Jochen Bergs

Systematic review and meta-analysis of the effect of the World Health Organization surgical safety checklist on postoperative complications

The World Health Organization (WHO) surgical safety checklist (SSC) was introduced to improve the safety of surgical procedures. This systematic review evaluated current evidence regarding the effectiveness of this checklist in reducing postoperative complications.

Prevention of central line-associated bloodstream infections through quality improvement interventions: a systematic review and meta-analysis

This systematic review and meta-analysis examines the impact of quality improvement interventions on central line-associated bloodstream infections in adult intensive care units. Studies were identified through Medline and manual searches (1995-June 2012). Random-effects meta-analysis obtained pooled odds ratios (ORs) and 95% confidence intervals (CIs). Meta-regression assessed the impact of bundle/checklist interventions and high baseline rates on intervention effect. Forty-one before-after studies identified an infection rate decrease (OR, 0.39 [95% CI, .33-.46]; P < .001). This effect was more pronounced for trials implementing a bundle or checklist approach (P = .03). Furthermore, meta-analysis of 6 interrupted time series studies revealed an infection rate reduction 3 months postintervention (OR, 0.30 [95% CI, .10-.88]; P = .03). There was no difference in infection rates between studies with low or high baseline rates (P = .18). These results suggest that quality improvement interventions contribute to the prevention of central line-associated bloodstream infections. Implementation of care bundles and checklists appears to yield stronger risk reductions.

Barriers and facilitators related to the implementation of surgical safety checklists: a systematic review of the qualitative evidence

Objective The objective of this review is to obtain a better understanding of the user-related barriers against, and facilitators for, the implementation of surgical safety checklists. Methods We searched MEDLINE for articles describing stakeholders’ perspectives regarding, and experiences with, the implementation of surgical safety checklists. The quality of the papers was assessed by means of the Qualitative Assessment and Review Instrument. Thematic synthesis was used to integrate the emergent descriptive themes into overall analytical themes. Results The synthesis of 18 qualitative studies indicated that implementation requires change in the workflow of healthcare professionals as well as in their perception of the checklist and the perception of patient safety in general. The factors impeding or advancing the required change concentrated around the checklist, the implementation process and the local context. We found that the required safety checks disrupt operating theatre staffs’ routines. Furthermore, conflicting priorities and different perspectives and motives of stakeholders complicate checklist implementation. When approaching the checklist as a simple technical intervention, the expectation of cooperation between surgeons, anaesthetists and nurses is often not addressed, reducing the checklist to a tick-off exercise. Conclusions The complex reality in which the checklist needs to be implemented requires an approach that includes more than eliminating barriers and supporting facilitating factors. Implementation leaders must facilitate team learning to foster the mutual understanding of perspectives and motivations, and the realignment of routines. This paper provides a pragmatic overview of the user-related barriers and facilitators upon which theories, hypothesising potential change strategies and interactions, can be developed and tested empirically.

Incidence and outcome of inappropriate in-hospital empiric antibiotics for severe infection: a systematic review and meta-analysis.

IntroductionThe aims of this study were to explore the incidence of in-hospital inappropriate empiric antibiotic use in patients with severe infection and to identify its relationship with patient outcomes.MethodsMedline (from 2004 to 2014) was systematically searched by using predefined inclusion criteria. Reference lists of retrieved articles were screened for additional relevant studies. The systematic review included original articles reporting a quantitative measure of the association between the use of (in)appropriate empiric antibiotics in patients with severe in-hospital infections and their outcomes. A meta-analysis, using a random-effects model, was conducted to quantify the effect on mortality by using risk ratios.ResultsIn total, 27 individual articles fulfilled the inclusion criteria. The percentage of inappropriate empiric antibiotic use ranged from 14.1% to 78.9% (Q1-Q3: 28.1% to 57.8%); 13 of 27 studies (48.1%) described an incidence of 50% or more. A meta-analysis for 30-day mortality and in-hospital mortality showed risk ratios of 0.71 (95% confidence interval 0.62 to 0.82) and 0.67 (95% confidence interval 0.56 to 0.80), respectively. Studies with outcome parameter 28-day and 60-day mortality reported significantly (P ≤0.02) higher mortality rates in patients receiving inappropriate antibiotics. Two studies assessed the total costs, which were significantly higher in both studies (P ≤0.01).ConclusionsThis systematic review with meta-analysis provides evidence that inappropriate use of empiric antibiotics increases 30-day and in-hospital mortality in patients with a severe infection.

Prehospital stroke scales in a Belgian prehospital setting: A pilot study

Objective To compare the diagnostic value of the Cincinnati Prehospital Stroke Scale, the Face Arm Speech Test, the Los Angeles Prehospital Stroke Screen and the Melbourne Ambulance Stroke Screen for identifying patients with an acute stroke in a prehospital setting in Belgium. Methods A prospective study was performed, using a questionnaire for every primarily transported patient within emergency medial service with relevant neurological complaints. Exclusion criteria were: patients below 18 years, trauma victims, Glasgow Coma Scale of less than 8 or transported to another hospital. The questionnaire is a comprehension of different stroke scales. Results The Face Arm Speech Test and Cincinnati Prehospital Stroke Scale demonstrate a high sensitivity (95%) but a lower specificity (33%). The sensitivity of the Los Angeles Prehospital Stroke Screen and Melbourne Ambulance Stroke Screen was lower (74%), but the specificity increased (83 and 67%). Items investigating unilateral facial paralysis and unilateral loss/absence of motor response in upper extremities seemed to be most discriminating between the stroke group (68–78%) and the nonstroke group (17%), suggesting that items related to clinical assessment are more important in stroke recognition than history items. Combination of all clinical parameters of the different scores resulted in a sensitivity and specificity of 95 and 83%, respectively. Conclusion The results obtained in this study are comparable with earlier investigations. Given the limitations of the study, we could not identify the most adequate stroke scale. History items seem to be less relevant compared with clinical assessment. Further research is needed to determine the most adequate stroke scale.

SHORT-TERM UNSCHEDULED RETURN VISITS OF ADULT PATIENTS TO THE EMERGENCY DEPARTMENT

BACKGROUND Emergency department (ED) crowding is a major international concern that affects patients and providers. STUDY OBJECTIVE We describe the characteristics of patients who had an unscheduled related return visit to the ED and investigate its relation to ED crowding. METHODS Retrospective medical record review of all unscheduled related ED return visits by patients older than 16 years of age over a 1-year period. The top quartile of ED occupancy rates was defined as ED crowding. RESULTS Eight hundred thirty-seven patients (1.9%) made an unscheduled related return visit. Length of stay (LOS) at the ED for the index visit and the LOS for the return visit (5 h, 54 min vs. 6 h, 51 min) were significantly different, as were the percent admitted (11.6% vs. 46.1%). Of these patients, 85.1% and 12.0% returned due to persistence or a wrong initial diagnosis, of their initial illness, respectively, and 2.9% returned due to an adverse event related to the treatment initially received. Patients presented the least frequently with an alcohol-related complaint during the index visit (480 patients), but they had the highest number of unscheduled return visits (45 patients; 9.4%). Unscheduled related return visits were not associated with ED crowding. CONCLUSION Return visits impose additional pressure on the ED, because return patients have a significantly longer LOS at the ED. However, the rate of unscheduled return visits and ED crowding was not related. Because this parameter serves as an essential quality assurance tool, we can assume that the studied hospital scores well on this particular parameter.

Economic Impact of Integrated Care Models for Patients with Chronic Diseases: A Systematic Review

OBJECTIVES To assess the costs and potential financial benefits of integrated care models for patients with chronic diseases, that is, type 2 diabetes mellitus, schizophrenia, and multiple sclerosis, respectively. METHODS A systematic search of the literature was performed using EMBASE, MEDLINE, and Web of Science. Studies that conducted a cost analysis, considered at least two components of the chronic care model, and compared integrated care with standard care were included. RESULTS Out of 575 articles, 26 were included. Most studies examined integrated care models for type 2 diabetes mellitus (n = 18) and to a lesser extent for schizophrenia (n = 6) and multiple sclerosis (n = 2). Across the three disease groups, the incremental cost per patient per year ranged from - €3860 to + €613.91 (x¯ = - €533.61 ± €902.96). The incremental cost for type 2 diabetes mellitus ranged from - €1507.49 to + €299.20 (x¯ = - €518.22 ± + €604.75), for schizophrenia from - €3860 to + €613.91 (x¯ = - €677.21 ± + €1624.35), and for multiple sclerosis from - €822 to + €339.43 (x¯ = - €241.29 ± + €821.26). Most of the studies (22 of 26 [84.6%]) reported a positive economic impact of integrated care models: for type 2 diabetes mellitus (16 of 18 [88.9%]), schizophrenia (4 of 6 [66.7%]), and multiple sclerosis (1 of 2 [50%]). CONCLUSIONS In this systematic literature review, predominantly positive economic impacts of integrated care models for patients with chronic diseases were found.

Knowing what to expect, forecasting monthly emergency department visits: A time-series analysis

OBJECTIVE To evaluate an automatic forecasting algorithm in order to predict the number of monthly emergency department (ED) visits one year ahead. METHODS We collected retrospective data of the number of monthly visiting patients for a 6-year period (2005-2011) from 4 Belgian Hospitals. We used an automated exponential smoothing approach to predict monthly visits during the year 2011 based on the first 5 years of the dataset. Several in- and post-sample forecasting accuracy measures were calculated. RESULTS The automatic forecasting algorithm was able to predict monthly visits with a mean absolute percentage error ranging from 2.64% to 4.8%, indicating an accurate prediction. The mean absolute scaled error ranged from 0.53 to 0.68 indicating that, on average, the forecast was better compared with in-sample one-step forecast from the naïve method. CONCLUSION The applied automated exponential smoothing approach provided useful predictions of the number of monthly visits a year in advance.

The number of patients simultaneously present at the emergency department as an indicator of unsafe waiting times: A receiver operated curve-based evaluation

BACKGROUND Emergency department (ED) crowding and prolonged waiting times have been associated with adverse consequences towards quality and patient safety. OBJECTIVE This study investigates whether the number of patients simultaneously present at the ED might be an indicator of unsafe waiting and at what threshold hospital-wide measures to improve patient outflow could be justified. METHODS Data were retrospectively collected during a 1-year period; all ED patients aged ≥16 years, and triaged as ESI-1 or ESI-2 were eligible for inclusion. The number of patients simultaneously present was used as occupancy rate. Waiting time was considered unsafe if it was longer than 10 min for ESI-1 patients, or longer than 30 min for ESI-2 patients. Differences in waiting time and occupancy between patients with safe and unsafe waiting times were analysed using the Mann-Whitney U test. The ability of the occupancy rate to discriminate unsafe waiting times was analysed using a receiver operating characteristic curve. RESULTS The overall median waiting time was 5 min (IQR=4-8) for ESI-1, and 12 min (IQR=6-24) for ESI-2 patients. Unsafe waiting times occurred in 16.0% of ESI-1 patients (median waiting time=17 min, IQR=13-23), and in 18.9% of ESI-2 patients (median waiting time=48 min, IQR=37-68). The occupancy rate was a weak indicator for unsafe waiting times in ESI-1 patients (AUC=0.625, 95%CI 0.537-0.713) but a fair indicator for unsafe waiting times in ESI-2 patients (AUC=0.740, 95%CI 0.727-0.753) for which the threshold to predict unsafe waiting times with 90% sensitivity was 51 patients. CONCLUSION The number of patients simultaneously present is a moderate indicator of unsafe waiting times. Future initiatives to improve safe waiting times should not focus solely on occupancy, and expand their focus towards other factors affecting waiting time.

The WHO Surgical Safety Checklist : an Innovative or an Irrelevant Tool ?

[Vandijck, D.; Bergs, J.] Hasselt Univ, Res Grp Patient Safety & Hlth Econ, B-3500 Hasselt, Belgium. [Vandijck, D.] Univ Ghent, Dept Publ Hlth, B-9000 Ghent, Belgium.