Deborah Seys

Health Care Professionals as Second Victims after Adverse Events A Systematic Review

Adverse events within health care settings can lead to two victims. The first victim is the patient and family and the second victim is the involved health care professional. The latter is the focus of this review. The objectives are to determine definitions of this concept, research the prevalence and the impact of the adverse event on the second victim, and the used coping strategies. Therefore a literature research was performed by using a three-step search procedure. A total of 32 research articles and 9 nonresearch articles were identified. The second victim phenomenon was first described by Wu in 2000. In 2009, Scott et al. introduced a detailed definition of second victims. The prevalence of second victims after an adverse event varied from 10.4% up to 43.3%. Common reactions can be emotional, cognitive, and behavioral. The coping strategies used by second victims have an impact on their patients, colleagues, and themselves. After the adverse event, defensive as well as constructive changes have been reported in practice. The second victim phenomenon has a significant impact on clinicians, colleagues, and subsequent patients. Because of this broad impact it is important to offer support for second victims. When an adverse event occurs, it is critical that support networks are in place to protect both the patient and involved health care providers.

Supporting involved health care professionals (second victims) following an adverse health event: A literature review

BACKGROUND One out of seven patients is involved in an adverse event. The first priority after such an event is the patient and their family (first victim). However the involved health care professionals can also become victims in the sense that they are traumatized after the event (second victim). They can experience significant personal and professional distress. Second victims use different coping strategies in the aftermath of an adverse event, which can have a significant impact on clinicians, colleagues, and subsequent the patients. It is estimated that nearly half of health care providers experience the impact as a second victim at least once in their career. Because of this broad impact it is important to offer support. OBJECTIVE The focus of this review is to identify supportive interventional strategies for second victims. STUDY DESIGN An extensive search was conducted in the electronic databases Medline, Embase and Cinahl. We searched from the start data of each database until September 2010. RESULTS A total of 21 research articles and 10 non-research articles were identified in this literature review. There are numerous supportive actions for second victims described in the literature. Strategies included support organized at the individual, organizational, national or international level. A common intervention identified support for the health care provider to be rendered immediately. Strategies on organizational level can be separated into programs specifically aimed at second victims and more comprehensive programs that include support for all individuals involved in the adverse event including the patient, their family, the health care providers, and the organization. CONCLUSION Second victim support is needed to care for health care workers and to improve quality of care. Support can be provided at the individual and organizational level. Programs need to include support provided immediately post adverse event as well as on middle long and long term basis.

The Care Process Self-Evaluation Tool: a valid and reliable instrument for measuring care process organization of health care teams

BackgroundPatient safety can be increased by improving the organization of care. A tool that evaluates the actual organization of care, as perceived by multidisciplinary teams, is the Care Process Self-Evaluation Tool (CPSET). CPSET was developed in 2007 and includes 29 items in five subscales: (a) patient-focused organization, (b) coordination of the care process, (c) collaboration with primary care, (d) communication with patients and family, and (e) follow-up of the care process. The goal of the present study was to further evaluate the psychometric properties of the CPSET at the team and hospital levels and to compile a cutoff score table.MethodsThe psychometric properties of the CPSET were assessed in a multicenter study in Belgium and the Netherlands. In total, 3139 team members from 114 hospitals participated. Psychometric properties were evaluated by using confirmatory factor analysis (CFA), Cronbach’s alpha, interclass correlation coefficients (ICCs), Kruskall-Wallis test, and Mann–Whitney test. For the cutoff score table, percentiles were used. Demographic variables were also evaluated.ResultsCFA showed a good model fit: a normed fit index of 0.93, a comparative fit index of 0.94, an adjusted goodness-of-fit index of 0.87, and a root mean square error of approximation of 0.06. Cronbach’s alpha values were between 0.869 and 0.950. The team-level ICCs varied between 0.127 and 0.232 and were higher than those at the hospital level (0.071-0.151). Male team members scored significantly higher than females on 2 of the 5 subscales and on the overall CPSET. There were also significant differences among age groups. Medical doctors scored significantly higher on 4 of the 5 subscales and on the overall CPSET. Coordinators of care processes scored significantly lower on 2 of the 5 subscales and on the overall CPSET. Cutoff scores for all subscales and the overall CPSET were calculated.ConclusionsThe CPSET is a valid and reliable instrument for health care teams to measure the extent care processes are organized. The cutoff table permits teams to compare how they perceive the organization of their care process relative to other teams.

An International Study of Adherence to Guidelines for Patients Hospitalised with a COPD Exacerbation

ABSTRACT Guideline adherence rates for the treatment of chronic obstructive pulmonary disease (COPD) exacerbation are low. The aim of this study is to perform an importance-performance analysis as an approach for prioritisation of interventions by linking guidelines adherence rates to expert consensus rates for the in-hospital management of COPD exacerbation. We illustrate the relevance of such approach by describing variation in guideline adherence across indicators and hospitals. A secondary data analysis of patients with an acute COPD exacerbation admitted to Belgian, Italian and Portuguese hospitals was performed. Twenty-one process indicators were used to describe adherence to guidelines from patient record reviews. Expert consensus on the importance for follow-up of these 21 indicators was derived from a previous Delphi study. Three of the twenty-one indicators had high level of expert consensus and a high level of adherence. Eleven of the twenty-one indicators had high level of expert consensus but a low level of adherence. For none of the 378 patients included in this study were all process indicators adhered to, patients received 41.0% of the recommended care on average, and only 34.1% of the patients received 50% or more of the care they should receive. There was also a large variation within and between hospitals regarding the care received. This study confirms the findings of previous studies, indicating that COPD exacerbations are largely undertreated. Importance-performance analysis provides a decision-making tool for prioritising indicators. All hospitals in this study would benefit from having in place a quality framework for systematic follow-up of these indicators.

Impact of a care pathway for COPD on adherence to guidelines and hospital readmission: a cluster randomized trial.

Purpose Current in-hospital management of exacerbations of COPD is suboptimal, and patient outcomes are poor. The primary aim of this study was to evaluate whether implementation of a care pathway (CP) for COPD improves the 6 months readmission rate. Secondary outcomes were the 30 days readmission rate, mortality, length of stay and adherence to guidelines. Patients and methods An international cluster randomized controlled trial was performed in Belgium, Italy and Portugal. General hospitals were randomly assigned to an intervention group where a CP was implemented or a control group where usual care was provided. The targeted population included patients with COPD exacerbation. Results Twenty-two hospitals were included, whereof 11 hospitals (n=174 patients) were randomized to the intervention group and 11 hospitals (n=168 patients) to the control group. The CP had no impact on the 6 months readmission rate. However, the 30 days readmission rate was significantly lower in the intervention group (9.7%; 15/155) compared to the control group (15.3%; 22/144) (odds ratio =0.427; 95% confidence interval 0.222–0.822; P=0.040). Performance on process indicators was significantly higher in the intervention group for 2 of 24 main indicators (8.3%). Conclusion The implementation of this in-hospital CP for COPD exacerbation has no impact on the 6 months readmission rate, but it significantly reduces the 30 days readmission rate.

Variation in care for surgical patients with colorectal cancer: protocol adherence in 12 European hospitals

PurposeSurgical care for patients with colorectal cancer has become increasingly standardized. The Enhanced Recovery After Surgery (ERAS) protocol is a widely accepted structured care method to improve postoperative outcomes of patients after surgery. Despite growing evidence of effectiveness, adherence to the protocol remains challenging in practice. This study was designed to assess the adherence rate in daily practice and examine the relationship between the importance of interventions and adherence rate.MethodsThis international observational, cross-sectional multicenter study was performed in 12 hospitals in four European countries. Patients were included from January 1, 2014. Data was retrospectively collected from the patient record by the local study coordinator.ResultsA total of 230 patients were included in the study. Protocol adherence was analyzed for both the individual interventions and on patient level. The interventions with the highest adherence were antibiotic prophylaxis (95%), thromboprophylaxis (87%), and measuring body weight at admission (87%). Interventions with the lowest adherence were early mobilization—walking and sitting (9 and 6%, respectively). The adherence ranged between 16 and 75%, with an average of 44%.ConclusionOur results show that the average protocol adherence in clinical practice is 44%. The variation on patient and hospital level is considerable. Only in one patient the adherence rate was >70%. In total, 30% of patients received 50% or more of the key interventions. A solid implementation strategy seems to be needed to improve the uptake of the ERAS pathway. The importance-performance matrix can help in prioritizing the areas for improvement.

Better organized care via care pathways: A multicenter study

An increased need for efficiency and effectiveness in today’s healthcare system urges professionals to improve the organization of care. Care pathways are an important tool to achieve this. The overall aim of this study was to analyze if care pathways lead to better organization of care processes. For this, the Care Process Self-Evaluation tool (CPSET) was used to evaluate how healthcare professionals perceive the organization of care processes. Based on information from 2692 health care professionals gathered between November 2007 and October 2011 we audited 261 care processes in 108 organizations. Multilevel analysis was used to compare care processes without and with care pathways and analyze if care pathways led to better organization of care processes. A significant difference between care processes with and without care pathways was found. A care pathway in use led to significant better scores on the overall CPSET scale (p<0.001) and its subscales, “coordination of care” (p<0.001) and “follow-up of care” (p<0.001). Physicians had the highest score on the overall CPSET scale and the five subscales. Care processes organized by care pathways had a 2.6 times higher probability that the care process was well-organized. In around 75% of the cases a care pathway led to better organized care processes. Care processes supported by care pathways were better organized, but not all care pathways were well-organized. Managers can use care pathways to make healthcare professionals more aware of their role in the organization of the care process.

Minimal impact of a care pathway for geriatric hip fracture patients

BACKGROUND Adherence to guidelines for patients with proximal femur fracture is suboptimal. OBJECTIVE To evaluate the effect of a care pathway for the in-hospital management of older geriatric hip fracture patients on adherence to guidelines and patient outcomes. DESIGN The European Quality of Care Pathways study is a cluster randomized controlled trial. SETTING 26 hospitals in Belgium, Italy and Portugal. SUBJECTS Older adults with a proximal femur fracture (n = 514 patients) were included. METHODS Hospitals treating older adults (>65) with a proximal femur fracture were randomly assigned to an intervention group, i.e. implementation of a care pathway, or control group, i.e. usual care. Thirteen patient outcomes and 24 process indicators regarding in-hospital management, as well as three not-recommended care activities were measured. Adjusted and unadjusted regression analyses were conducted using intention-to-treat procedures. RESULTS In the intervention group 301 patients in 15 hospitals were included, and in the control group 213 patients in 11 hospitals. Sixty-five percent of the patients were older than 80 years. The implementation of this care pathway had no significant impact on the thirteen patient outcomes. The preoperative management improved significantly. Eighteen of 24 process indicators improved, but only two improved significantly. Only for a few teams a geriatrician was an integral member of the treatment team. DISCUSSION Implementation of a care pathway improved compliance to evidence, but no significant effect on patient outcomes was found. The impact of the collaboration between surgeons and geriatricians on adherence to guidelines and patient outcomes should be studied. TRIAL REGISTRATION ClinicalTrials.gov: NCT00962910.

In-hospital care pathways for patients admitted with an acute exacerbation of chronic obstructive pulmonary disease: From statistical significance to clinically relevance

For the treatment of chronic obstructive pulmonary disease (COPD), an international widely accepted guideline, Global Initiative for Chronic Obstructive Pulmonary Disease (GOLD) is available. However, patients in different patient groups still receive suboptimal care, and studies showed that teams can enhance their interprofessional collaboration and coordination. To improve the care for patients with a COPD exacerbation, the European Pathway Association (www.E-P-A.org) launched the European Quality of Care Pathways (EQCP) study. This study started in 2007 and included hospitals from Belgium, Italy and Portugal. The aim of this study was to evaluate the impact of care pathways (CPs) on variation in care, adherence to guidelines, patient outcomes and teamwork for patients admitted with a COPD exacerbation. CPs are defined as ‘complex interventions for the mutual decision making and organization of predictable care for a well-defined group of patients during a well-defined period’. In general, this EQCP study learned us two things regarding the reduction in length of stay and readmission rates for patients with a COPD exacerbation. First, the implementation of this in-hospital CP led to significantly reduced 30-day readmission rates (in the CP group, 9.7% of the patients were readmitted within 30 days, while in the control group, 15.3% were readmitted). The CP had no significant impact on length of stay (12.0 days in the CP group compared to 12.4 days in the control group) or on six-month readmission rate (27.3% in the CP group compared to 33.0% in the control group). This significant reduction in 30-day readmission rates is important for hospitals, as based on the worldwide data of the World Health Organization, this effect is expected to lead to a reduction of approximately four million readmissions. Second, although a golden standard is available, a significant number of patients still receive underuse. This was visualized by an importance-performance analysis. In importance-performance analysis, the importance rate, based on guidelines or international Delphi results, is plot against the performance rate, measured as process indicators on adherence to guidelines. Care activities with high importance but low performance are high priorities for hospitals. Based on the EQCP data before the implementation of our CP, hospitals should have five high priorities, these priorities are performed in less than 20% of the patients, and are (i) smoking cessation intervention in active smokers at admission, (ii) adequate discharge management, (iii) performance of revalidation tests during the past year, (iv) education regarding inhaler therapy in patients for whom inhaler therapy is prescribed and (v) education regarding home oxygen therapy in patients for whom home oxygen is prescribed. The impact of these care activities on COPD is not only a direct effect but mainly an indirect effect. To improve the care patients receive, behavioural change by both the patient and the interprofessional team is needed. Receiving adequate information and advice is a first step in behavioural change and

Better hospital context increases success of care pathway implementation on achieving greater teamwork: a multicenter study on STEMI care

Objective To evaluate whether hospital context influences the effect of care pathway implementation on teamwork processes and output in STEMI care. Design A multicenter pre-post intervention study. Setting Eleven acute hospitals. Participants Cardiologists-in-chief, nurse managers, quality staff, quality managers and program managers reported on hospital context. Teamwork was rated by professional groups (medical doctors, nurses, allied health professionals, other) in the following departments: emergency room, catheterization lab, coronary care unit, cardiology ward and rehabilitation. Intervention Care pathway covering in-hospital care from emergency services to rehabilitation. Main outcome measures Hospital context was measured by the five dimensions of the Model for Understanding Success in Quality: microsystem, quality improvement team, quality improvement support, high-level organization, external environment. Teamwork process measures reflected teamwork between professional groups within departments and teamwork between departments. Teamwork output was measured through the level of organized care. Two-level regression analysis accounted for clustering of respondents within hospitals and assessed the influence of hospital context on the impact of care pathway implementation on teamwork. Results Care pathway implementation significantly improved teamwork processes both between professional groups (P < 0.001) and between departments (P < 0.001). Teamwork output also improved (P < 0.001). The effect of care pathway implementation on teamwork was more pronounced when the quality improvement team and quality improvement support and capacity were more positively reported on. Conclusions Hospitals can leverage the effect of quality improvement interventions such as care pathways by evaluating and improving aspects of hospital context.