); 83, 81, and 84%, respectively, were tested for macroproteinuria (P < 0.11) and 16, 17, and 23%, respectively were tested for microproteinuria (P < 0.001); total cholesterol was assessed in 80, 81, and 85%, respectively (P < 0.001), and corresponding proportions of those with values <5.17 mmol/l were 48, 50, and 52%, respectively; triglyceride values were measured for 75,75, and 80%, respectively (P < 0.001), and the corresponding median triglyceride levels were 199, 198, and 193 mg/dl, respectively (P < 0.001); the proportion of clients with a blood pressure <140/90 mmHg was 64, 64, and 66%, respectively (P < 0.05); 55, 56, and 55%, respectively, had a dilated eye exam (P < 0.053); and the proportion of clients who had a comprehensive foot exam were 59, 59, and 61%, respectively (P < 0.05). CONCLUSIONS: The DQIP accountability and quality improvement measures could be easily applied to the IHS Diabetes Care and Outcomes Audit, and the process can prove to be practical. However, data alone are not sufficient to effect change. Use of the measures to ensure that the quality of care improves must also be stressed, because measuring alone will not guarantee such improvement.     

我国目前开展延续护理的SWOT分析

延续护理是适应经济社会发展需要的新型护理模式.本研究运用SWOT分析,对我国开展延续护理的优势、劣势、机遇和挑战进行综合分析,并为其发展提出相应建议.     

Clinical leadership: using observations of care to focus risk management and quality improvement activities in the clinical setting

In an era when patient safety and quality of care are a daily concern for health care professionals, it is important for nurse managers and other clinical leaders to have a repertoire of skills and interventions that can be used to motivate and engage clinical teams in risk assessment and continuous quality improvement at the level of patient care delivery. This paper describes how a cohort of clinical leaders who were undertaking a leadership development program used a relatively simple, patient-focused intervention called the 'observation of care' to help focus the clinical team's attention on areas for improvement within the clinical setting. The main quality and safety themes arising out of the observations that were undertaken by the Clinical Leaders (CLs) were related to the environment, occupational health and safety, communication and team function, clinical practice and patient care. The observations of care also provided the CLs with many opportunities to acknowledge and celebrate exemplary practice as it was observed as a means of enhancing the development of a quality and safety culture within the clinical setting. The 'observation of care' intervention can be used by Clinical Leader's to engage and motivate clinical teams to focus on continuously improving the safety and quality of their own work environment and the care delivered to patients within that environment.     

慢性病患者延续护理质量改进策略的研究进展

文章综述了从医院到家庭的延续护理常规模式,即护理转移干预模式、延续护理模式、老年人安全转移优化效果模式、重新设计的出院模式等;分析了慢性病延续护理无效的根本原因及质量改进策略,即对执行延续护理的人员进行培训与资质认证考核、明确发送方与接收方的职责、开发并利用电子通讯体系进行患者信息的转移、管理人员监控延续护理的质量、促进护理人员之间及护患之间的沟通与协作、鼓励患者参与护理计划并采用“回教”的方法检验健康教育效果,以期为我国大规模开展延续护理提供指导和帮助.     

延伸护理实施在小儿肺炎护理中的作用

【摘要】目的：在小儿肺炎护理中实施延伸护理,并分析其护理价值。方法：选取2020年4月-2022年4月,在我院治疗的82例小儿肺炎患儿。按照随机分组原则,将其分为两组,每组41例。对照组患儿应用常规护理,观察组患儿在对照组基础上,对患儿开展延伸护理。比较两组患儿的病情恢复情况、家属护理满意度以及患儿心理健康、生活质量。结果：与对照组患儿比较,观察组患儿经干预后气喘、咳嗽、体温恢复等时间均更短,差异明显（P＜0.05）;经干预后,观察组患儿家属对护理工作的总满意率评价结果为97.56%,对照组为82.93%,差异明显（P＜0.05）;观察组患儿护理后的SCARED 评分更低,生活质量评分更高,与对照组比较均差异明显（P＜0.05）。结论：在小儿肺炎护理中实施延伸护理能够促进患儿病情恢复,改善患儿心理健康水平及生活质量,患儿家属对护理工作的满意度更高,实施效果良好,值得推广。     

我院护理质量检查存在的问题及改进

护理质量检查,其目的在于保证患者得到高质量的护理服务。分析2008~2010年护理质量检查中存在的问题,提出合理有效的针对性建议,以便提高护理质量,更好地服务患者,进而提升医院的综合竞争力。     

Implementation, management and continuous quality improvement of point-of-care testing in an academic health care setting

Point-of-care testing (POCT) has economic and medical benefits in the areas of immediate medical management, resource utilization and time management. Starting with bedside glucose, the Mount Sinai Medical Center has, over the past 11 years, implemented 23 POC tests, spanning complexity from blood gas/electrolyte testing to occult blood, in compliance with all regulatory and accreditation requirements. QC data are reviewed on a daily and weekly basis and all patient results are in the electronic medical record. A variety of healthcare workers; nurses, physicians, respiratory therapists and technologists, perform testing. Since POCT impacts on a variety of hospital departments, proper implementation and management requires a multi-disciplinary team approach with focus on the financial, regulatory, quality assurance and data integration issues. Established in 1996, the institutional committee, with laboratory leadership, handles the establishment, compliance review and future direction setting of the program. In 1999, over 1300 individuals performed over 440,000 POC tests within the institution. A formalized continuous quality improvement (CQI) program for the POCT program was developed in the fall of 1999. All testing sites are reviewed on a monthly basis for various quality indicators that cover QC performance, maintenance performance, proficiency testing, patient identification, and alert value confirmations.     

Assessing the quality of transitional care: further applications of the care transitions measure

BACKGROUND: The Institute of Medicine has identified care transitions as a priority area for performance measurement. OBJECTIVES: To examine the performance of the Care Transitions Measure (CTM) in more diverse populations and to introduce a 3-item CTM. RESEARCH DESIGN: Cross-sectional study with purposive sampling of traditionally underserved populations. Confirmatory factor analyses, internal consistency reliability analyses, and differential item function tests were performed to explore the stability and performance of the 15-item CTM. Regression assessed the ability of the 3-item CTM to predict the 15-item CTM total score. Analysis of variance tests were conducted to explore CTM performance in different populations with respect to health and demographics. SUBJECTS: A total of 225 patients age 18-90 who were hospitalized in the past 12 months and were African American, Hispanic American, or rural-dwelling. MEASURES: CTM-15, CTM-3, age, gender, education, and health status. RESULTS: Mplus confirmatory factor analysis supported the CTM-15 factor structure in more diverse population (Comparative Fit Index [CFI] = 0.954). The 3-item CTM explained 88% of the variance in the 15-item CTM score. Differential item function analysis did not reveal any differential item difficulty by age, gender, education, self-rated health, or group (African American, Hispanic American, and rural-dwelling). CONCLUSIONS: Following endorsement by National Quality Forum, findings support use of the CTM in national public reporting efforts. The 3-item CTM closely approximates the 15-item instrument and may be attractive to purchasers and health care organizations that want to assess quality in this area while minimizing cost and response burden.     

Knowledge development, quality improvement, and research ethics

Significant contributions to the improvement of health care have been made through research and quality improvement activities. Scientists are involved in knowledge generation and new forms of evidence as they test or reshape theory. Clinicians more typically are involved in identifying ways to improve the quality of practice and patient care in their practice environments. These types of activities often are referred to as quality improvement projects. While quality improvement and research projects both rely on powerful and precise measurement, the lines between these domains and how they may relate to each other have been blurred (Grady, 2007). Recent insights have helped to clarify the contributions of quality improvement activities as well as some of the challenges those types of projects may face from an ethical perspective.     

Improving quality in the intensive care unit setting

Summarizing the mission of the ICU, the institution directive board and the unit director must generate a structure, proceedings criteria, management, and analysis of results capable of providing satisfactory care. Furthermore, they must take into account each organizational aspect that is necessary to offer an appropriate service for the patient. Medicine in general and intensive care in particular require that precautions be taken to avoid the patient and family feeling uncertain and fearful about the quality of the attention and care they receive.     

A practical guide to male hypogonadism in the primary care setting

There is a high prevalence of hypogonadism in the older adult male population and the proportion of older men in the population is projected to rise in the future. As hypogonadism increases with age and is significantly associated with various comorbidities such as obesity, type 2 diabetes, hypertension, osteoporosis and metabolic syndrome, the physician is increasingly likely to have to treat hypogonadism in the clinic. The main symptoms of hypogonadism are reduced libido/erectile dysfunction, reduced muscle mass and strength, increased adiposity, osteoporosis/low bone mass, depressed mood and fatigue. Diagnosis of the condition requires the presence of low serum testosterone levels and the presence of hypogonadal symptoms. There are a number of formulations available for testosterone therapy including intramuscular injections, transdermal patches, transdermal gels, buccal patches and subcutaneous pellets. These are efficacious in establishing eugonadal testosterone levels in the blood and relieving symptoms. Restoration of testosterone levels to the normal range improves libido, sexual function, and mood; reduces fat body mass; increases lean body mass; and improves bone mineral density. Testosterone treatment is contraindicated in subjects with prostate cancer or benign prostate hyperplasia and risks of treatment are perceived to be high by many physicians. These risks, however, are often exaggerated and should not outweigh the benefits of testosterone treatment.     

A practical approach to goal-directed echocardiography in the critical care setting

Urgent cardiac ultrasound examination in the critical care setting is clinically useful. Application of goal-directed echocardiography in this setting is quite distinct from typical exploratory diagnostic comprehensive echocardiography, because the urgent critical care setting mandates a goal-directed approach. Goal-directed echocardiography most frequently aims to rapidly identify and differentiate the cause(s) of hemodynamic instability and/or the cause(s) of acute respiratory failure. Accordingly, this paper highlights 1) indications, 2) an easily memorized differential diagnostic framework for goal-directed echocardiography, 3) clinical questions that must be asked and answered, 4) practical issues to allow optimal image capture, 5) primary echocardiographic views, 6) key issues addressed in each view, and 7) interpretation of findings within the differential diagnostic framework. The most frequent indications for goal-directed echocardiography include 1) the spectrum of hemodynamic instability, shock, and pulseless electrical activity arrest and 2) acute respiratory failure. The differential diagnostic categories for hemodynamic instability can be remembered using the mnemonic ‘SHOCK’ (for Septic, Hypovolemic, Obstructive, Cardiogenic, and (K) combinations/other kinds of shock). RESP-F (for exacerbation of chronic Respiratory disease, pulmonary Embolism, ST changes associated with cardiac or pericardial disease, Pneumonia, and heart Failure) can be used for acute respiratory failure. The goals of goal-directed echocardiography in the unstable patient are: assessing global ventricular systolic function, identifying marked right ventricular and left ventricular enlargement, assessing intravascular volume, and the presence of a pericardial effusion. In an urgent or emergent setting, it is recommended to go directly to the best view, which is frequently the subcostal or apical view. The five views are the subcostal four-chamber view, subcostal inferior vena cava view, parasternal long axis view, parasternal short axis view, and the apical four chamber view. Always interpret goal-directed echocardiographic findings in the context of clinically available hemodynamic information. When goal-directed echocardiography is insufficient or when additional abnormalities are appreciated, order a comprehensive echocardiogram. Goal-directed echocardiography and comprehensive echocardiography are not to be used in conflict with each other.     

Continuous quality improvement in health care

CQI is most effective when it focuses performance on chronic, critical problems and identifies the "vital few" performance benchmarks. CQI in any health care setting depends on early success, on clear lessons learned, and on the feeling of achievement and "moving forward" that this engenders throughout the organization. If there is a secret formula, it is an initial successful project.