Brigette Hales

A multifaceted intervention for quality improvement in a network of intensive care units: a cluster randomized trial.

CONTEXT Evidence-based practices improve intensive care unit (ICU) outcomes, but eligible patients may not receive them. Community hospitals treat most critically ill patients but may have few resources dedicated to quality improvement. OBJECTIVE To determine the effectiveness of a multicenter quality improvement program to increase delivery of 6 evidence-based ICU practices. DESIGN, SETTING, AND PARTICIPANTS Pragmatic cluster-randomized trial among 15 community hospital ICUs in Ontario, Canada. A total of 9269 admissions occurred during the trial (November 2005 to October 2006) and 7141 admissions during a decay-monitoring period (December 2006 to August 2007). INTERVENTION We implemented a videoconference-based forum including audit and feedback, expert-led educational sessions, and dissemination of algorithms to sequentially improve delivery of 6 practices. We randomized ICUs into 2 groups. Each group received this intervention, targeting a new practice every 4 months, while acting as control for the other group, in which a different practice was targeted in the same period. MAIN MEASURE OUTCOMES: The primary outcome was the summary ratio of odds ratios (ORs) for improvement in adoption (determined by daily data collection) of all 6 practices during the trial in intervention vs control ICUs. RESULTS Overall, adoption of the targeted practices was greater in intervention ICUs than in controls (summary ratio of ORs, 2.79; 95% confidence interval [CI], 1.00-7.74). Improved delivery in intervention ICUs was greatest for semirecumbent positioning to prevent ventilator-associated pneumonia (90.0% of patient-days in last month vs 50.0% in first month; OR, 6.35; 95% CI, 1.85-21.79) and precautions to prevent catheter-related bloodstream infection (70.0% of patients receiving central lines vs 10.6%; OR, 30.06; 95% CI, 11.00-82.17). Adoption of other practices, many with high baseline adherence, changed little. CONCLUSION In a collaborative network of community ICUs, a multifaceted quality improvement intervention improved adoption of care practices. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00332982.

Work-Related Lost Productivity and Its Economic Impact on Canadian Patients with Moderate to Severe Psoriasis

Background: Psoriasis impacts many different areas of a patients life, including work productivity. There is no information regarding lost productivity owing to psoriasis in a Canadian population. Objective: The objective of this study was to determine the lost productivity of Canadian patients with moderate to severe psoriasis. Methods: Seventy-nine consecutive Canadian dermatology patients were interviewed and completed the Work Productivity and Activity Impairment Questionnaire (WPAIQ). Results: On average, 2.2 hours (± 5.6 hours) were lost from work per week owing to psoriasis-related events. Absence from work may result in lost mean patient wages of C

An interactive educational workshop to improve end of life communication skills

2,270.84 per person per year. Total lost wages owing to moderate to severe psoriasis may cost up to approximately

Factors Affecting Family Satisfaction with Inpatient End-of-Life Care

749 million for all moderate to severe psoriasis patients in Canada. Conclusion: The results from our study indicate that moderate to severe psoriasis may have a substantial impact on the work productivity of patients with this disease.

An innovative telemedicine knowledge translation program to improve quality of care in intensive care units: protocol for a cluster randomized pragmatic trial

Introduction: An understanding of legal, ethical, and cultural concerns and an ability to communicate when faced with clinical dilemmas are integral to the end of life decision‐making process. Yet teaching practicing clinicians these important skills in addressing conflict situations is not strongly emphasized. Methods: A one‐day interactive continuing education workshop was designed to improve interactions among multiprofessional intensive care unit (ICU) clinicians, their colleagues, and families in a range of end of life situations using standardized families and colleagues (SF/SCs). Workshop participants completed preworkshop and postworkshop evaluations. Data were analyzed using the McNemar test for paired categorical data to evaluate changes in comfort, knowledge, and skill. Results: The majority of evaluation respondents were nursing professionals, while only one physician (of two in attendance) responded. Statistically significant improvement was seen in all comfort levels, except when approaching cultural differences. Expectations were exceeded according to 76.2% of responses, while 82.4% rated SF/SCs “excellent” for improving communication skills and comfort levels with ethical and legal dilemmas. Peer discussions were highly valued in meeting educational objectives (95.2% good or excellent), and 95.2% rated achievement of personal learning objectives good or excellent. Qualitative data supported a high overall perception of success and achievement of educational objectives. Discussion: An interactive workshop can be a valuable educational intervention for building capacity and confidence in end of life communication skills and ethical and legal knowledge for health care providers; further physician involvement is required to extrapolate results to this population.

The checklist-a tool for error management and performance improvement

Background Little data exists addressing satisfaction with end-of-life care among hospitalized patients, as they and their family members are systematically excluded from routine satisfaction surveys. It is imperative that we closely examine patient and institution factors associated with quality end-of-life care and determine high-priority target areas for quality improvement. Methods Between September 1, 2010 and January 1, 2012 the Canadian Health care Evaluation Project (CANHELP) Bereavement Questionnaire was mailed to the next-of-kin of recently deceased inpatients to seek factors associated with satisfaction with end-of-life care. The primary outcome was the global rating of satisfaction. Secondary outcomes included rates of actual versus preferred location of death, associations between demographic factors and global satisfaction, and identification of targets for quality improvement. Results Response rate was 33% among 275 valid addresses. Overall, 67.4% of respondents were very or completely satisfied with the overall quality of care their relative received. However, 71.4% of respondents who thought their relative did not die in their preferred location favoured an out-of-hospital location of death. A common location of death was the intensive care unit (45.7%); however, this was not the preferred location of death for 47.6% of such patients. Multivariate Poisson regression analysis showed respondents who believed their relative died in their preferred location were 1.7 times more likely to be satisfied with the end-of-life care that was provided (p = 0.001). Items identified as high-priority targets for improvement included: relationships with, and characteristics of health care professionals; illness management; communication; and end-of-life decision-making. Interpretation Nearly three-quarters of recently deceased inpatients would have preferred an out-of-hospital death. Intensive care units were a common, but not preferred, location of in-hospital deaths. Family satisfaction with end-of-life care was strongly associated with their relative dying in their preferred location. Improved communication regarding end-of-life care preferences should be a high-priority quality improvement target.

Development of medical checklists for improved quality of patient care

BackgroundThere are challenges to timely adoption of, and ongoing adherence to, evidence-based practices known to improve patient care in the intensive care unit (ICU). Quality improvement initiatives using a collaborative network approach may increase the use of such practices. Our objective is to evaluate the effectiveness of a novel knowledge translation program for increasing the proportion of patients who appropriately receive the following six evidence-based care practices: venous thromboembolism prophylaxis; ventilator-associated pneumonia prevention; spontaneous breathing trials; catheter-related bloodstream infection prevention; decubitus ulcer prevention; and early enteral nutrition.Methods and designWe will conduct a pragmatic cluster randomized active control trial in 15 community ICUs and one academic ICU in Ontario, Canada. The intervention is a multifaceted videoconferenced educational and problem-solving forum to organize knowledge translation strategies, including comparative audit and feedback, educational sessions from content experts, and dissemination of algorithms. Fifteen individual ICUs (clusters) will be randomized to receive quality improvement interventions targeting one of the best practices during each of six study phases. Each phase lasts four months during the first study year and three months during the second. At the end of each study phase, ICUs are assigned to an intervention for a best practice not yet received according to a random schedule. The primary analysis will use patient-level process-of-care data to measure the interventions effect on rates of adoption and adherence of each best practice in the targeted ICU clusters versus controls.DiscussionThis study design evaluates a new system for knowledge translation and quality improvement across six common ICU problems. All participating ICUs receive quality improvement initiatives during every study phase, improving buy-in. This study design could be considered for other quality improvement interventions and in other care settings.Trial RegistrationThis trial is registered with http://www.clinicaltrials.gov (ID #: NCT00332982)