Julius Cuong Pham

Rapid response systems: a systematic review.

Context:Rapid response systems have been advocated as a potential model to identify and intervene in patients who are experiencing deterioration on general hospital wards. Objective:To conduct a meta-analysis to evaluate the impact of rapid response systems on hospital mortality and cardiac arrest rates. Data Source:We searched MEDLINE, EMBASE, and the Cochrane Library from January 1, 1990, to June 30, 2005, for all studies relevant to rapid response systems. We restricted the search to the English language and by age category (all adults: ≥19 years). Study Selection:We selected observational and randomized trials of rapid response systems that provided empirical data on hospital mortality and cardiac arrest in control and intervention groups. We reviewed 10,228 abstracts and identified eight relevant studies meeting these criteria. Data Synthesis:Of the included studies, five used historical controls, one used concurrent controls, and two used a cluster-randomized design. The pooled relative risk for hospital mortality comparing rapid response teams to control was 0.76 (95% confidence interval, 0.39–1.48) between the two randomized studies and 0.87 (95% confidence interval, 0.73–1.04) among the five observational studies. The pooled relative risk for cardiac arrest comparing rapid response systems to control was 0.94 (95% confidence interval, 0.79–1.13) in the single randomized study and 0.70 (95% confidence interval, 0.56–0.92) in four observational studies. Conclusions:We found weak evidence that rapid response systems are associated with a reduction in hospital mortality and cardiac arrest rates, but limitations in the quality of the original studies, the wide confidence intervals, and the presence of heterogeneity limited our ability to conclude that rapid response systems are effective interventions. Large randomized controlled trials are needed to clarify the efficacy of rapid response systems before they should become standard of care.

Rapid-Response Systems as a Patient Safety Strategy: A Systematic Review

Rapid-response systems (RRSs) are a popular intervention in U.S. hospitals and are supported by accreditors and quality improvement organizations. The purpose of this review is to evaluate the effectiveness and implementation of these systems in acute care settings. A literature search was performed between 1 January 2000 through 30 October 2012 using PubMed, PsycINFO, CINAHL, and the Cochrane Central Register of Controlled Trials. Studies published in any language evaluating outcome changes that occurred after implementing an RRS and differences between groups using and not using an RRS (effectiveness) or describing methods used by RRSs (implementation) were reviewed. A single reviewer (checked by a second reviewer) abstracted data and rated study quality and strength of evidence. Moderate-strength evidence from a high-quality meta-analysis of 18 studies and 26 lower-quality before-and-after studies published after that meta-analysis showed that RRSs are associated with reduced rates of cardiorespiratory arrest outside of the intensive care unit and reduced mortality. Eighteen studies examining facilitators of and barriers to implementation suggested that the rate of use of RRSs could be improved.

Framework for Patient Safety Research and Improvement

Lapses in patient safety represent a significant global problem that results in preventable morbidity, mortality, and costs of care. In the 1999 landmark report To Err Is Human , the Institute of Medicine shocked the healthcare industry with estimates that up to 98 000 people die because of medical errors each year in the United States.1 This glaring report was amplified by a 2003 RAND study that suggested that hospitalized patients in the United States on average receive only half the recommended therapies.2 The impact of these reports damaged consumer confidence in the healthcare industry and galvanized broad industry support to improve patient safety. Five years after the Institute of Medicine publication, there was increasing concern that little measurable progress had been made to improve patient safety.3–5 Since then, the number of quality- and safety-related activities has grown steadily, but there is still minimal empiric evidence demonstrating progress. Our inability to evaluate progress toward improving patient safety results from poorly articulated safety improvement goals and measures and the absence of a simple yet meaningful framework to identify and prioritize the most effective and efficient patient safety interventions. The present report presents a framework to help organize future patient safety research and improvement efforts. We sought to develop a framework for patient safety research and improvement that would address many issues emerging from an expanding international appetite for higher-quality and safer care. We acknowledge that the boundaries between safety and the broader concept of quality remain poorly defined. As we developed and revised this framework, we reflected on our experiences, revisited the Institute of Medicine’s strategies for improvement, and studied the literature on knowledge transfer and diffusion of innovation.6–14 The framework presented includes the following 5 domains (Table 1): (1) evaluating progress in patient safety; (2) translating …

Improving Handoffs in the Emergency Department

Patient handoffs at shift change are a ubiquitous and potentially hazardous process in emergency care. As crowding and lengthy evaluations become the standard for an increasing proportion of emergency departments (EDs), the number of patients handed off will likely increase. It is critical now more than ever before to ensure that handoffs supply valid and useful shared understandings between providers at transitions of care. The purpose of this article is to provide the most up-to-date evidence and collective thinking about the process and safety of handoffs between physicians in the ED. It offers perspectives from other disciplines, provides a conceptual framework for handoffs, and categorizes models of existing practices. Legal and risk management issues are also addressed. A proposal for the development of handoff quality measures is outlined. Practical strategies are suggested to improve ED handoffs. Finally, a research agenda is proposed to provide a roadmap to future work that may increase knowledge in this area.

Collaborative Cohort Study of an Intervention to Reduce Ventilator-Associated Pneumonia in the Intensive Care Unit

OBJECTIVE To evaluate the impact of a multifaceted intervention on compliance with evidence-based therapies and ventilator-associated pneumonia (VAP) rates. DESIGN Collaborative cohort before-after study. SETTING Intensive care units (ICUs) predominantly in Michigan. INTERVENTIONS We implemented a multifaceted intervention to improve compliance with 5 evidence-based recommendations for mechanically ventilated patients and to prevent VAP. A standardized CDC definition of VAP was used and maintained at each site, and data on the number of VAPs and ventilator-days were obtained from the hospitals infection preventionists. Baseline data were reported and postimplementation data were reported for 30 months. VAP rates (in cases per 1,000 ventilator-days) were calculated as the proportion of ventilator-days per quarter in which patients received all 5 therapies in the ventilator care bundle. Two interventions to improve safety culture and communication were implemented first. RESULTS One hundred twelve ICUs reporting 3,228 ICU-months and 550,800 ventilator-days were included. The overall median VAP rate decreased from 5.5 cases (mean, 6.9 cases) per 1,000 ventilator-days at baseline to 0 cases (mean, 3.4 cases) at 16-18 months after implementation (P < .001) and 0 cases (mean, 2.4 cases) at 28-30 months after implementation (P < .001). Compared to baseline, VAP rates decreased during all observation periods, with incidence rate ratios of 0.51 (95% confidence interval, 0.41-0.64) at 16-18 months after implementation and 0.29 (95% confidence interval, 0.24-0.34) at 28-30 months after implementation. Compliance with evidence-based therapies increased from 32% at baseline to 75% at 16-18 months after implementation (P < .001) and 84% at 28-30 months after implementation (P < .001). CONCLUSIONS A multifaceted intervention was associated with an increased use of evidence-based therapies and a substantial (up to 71%) and sustained (up to 2.5 years) decrease in VAP rates.

National Study on the Frequency, Types, Causes, and Consequences of Voluntarily Reported Emergency Department Medication Errors

BACKGROUND Medication errors contribute to significant morbidity, mortality, and costs to the health system. Little is known about the characteristics of Emergency Department (ED) medication errors. STUDY OBJECTIVE To examine the frequency, types, causes, and consequences of voluntarily reported ED medication errors in the United States. METHODS A cross-sectional study of all ED errors reported to the MEDMARX system between 2000 and 2004. MEDMARX is an anonymous, confidential, de-identified, Internet-accessible medication error-reporting program designed to allow hospitals to report, track, and share error data in a standardized format. RESULTS There were 13,932 medication errors from 496 EDs analyzed. The error rate was 78 reports per 100,000 visits. Physicians were responsible for 24% of errors, nurses for 54%. Errors most commonly occurred in the administration phase (36%). The most common type of error was improper dose/quantity (18%). Leading causes were not following procedure/protocol (17%), and poor communication (11%), whereas contributing factors were distractions (7.5%), emergency situations (4.1%), and workload increase (3.4%). Computerized provider order entry caused 2.5% of errors. Harm resulted in 3% of errors. Actions taken as a result of the error included informing the staff member who committed the error (26%), enhancing communication (26%), and providing additional training (12%). Patients or family members were notified about medication errors 2.7% of the time. CONCLUSION ED medication errors may be a result of the acute, crowded, and fast-paced nature of care. Further research is needed to identify interventions to reduce these risks and evaluate the effectiveness of these interventions.

Reducing Health Care Hazards: Lessons From The Commercial Aviation Safety Team

The movement to improve quality of care and patient safety has grown, but examples of measurable and sustained progress are rare. The slow progress made in health care contrasts with the success of aviation safety. After a tragic 1995 plane crash, the aviation industry and government created the Commercial Aviation Safety Team to reduce fatal accidents. This public-private partnership of safety officials and technical experts is responsible for the decreased average rate of fatal aviation accidents. We propose a similar partnership in the health care community to coordinate national efforts and move patient safety and quality forward.

Using evidence, rigorous measurement, and collaboration to eliminate central catheter-associated bloodstream infections.

Healthcare-associated infections are common, costly, and often lethal. Although there is growing pressure to reduce these infections, one project thus far has unprecedented collaboration among many groups at every level of health care. After this project produced a 66% reduction in central catheter-associated bloodstream infections and a median central catheter-associated bloodstream infection rate of zero across >100 intensive care units in Michigan, the Agency for Healthcare Research and Quality awarded a grant to spread this project to ten additional states. A program, called On the CUSP: Stop BSI, was formulated from the Michigan project, and additional funding from the Agency for Healthcare Research and Quality and private philanthropy has positioned the program for implementation state by state across the United States. Furthermore, the program is being implemented throughout Spain and England and is undergoing pilot testing in several hospitals in Peru. The model in this program balances the tension between being scientifically rigorous and feasible. The three main components of the model include translating evidence into practice at the bedside to prevent central catheter-associated bloodstream infections, improving culture and teamwork, and having a data collection system to monitor central catheter-associated bloodstream infections and other variables. If successful, this program will be the first national quality improvement program in the United States with quantifiable and measurable goals.

National study on the distribution, causes, and consequences of voluntarily reported medication errors between the ICU and non-ICU settings.

Objective:To compare the distribution, causes, and consequences of medication errors in the ICU with those in non-ICU settings. Design:A cross-sectional study of all hospital ICU and non-ICU medication errors reported to the MEDMARX system between 1999 and 2005. Adjusted odds ratios are presented. Setting:Hospitals participating in the MEDMARX reporting system. Interventions:None. Measurements and Main Results:MEDMARX is an anonymous, self-reported, confidential, deidentified, internet-accessible medication error reporting program that allows hospitals to report, track, and share medication error data. There were 839,553 errors reported from 537 hospitals. ICUs accounted for 55,767 (6.6%) errors, of which 2,045 (3.7%) were considered harmful. Non-ICUs accounted for 783,800 (93.4%) errors, of which 14,471 (1.9%) were harmful. Errors most often originated in the administration phase (ICU 44% vs. non-ICU 33%; odds ratio 1.63 [1.43–1.86]). The most common error type was omission (ICU 26% vs. non-ICU 28%; odds ratio 1.00 [0.91–1.10]). Among harmful errors, dispensing devices (ICU 14% vs. non-ICU 7.1%; odds ratio 2.09 [1.69–2.59]) and calculation mistakes (ICU 9.8% vs. non-ICU 5.3%; odds ratio 1.82 [1.48–2.24]) were more commonly identified to be the cause in the ICU compared to the non-ICU setting. ICU errors were more likely to be associated with any harm (odds ratio 1.89 [1.62–2.17]), permanent harm (odds ratio 2.45 [1.17–5.13]), harm requiring life-sustaining intervention (odds ratio 2.91 [1.86–4.56]), or death (odds ratio 2.48 [1.18–5.19]). When an error did occur, patients and their caregivers were rarely informed (ICU 1.5% vs. non-ICU 2.1%; odds ratio 0.63 [0.48–0.84]) by the time of reporting. Conclusions:More harmful errors are reported in ICU than non-ICU settings. Medication errors occur frequently in the administration phase in the ICU. When errors occur, patients and their caregivers are rarely informed. Consideration should be given to developing additional safeguards against ICU errors, particularly during drug administration, and eliminating barriers to error disclosures.

Mortality Among Marathon Runners in the United States, 2000-2009

Background: As participation in marathon running has increased, there has also been concern regarding its safety. Purpose: To determine if the increase in marathon participation from 2000 to 2009 has affected mortality and overall performance. Study Design: Descriptive epidemiology study. Methods: We used publicly available racing and news databases to analyze the number of marathon races, finishing race times, and deaths from 2000 to 2009 in marathons in the United States. Results: The total number of marathon finishers has increased over this decade from 299,018 in 2000 to 473,354 in 2009. The average overall marathon finishing time has remained unchanged from 2000 to 2009 (4:34:47 vs 4:35:28; P = .85). Of 3,718,336 total marathon participants over the 10-year study period, we identified 28 people (6 women and 22 men) who died during the marathon race and up to 24 hours after finishing. The overall, male, and female death rates for the 10-year period were 0.75 (95% confidence interval [CI], 0.38-1.13), 0.98 (95% CI, 0.48-1.36), and 0.41 (95% CI, 0.21-0.79) deaths per 100,000 finishers, respectively. There was no change in the death rate during this time period for overall, male, or female groups (P = .860, .533, and .238, respectively). The median age among deaths was 41.5 years (interquartile range, 25.5 years). Fifty percent (14/28) of deaths occurred in participants less than 45 years old. Myocardial infarction/atherosclerotic heart disease caused 93% (13/14) of deaths in those 45 years and older. A variety of conditions caused death in younger racers, the most common being cardiac arrest not otherwise specified (21%, n = 3). Conclusion: Participation in marathons has increased without any change in mortality or average overall performance from 2000 to 2009.