Kurt R. Herzer

Vitamin A supplements for preventing mortality, illness, and blindness in children aged under 5: systematic review and meta-analysis

Objective To determine if vitamin A supplementation is associated with reductions in mortality and morbidity in children aged 6 months to 5 years. Design Systematic review and meta-analysis. Two reviewers independently assessed studies for inclusion. Data were double extracted; discrepancies were resolved by discussion. Meta-analyses were performed for mortality, illness, vision, and side effects. Data sources Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, Medline, Embase, Global Health, Latin American and Caribbean Health Sciences, metaRegister of Controlled Trials, and African Index Medicus. Databases were searched to April 2010 without restriction by language or publication status. Eligibility criteria for selecting studies Randomised trials of synthetic oral vitamin A supplements in children aged 6 months to 5 years. Studies of children with current illness (such as diarrhoea, measles, and HIV), studies of children in hospital, and studies of food fortification or β carotene were excluded. Results 43 trials with about 215 633 children were included. Seventeen trials including 194 483 participants reported a 24% reduction in all cause mortality (rate ratio=0.76, 95% confidence interval 0.69 to 0.83). Seven trials reported a 28% reduction in mortality associated with diarrhoea (0.72, 0.57 to 0.91). Vitamin A supplementation was associated with a reduced incidence of diarrhoea (0.85, 0.82 to 0.87) and measles (0.50, 0.37 to 0.67) and a reduced prevalence of vision problems, including night blindness (0.32, 0.21 to 0.50) and xerophthalmia (0.31, 0.22 to 0.45). Three trials reported an increased risk of vomiting within the first 48 hours of supplementation (2.75, 1.81 to 4.19). Conclusions Vitamin A supplementation is associated with large reductions in mortality, morbidity, and vision problems in a range of settings, and these results cannot be explained by bias. Further placebo controlled trials of vitamin A supplementation in children between 6 and 59 months of age are not required. However, there is a need for further studies comparing different doses and delivery mechanisms (for example, fortification). Until other sources are available, vitamin A supplements should be given to all children at risk of deficiency, particularly in low and middle income countries.

A novel process for introducing a new intraoperative program: A multidisciplinary paradigm for mitigating hazards and improving patient safety

BACKGROUND: Since the Institute of Medicine’s report, To Err is Human, was published, numerous interventions have been designed and implemented to correct the defects that lead to medical errors and adverse events; however, most efforts were largely reactive. Safety, communication, team performance, and efficiency are areas of care that attract a great deal of attention, especially regarding the introduction of new technologies, techniques, and procedures. We describe a multidisciplinary process that was implemented at our hospital to identify and mitigate hazards before the introduction of a new technique: high-dose-rate intraoperative radiation therapy, (HDR-IORT). METHODS: A multidisciplinary team of surgeons, anesthesiologists, radiation oncologists, physicists, nurses, hospital risk managers, and equipment specialists used a structured process that included in situ clinical simulation to uncover concerns among care providers and to prospectively identify and mitigate defects for patients who would undergo surgery using the HDR-IORT technique. RESULTS: We identified and corrected 20 defects in the simulated patient care process before application to actual patients. Subsequently, eight patients underwent surgery using the HDR-IORT technique with no recurrence of simulation-identified or unanticipated defects. CONCLUSION: Multiple benefits were derived from the use of this systematic process to introduce the HDR-IORT technique; namely, the safety and efficiency of care for this select patient population was optimized, and this process mitigated harmful or adverse events before the inclusion of actual patients. Further work is needed, but the process outlined in this paper can be universally applied to the introduction of any new technologies, treatments, or procedures.

Difficult Airway Response Team: A Novel Quality Improvement Program for Managing Hospital-Wide Airway Emergencies

BACKGROUND:Difficult airway cases can quickly become emergencies, increasing the risk of life-threatening complications or death. Emergency airway management outside the operating room is particularly challenging. METHODS:We developed a quality improvement program—the Difficult Airway Response Team (DART)—to improve emergency airway management outside the operating room. DART was implemented by a team of anesthesiologists, otolaryngologists, trauma surgeons, emergency medicine physicians, and risk managers in 2005 at The Johns Hopkins Hospital in Baltimore, Maryland. The DART program had 3 core components: operations, safety, and education. The operations component focused on developing a multidisciplinary difficult airway response team, standardizing the emergency response process, and deploying difficult airway equipment carts throughout the hospital. The safety component focused on real-time monitoring of DART activations and learning from past DART events to continuously improve system-level performance. This objective entailed monitoring the paging system, reporting difficult airway events and DART activations to a Web-based registry, and using in situ simulations to identify and mitigate defects in the emergency airway management process. The educational component included development of a multispecialty difficult airway curriculum encompassing case-based lectures, simulation, and team building/communication to ensure consistency of care. Educational materials were also developed for non-DART staff and patients to inform them about the needs of patients with difficult airways and ensure continuity of care with other providers after discharge. RESULTS:Between July 2008 and June 2013, DART managed 360 adult difficult airway events comprising 8% of all code activations. Predisposing patient factors included body mass index >40, history of head and neck tumor, prior difficult intubation, cervical spine injury, airway edema, airway bleeding, and previous or current tracheostomy. Twenty-three patients (6%) required emergent surgical airways. Sixty-two patients (17%) were stabilized and transported to the operating room for definitive airway management. There were no airway management–related deaths, sentinel events, or malpractice claims in adult patients managed by DART. Five in situ simulations conducted in the first program year improved DART’s teamwork, communication, and response times and increased the functionality of the difficult airway carts. Over the 5-year period, we conducted 18 airway courses, through which >200 providers were trained. CONCLUSIONS:DART is a comprehensive program for improving difficult airway management. Future studies will examine the comparative effectiveness of the DART program and evaluate how DART has impacted patient outcomes, operational efficiency, and costs of care.

A Practical Framework for Patient Care Teams to Prospectively Identify and Mitigate Clinical Hazards

BACKGROUND One of the greatest challenges facing both practitioners and risk managers is the identification of previously unknown clinical hazards and defects. With the rapid proliferation of new health care services, unknown hazards may propagate as new therapies are integrated into the existing health care system. The main goal of risk analysis is to make these hazards visible by proactively searching and probing the system. Yet, a comprehensive approach by which to safely integrate new therapies into the existing clinical environment has yet to be clearly articulated. Patient care teams can use the proposed framework when introducing new therapies. A PRACTICAL FRAMEWORK The framework includes a background investigation and literature search; an in situ simulation (in the actual clinical setting used for patients); a Failure Mode and Effects Analysis to determine the severity, probability, and risk of the potential hazards; and a multidisciplinary protocol and safety checklist to standardize practice and ensure provider accountability. CASE EXAMPLES Application of this framework to three operative scenarios--intraoperative radiation therapy (IORT), hyperthermic intraperitoneal chemotherapy (HIPEC), and an interventional pulmonology program--demonstrates its flexibility. Its use prospectively identified and mitigated 20 IORT, 5 HIPEC, and 18 interventional pulmonology hazards/defects. Subsequent patient cases were largely uneventful. All cases and patient safety reporting systems are monitored to identify any new defects in an effort to continuously improve patient care. CONCLUSION The use of a comprehensive framework to identify and mitigate hazards in an on-site simulated environment promotes safer care for target patient populations; results in familiarity with procedures, amelioration of staff concerns, and standardization of practice; and facilitates teamwork and communication.

Designing and implementing a comprehensive quality and patient safety management model: A paradigm for perioperative improvement

Objectives: The objectives of this article are to describe the design and implementation of a comprehensive perioperative quality and patient safety management model. This model used a systems approach to integrate (1) multiple data sources of defects, (2) a multidisciplinary team, (3) a quality improvement methodology successful in high-risk industries other than health care, (4) retrospective and near-real-time analyses of defects, and (5) proactive feedback to the team, reporters, and hospital risk managers. Methods: Two primary incident-reporting systems were selected. A multidisciplinary team of physicians, nurses, risk managers, and others was formed. A simple taxonomy was used to categorize defects. Lean Six Sigma methodologies were used to analyze the data. The team calculated a priority score for each defect and developed quality improvement projects for those with the highest priorities. Results: During this study, 532 perioperative defects were captured, with newly captured defects analyzed weekly in near real time. The team created 91 quality improvement projects targeting all defect categories, with 33% focused on patient safety. Many projects were not based on the incident-reporting systems but originated from the models systems approach. Feedback loops proactively revised formats for capturing defects, added patient-specific safety data to individuals medical records, and informed the hospitals risk managers of ongoing quality improvement projects. Conclusions: This comprehensive model used a systems approach to successfully integrate aggregate data from incident-reporting systems, empowered stakeholders from a multidisciplinary team, and Lean Six Sigma methodologies to develop sustainable quality improvement projects to mitigate defects and positively impact perioperative processes.

Cost-effectiveness of a quality improvement programme to reduce central line-associated bloodstream infections in intensive care units in the USA

Objective To assess the cost-effectiveness of a multifaceted quality improvement programme focused on reducing central line-associated bloodstream infections in intensive care units. Design Cost-effectiveness analysis using a decision tree model to compare programme to non-programme intensive care units. Setting USA. Population Adult patients in the intensive care unit. Costs Economic costs of the programme and of central line-associated bloodstream infections were estimated from the perspective of the hospital and presented in 2013 US dollars. Main outcome measures Central line-associated bloodstream infections prevented, deaths averted due to central line-associated bloodstream infections prevented, and incremental cost-effectiveness ratios. Probabilistic sensitivity analysis was performed. Results Compared with current practice, the programme is strongly dominant and reduces bloodstream infections and deaths at no additional cost. The probabilistic sensitivity analysis showed that there was an almost 80% probability that the programme reduces bloodstream infections and the infections’ economic costs to hospitals. The opportunity cost of a bloodstream infection to a hospital was the most important model parameter in these analyses. Conclusions This multifaceted quality improvement programme, as it is currently implemented by hospitals on an increasingly large scale in the USA, likely reduces the economic costs of central line-associated bloodstream infections for US hospitals. Awareness among hospitals about the programmes benefits should enhance implementation. The programmes implementation has the potential to substantially reduce morbidity, mortality and economic costs associated with central line-associated bloodstream infections.

Physician Motivation: Listening to What Pay-for-Performance Programs and Quality Improvement Collaboratives Are Telling Us

Peter J. Pronovost, MD, PhD is Senior Vice President for Patient Safety and Quality, and Director, Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore; Professor of Anesthesiology and Critical Care Medicine, Surgery, and Health Policy and Management, The Johns Hopkins University, Baltimore; and a member of The Joint Commission Journal on Quality and Patient Safetys Editorial Advisory Board.

Vitamin A supplementation in Indian children

594 www.thelancet.com Vol 382 August 17, 2013 The report of DEVTA was the 44th published trial of vitamin A. The eff ect on its primary outcome, mortality, is noticeably smaller than the results of 15 previous trials including more than 200 000 participants. In view of problems with the delivery of the intervention in DEVTA, meta-analyses of previous high-quality trials might more accurately show the effi cacy of vitamin A. In a meta-analysis using a fixedeffect model, DEVTA accounts for 65% of the weight and reduces the average eff ect by half (risk ratio [RR] 0·88, 95% CI 0·84–0·94; I2=64%), consistent with the meta-analysis reported by Awasthi and colleagues. Using random-eff ects, which might be a more appropriate model in view of diff erences between the included trials, DEVTA accounts for 14% of the overall eff ect, which suggests a 26% average reduction in mortality (RR 0·74, 95% CI 0·64–0·87). Since model choice meaningfully changes the outcome, both averages should be interpreted with caution. Continued research to improve the delivery of vitamin A remains important, but further trials are not needed. Because of the size of DEVTA and the stability of previous estimates, average eff ects are highly unlikely to change. We believe that the metaanalysis by Awasthi and colleagues underestimates the eff ect of vitamin A when delivered faithfully to children at high risk of deficiency; however, their report affirms that vitamin A supplementation prevents death, illness, and blindness for children who are defi cient and cannot obtain enough vitamin A through diet alone. It would no longer be ethical to compare vitamin A with a placebo or with a nutritional intervention that lacks this essential nutrient. DEVTA should be the last trial of this kind.

Prevalence of Self-disclosed Disability Among Medical Students in US Allopathic Medical Schools.

Prevalence of Self-disclosed Disability Among Medical Students in US Allopathic Medical Schools Studying the performance of medical students with disabilities requires a better understanding of the prevalence and categories of disabilities represented.1-4 It remains unclear how many medical students have disabilities; prior estimates are out-of-date and psychological, learning, and chronic health disabilities have not been evaluated.5 This study assessed the prevalence of all disabilities and the accommodations in use at allopathic medical schools in the United States.

A Decade of Difficult Airway Response Team: Lessons Learned from a Hospital-Wide Difficult Airway Response Team Program

A decade ago the Difficult Airway Response Team (DART) program was created at The Johns Hopkins Hospital as a multidisciplinary effort to address airway-related adverse events in the nonoperative setting. Root cause analysis of prior events indicated that a major factor in adverse patient outcomes was lack of a systematic approach for responding to difficult airway patients in an emergency. The DART program encompasses operational, safety, and educational initiatives and has responded to approximately 1000 events since its initiation, with no resultant adult airway-related adverse events or morbidity. This article provides lessons learned and recommendations for initiating a DART program.