Dr Peter Pronovost Ted Talk

Healthy at Home - Peter Pronovost

Love Wins

Making a Dent in the Trllion Dollar Problem in Zero Defects

Peter Pronovost's Keynote: Leading with Love to Eliminate Harm

Dr. Peter Pronovost is well known across the world for his work to standardize central-line blood stream infection improvement. Dr. Pronovost joins us to share how we can "lead with love" to eliminate harm. Don't miss this inspirational session!

POZ HAC Facts - CLABSI

The Checklist - Overview

Value Alliance - High Reliability Medicine - Zero Defects

Zero Harm--Aiming for Excellence Together, Pt 4 of 4

VITALS with Peter Pronovost, Dec. 14, 2023

Lead With Love - Dr.Peter Pronovost MD, PhD. 2023 - The Healthcare Unconference JCU

John Carroll University - The Healthcare Unconference Dr. Pronovost fuses evangelism and science as vital for successful large-scale changes. His “leading with love" approach drives innovation while maintaining a focus on keeping people healthy. Hear how Dr. Pronovost operationalizes love to transform care. John Carroll University Unconference_LeadWithLove Dr.Peter Pronovost MD, PhD. 2023

Peter Pronovost's Keynote: Leading with Love to Eliminate Harm

Dr. Peter Pronovost is well known across the world for his work to standardize central-line blood stream infection improvement. Dr. Pronovost joins us to share how we can "lead with love" to eliminate harm. Don't miss this inspirational session!

Zero Harm--Aiming for Excellence Together, Pt 4 of 4

Zero Harm--Aiming for Excellence Together (full version)

ZERO HARM, Part 3

Peter Pronovost on Healthcare Quality - MP4 Video

Dr. Peter Pronovost, Director Armstrong Institute for Patient Safety and Quality, Johns Hopkins along with Dr. Kevin Kavanagh from Health Watch USA discuss the prevention of adverse events, hospital acquired conditions, checklists and quality Improvement in Healthcare - MP4 Video

SPEAK UP AND STAY ALIVE PATIENT SAFETY RADIO

#TomorrowsDiscoveries: Eliminating Harm to Patients | Dr. Peter Pronovost - Johns Hopkins Medicine

#TomorrowsDiscoveries: Hospitalized patients face the potential for hundreds of complications. See how researchers at Johns Hopkins Armstrong Institute work with health care providers, engineers, psyc...

Zero Harm--Aiming for Excellence Together (full version)

Quality Patient and Safety Week 2021 - Emergency Critical Care and Hospitalist - Zero Harm

The Science of Safety - Part 3

The Science of Safety - Part 2

The Science of Safety - Part 1

The Journey to High Value Care the Power of Narrative by Peter J Pronovost md phd

The Journey to Enhancing Value for Patients

The Future is Now

Solving Problems and Solving Puzzles The Need for Improvement Science

Speak Up and Stay Alive with Dr. Peter Pronovost Broadcast

ShareSafe Media 1 - Dr. Peter Pronovost and Christine Haas

Securing a Science Strong Future

Science of Improvement What Will it Take to Improve Quality and Reduce Costs --February 20, 2013

Safety in Practice - Peter Pronovost

Pronovost mentioned on CBS

Pronovost Checklist

Primary Care Webinar Health and Wellness the Power of You

Peter Pronovost In the Interest of Patient Safety

Peter Pronovost safe

Perioperative Handoff Toolkit by Johns Hopkins

Patient Safety

Patient Safety Conversations - Janet Walls Story

Panel 4 - National Institute of Medicine

Open Forum Johns Hopkins Hospital

Masimo Webinar- Masimo SafetyNet and COVID-19

Keynote Address - UH Ventures Health Voyagers Series

How Love Can Heal Healthcare

High Reliability Organizing in Healthcare

GPS for CUSP Working Together Armstrong Institute for Patient Safety and Quality

David E Rogers Award Peter Pronovost md phd

CUSP Understand the Science of Safety

Culture

CLABSI Prevention by Peter Pronovost MD PhD

CDC and Johns Hopkins Develop Ebola Training Modules for Health Care Workers

Building infrastructure to support quality improvement

Best Practices for Better Care Pronovost Interview June 14, 2011

A Second Act for Dr. Checklist at University Hospitals in Cleveland

A New Narrative from Healing in Hospital to Healthy at Home

2008 MacArthur Fellow Peter Pronovost

20 Voices 3 Minutes 1 Question

Addressing the workforce crisis: Insights from University Hospitals' leaders

Recent research shows that the workforce shortage — particularly among registered nurses — is the top issue for healthcare CEOs. Radio Advisory's Rachel Woods sat down with two leaders from University Hospitals — Chief Quality & Clinical Transformation Officer, Peter Pronovost, and Chief Nursing Executive, Michelle Hereford — to talk about recent data and their experiences navigating the complexity of the workforce shortage.

Eliminating Defects in Value Turnaround of an MSSP ACO

Hospital safety strategies improve quality, patient experiences - Modern Healthcare - 2023 02 20

Patient Safety Performance- Reversing Recent Declines through Shared Profession-Wide System-Level Solutions

University Hospitals receives two national awards

A Second Opinion with Senator Bill Frist, M.D.: 173 - Dr. Peter Pronovost, Chief Clinical Transformation Officer at University Hospitals, on Achieving Zero Harm in Healthcare & Why Love Wins

Today, Dr. Peter Pronovost joins us. He is the Chief Clinical Transformation Officer at University Hospitals in Cleveland, Ohio, where he is a champion for innovation as well as patient safety and value improvement. His devotion to value improvement in this role reduced Medicare Annual expenditures by 21% over a two-year period. Nicknamed “Dr. Checklist,” Peter garnered worldwide recognition for a patient safety checklist that he developed. And, in 2008, he received a MacArthur Foundation “Genius Grant” and was named by Time magazine as one of the “100 Most Influential People.” In our conversation today, Peter and I talk about what it means to provide high quality care, about the necessary cultural shifts that are taking place in healthcare, about how even seemingly simple innovations can have long-lasting impacts on providing patients with better care, and about the power of our beliefs, human connection, and love in positively impacting others. Additional Resources: University Hospitals’ Journey to Zero Harm: Pronovost on Love Wins:

Value Defects In The Health Services Sector | Health Affairs Forefront

Ultimately, the solution to value defects is not as simple as withholding spending on low-value care for the US to save a trillion dollars. To repair our spending on wasteful services that increase opportunity costs, we have to pay for solutions that move health care delivery over to a new production function.

Remote Patient Monitoring During COVID-19An Unexpected Patient Safety Benefit - Feb 25 2022

Multisystem inflammatory syndrome is rare among young people vaccinated for COVID-19, a new study suggests, Coronavirus update for March 1, 2022 - cleveland.com

Researchers Remote patient monitoring, telehealth saved lives during pandemic - Clinical Daily News - McKnight's Long-Term Care News - Feb 28 2022

Build Lasting Healthy Habits

Healthcare workers can't get off the COVID-19 rollercoaster - Jan 18 2022

Leading with Love - Learning and Shared Accountability JHOM-10-2021

New commentary paper highlights costs of defects in surgical care and calls for elimination of defects in value - EurekAlert Nov 3 2021

What Goes Missing in the Rush to Virtual Care MedPage Today

Can AI help improve racial disparities in healthcare

UH Continues to Lead in Value Cleveland, OH Patch

Diagnostic Errors, Health Disparities, and Artificial Intelligence - A Combination for Health or Harm

The organization of intensive care unit physician services

Objective: To describe the organization of physician services in intensivist-staffed intensive care units (ICU) reporting that they meet vs. do not meet the Leapfrog Physician Staffing standard, and to describe ICU directors' perceptions of the quality of care in their unit.

Barriers to low tidal volume ventilation in acute respiratory distress syndrome: Survey development, validation, and results

Objective: To evaluate perceived attitudes, knowledge, and behaviors regarding the use of low tidal volume ventilation in acute respiratory distress syndrome among physicians, nurses, and respiratory therapists in intensive care units.

Informed consent in the critically ill: A two-step approach incorporating delirium screening

Objectives: Sedation-agitation and delirium are common in critically ill patients and may be important barriers to informed consent. We describe a two-step process for informed consent and evaluate the natural history of patients' competency by repeated application of this process during their hospitalization. Design: Observational study. Setting: Nine intensive care units (ICUs) in three teaching hospitals in Baltimore, MD. Patients: One hundred fifty patients with acute lung injury. Interventions: Two-step process involving objective evaluation with Richmond Agitation-Sedation Scale (RASS) and Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) (step 1), followed by traditional assessment for competency (step 2) in those patients passing step 1. Measurements and Main Results: RASS and CAM-ICU assessments (during ICU stay, at consent and hospital discharge); cumulative proportion of patients providing consent at extubation and at ICU and hospital discharge. Of 150 patients, 86 (57%) survived and 77 (90% of survivors) provided consent. Patients were delirious/deeply sedated in 89% of daily assessments during mechanical ventilation. By extubation, 31 (44%) patients passed step 1 and 8 (11%) passed step 2 and were consented. By ICU and hospital discharge, these numbers were 50 (58%) and 18 (21%), and 81 (94%) and 67 (78%), respectively. The median (interquartile range) time to patient consent after acute lung injury diagnosis was 15 (9–28) days. Conclusions: More than three fourths of critically ill patients are unable to provide informed consent throughout their ICU stay, even after extubation. Sedation-agitation and delirium are common barriers to consent. A two-step consent process, using validated instruments for sedation-agitation and delirium, provides a means of rapidly screening critically ill patients before a more detailed traditional assessment of competency is conducted.

PERCEPTIONS OF HIGH AND LOW QUALITY CARE IN SURGICAL INTENSIVE CARE UNITS AMONG PATIENTS AND THEIR FAMILIES

Introduction: Little is known about how stakeholders characterize care quality in critical care units, particularly in surgical intensive care units (SICUs). This qualitative study explores SICU patient and family perceptions of care, specifically what is high and low quailty ICU care as defined by patients and families. Hypothesis: SICU patients and family members relay key insights into high and low quality patient- and family-centered ICU care. Methods: We conducted one-on-one, in-person, in-depth interviews with 13 patients or family members recruited from SICUs in an academic, inner-city, tertiary care hospital. The interviewers used open-ended questions to assess patient and family perceptions of “high” and “low” quality SICU care. Informed by a grounded theory approach and utilizing line-by-line, focused, axial, and theoretical coding, we performed consensus coding on transcribed interviews using co-occurrence matrices to examine the data. Results: In defining “high” quality SICU care, six domains emerged: communication, trust, compassion, involving families in patient care, having a plan, and teamwork. In defining “low” quality SICU care, five domains emerged: poor communication, lack of trust, poor continuity of care providers, lack of teamwork, and unclear provider roles. Conclusions: Domains identified by patients and families as “high” quality SICU care can be largely met by involving patients and families in daily rounds and are consistent with palliative care skills and principles – communication, instilling trust and facilitating teamwork between providers, patients, and families, and supporting and involving both the patient and the family throughout the illness process. Future studies are needed to further explore provider beliefs about quality of SICU care and how they may differ from those identified by patients and families.

Using an interdisciplinary approach to identify factors that affect clinicians' compliance with evidence-based guidelines

Objective: Our objective was to identify factors that affect clinicians' compliance with the evidence-based guidelines using an interdisciplinary approach and develop a conceptual framework that can provide a comprehensive and practical guide for designing effective interventions. Design: A literature review and a brainstorming session with 11 researchers from a variety of scientific disciplines were used to identify theoretical and conceptual models describing clinicians' guideline compliance. MEDLINE, EMBASE, CINAHL, and the bibliographies of the papers identified were used as data sources for identifying the relevant theoretical and conceptual models. Results: Thirteen different models that originated from various disciplines including medicine, rural sociology, psychology, human factors and systems engineering, organizational management, marketing, and health education were identified. Four main categories of factors that affect compliance emerged from our analysis: clinician characteristics, guideline characteristics, system characteristics, and implementation characteristics. Based on these findings, we developed an interdisciplinary conceptual framework that specifies the expected interrelationships among these four categories of factors and their impact on clinicians' compliance. Conclusions: An interdisciplinary approach is needed to improve clinicians' compliance with evidence-based guidelines. The conceptual framework from this research can provide a comprehensive and systematic guide to identify barriers to guideline compliance and design effective interventions to improve patient safety.

Shepherding change: How the market, healthcare providers, and public policy can deliver quality care for the 21st century

Background: Data are scarce that inform the ways consumers of health care and caregivers help improve the care that is delivered. The healthcare system is quite broad. To improve it, we first must understand it, understand its various subsystems, and understand how they shape individual behavior. Discussion: Both consumers and providers can effectively improve health care. An example of an influential consumer is provided, focusing a successful effort to improve care in the intensive care unit. The overall model for improving outcomes assumes providers can be classified into high-quality and low-quality providers. The model then aims to increase the number of people exposed to high-quality caregivers. There are three primary levers for driving this change: using market forces, provider improvements, and policy change. This article touches briefly on the first and focuses on the second and third. Conclusion: A number of grassroots programs highlight ways providers can improve care by approaching patient safety and quality as a science. In addition, the Josie King Act and its legislative progeny provide some hope that a new policy environment can reward and reinforce providers' efforts to drive up safety and quality.

Patient flow variability and unplanned readmissions to an intensive care unit - PubMed

Days of high patient inflow volumes to the unit were associated significantly with subsequent unplanned readmissions to the unit. Furthermore, the data indicate a possible dose-response relationship between intensive care unit inflow and patient outcomes. Further research is needed to understand how …

Long-term mortality and quality of life in sepsis: a systematic review - PubMed

Patients with sepsis have ongoing mortality beyond short-term end points, and survivors consistently demonstrate impaired quality of life. The use of 28-day mortality as an end point for clinical studies may lead to inaccurate inferences. Both observational and interventional future studies should i …

Critical Care Delivery The Importance of Process of Care and ICU Structure to Improved Outcomes

In 2001, the Society of Critical Care Medicine published practice model guidelines that focused on the delivery of critical care and the roles of different ICU team members. An exhaustive review of the additional literature published since the last guideline has demonstrated that both the structure and process of care in the ICU are important for achieving optimal patient outcomes. Since the publication of the original guideline, several authorities have recognized that improvements in the processes of care, ICU structure, and the use of quality improvement science methodologies can beneficially impact patient outcomes and reduce costs. Herein, we summarize findings of the American College of Critical Care Medicine Task Force on Models of Critical Care: 1) An intensivist-led, high-performing, multidisciplinary team dedicated to the ICU is an integral part of effective care delivery; 2) Process improvement is the backbone of achieving high-quality ICU outcomes; 3) Standardized protocols including care bundles and order sets to facilitate measurable processes and outcomes should be used and further developed in the ICU setting; and 4) Institutional support for comprehensive quality improvement programs as well as tele-ICU programs should be provided.

Improving Cardiac Surgery Outcomes

Introduction: Efforts to reduce hospital-acquired infections (HAIs) have been shown to result in substantial reductions in homogenous clinical settings such as intensive care units (ICU), but little is known about expanding these efforts to a single service line. In this study, we examine the effect of a multifaceted intervention on HAIs and patient safety culture in the cardiac surgery service line across the operating room (OR), ICU, and floor units. Methods: A cohort of 11 hospitals across the nation participated in this study, comprising of 11 ORs, 8 ICUs, 9 floor units, and 3 universal-bed units. Median and weighted mean rates of CLABSI, SSI and VAP were calculated for all units. We compared Hospital Survey on Patient Safety (HSOPS) measures at baseline and at one year (Time 2) using t tests. Results: The baseline median CLABSI rates were 1.10 and 1.39 per 1,000 central line days respectively for two-year and one-year prior to implementation. Upon implementation of the interventions, median CLABSI rates decreased to 0 per 1,000 central line days. Median VAP rates were sustained at 0 per 1,000 ventilation days. A downward trend was also observed in median SSI rates for coronary artery bypass grafts (CABGs) with and without donor incisions. Culture regarding leadership and teamwork across hospital units improved from baseline to Time 2; however, scores on communication and staffing were lower at Time 2 compared to baseline. The less positive communication scores might be due to pressures from hospital management that increasingly focus on patient safety. Conclusions: Designing and implementing patient safety interventions across different unit types of the same service line have the potential to increase synergy in patient safety efforts. This study demonstrates a multifaceted intervention combining CUSP and TRiP can be implemented in a single service line and achieve sustainable reductions in HAIs.

A multicenter, phased, cluster-randomized controlled trial to reduce central line-associated bloodstream infections in intensive care units

Objectives: To determine the causal effects of an intervention proven effective in pre-post studies in reducing central line-associated bloodstream infections in the intensive care unit.

Preventing Harm in the ICU—Building a Culture of Safety and Engaging Patients and Families

Preventing harm remains a persistent challenge in the ICU despite evidence-based practices known to reduce the prevalence of adverse events. This review seeks to describe the critical role of safety culture and patient and family engagement in successful quality improvement initiatives in the ICU. We review the evidence supporting the impact of safety culture and provide practical guidance for those wishing to implement initiatives aimed at improving safety culture and more effectively integrate patients and families in such efforts.

RBC Transfusion Practices Among Critically Ill Patients Has Evidence Changed Practice?

Objective: Increasing evidence, including publication of the Transfusion Requirements in Critical Care trial in 1999, supports a lower hemoglobin threshold for RBC transfusion in ICU patients. However, little is known regarding the influence of this evidence on clinical practice over time in a large population-based cohort.

Impact of a National Multimodal Intervention to Prevent Catheter-Related Bloodstream Infection in the ICU

Objective: Prevention of catheter-related bloodstream infection is a basic objective to optimize patient safety in the ICU. Building on the early success of a patient safety unit-based comprehensive intervention (the Keystone ICU project in Michigan), the Bacteremia Zero project aimed to assess its effectiveness after contextual adaptation at large-scale implementation in Spanish ICUs. Design: Prospective time series. Setting: A total of 192 ICUs throughout Spain. Patients: All patients admitted to the participating ICUs during the study period (baseline April 1 to June 30, 2008; intervention period from January 1, 2009, to June 30, 2010). Intervention: Engagement, education, execution, and evaluation were key program features. Main components of the intervention included a bundle of evidence-based clinical practices during insertion and maintenance of catheters and a unit-based safety program (including patient safety training and identification and analysis of errors through patient safety rounds) to improve the safety culture. Measurements and Main Results: The number of catheter-related bloodstream infections was expressed as median and interquartile range. Poisson distribution was used to calculate incidence rates and risk estimates. The participating ICUs accounted for 68% of all ICUs in Spain. Catheter-related bloodstream infection was reduced after 16–18 months of participation (median 3.07 vs 1.12 episodes per 1,000 catheter-days, p < 0.001). The adjusted incidence rate of bacteremia showed a 50% risk reduction (95% CI, 0.39–0.63) at the end of the follow-up period compared with baseline. The reduction was independent of hospital size and type. Conclusions: Results of the Bacteremia Zero project confirmed that the intervention significantly reduced catheter-related bloodstream infection after large-scale implementation in Spanish ICUs. This study suggests that the intervention can also be effective in different socioeconomic contexts even with decentralized health systems.

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.

Cost effectiveness of reducing CLABSI in the limited resource setting of developing countries

Introduction: A recent meta-analysis by the World Health Organization estimated that the rate of central-line associated blood stream infections (CLABSIs) among adult ICU patients in developing countries was 12.2 per 1000 central line days which is 2-3 fold higher than in developed countries, and account for a crude unadjusted excess mortality of 15% to 24%. This burden is not only unacceptably high, but for the most part remains unaddressed. Excellent evidence exists for CLABSI rate reduction, like the bundled initiative by Pronovost et al. that utilized five steps to significantly reduce the incidence of CLABSIs. We will evaluate the cost effectiveness of implementing the bundled care approach published by Pronovost et al for CLABSI prevention, and compare it to the scenario of not utilizing it at baseline. Methods: We performed a cost-effectiveness evaluation using a decision tree analysis with the TreeAge software. The intervention was considered to be the implementation of a bundled intervention to reduce CLABSI, and was compared to the baseline of not applying it. A probabilistic sensitivity analysis was performed using a Monte Carlo simulation of 10,000 patients. Distributions were created for several parameters including total costs, total effects and probability of developing a CLABSI with and without the bundle intervention. Results: Patients in the baseline group who expire from a CLABSI were found to incur costs of $3531, while those who survive cost $4136 per patient. By comparison at baseline, ICU patients without CLABSI who are discharged cost $1502 and those who expire in the ICU cost $1199. With bundle implementation, patients who die from CLABSI were found to cost $3609 while those that survive having a CLABSI $4214. With the bundled intervention, average patients discharged from the ICU cost $1579 and those who die cost $1277. As a group, regardless of intervention, patient who died from a CLABSI lost 21.89 DALYS, while patients who survived a CLABSI lost 6.8 DALYs. By contrast, the average ICU survivor who did not experience a CLABSI lost 1.38 DALYs, while those who died lost 21.91 DALYs. The baseline cost-effectiveness analysis results show that implementing the bundled intervention as modeled was more expensive by $43.65 for the overall ICU stay of the average patient, but saved 0.14 DALY per patient with a central line. For these estimates, the incremental cost-effectiveness ratio come out to $301.57 per DALY averted, well under the cost-effectiveness acceptability threshold of twice the capital gross national income of most low- and middle-income countries. Conclusions: This analysis provides evidence that implementation of a bundled approach to reduction of CLABSI can be both effective and cost-effective across limited resource settings such as those found in developing countries.

Plasma Biomarkers of Brain Injury as Diagnostic Tools and Outcome Predictors After Extracorporeal Membrane Oxygenation

Objective: To determine if elevations in plasma brain injury biomarkers are associated with outcome at hospital discharge in children who require extracorporeal membrane oxygenation. Design: Prospective observational study. Setting: Single tertiary-care academic center.

Evaluation of a Measurement System to Assess ICU Team Performance

Objective: Measuring teamwork is essential in critical care, but limited observational measurement systems exist for this environment. The objective of this study was to evaluate the reliability and validity of a behavioral marker system for measuring teamwork in ICUs. Design: Instances of teamwork were observed by two raters for three tasks: multidisciplinary rounds, nurse-to-nurse handoffs, and retrospective videos of medical students and instructors performing simulated codes. Intraclass correlation coefficients were calculated to assess interrater reliability. Generalizability theory was applied to estimate systematic sources of variance for the three observed team tasks that were associated with instances of teamwork, rater effects, competency effects, and task effects. Setting: A 15-bed surgical ICU at a large academic hospital.

The Johns Hopkins Venous Thromboembolism Collaborative Multidisciplinary team approach to achieve perfect prophylaxis

Red blood cell transfusion practices in two surgical intensive care units: a mixed methods assessment of barriers to evidence-based practice

Background Despite evidence supporting restrictive red blood cell (RBC) transfusion thresholds and the associated clinical practice guidelines, clinical practice has been slow to change in the intensive care unit (ICU). Our aim was to identify barriers to conservative transfusion practice adherence. Study Design and Methods A mixed-methods study involving observation of prescriber (i.e., physicians, physician assistants, nurse practitioners) and bedside nurse daily bedside rounds, provider survey, and medical record abstraction was conducted in one cardiac surgical ICU (CSICU) and one surgical ICU (SICU) in an academic hospital in Baltimore, Maryland. Results Of 52 patient encounters observed during bedside rounds, 38 (73%) involved patients without evidence of active bleeding or cardiac ischemia. Surveys were completed by 52 (93%) of the 56 providers participating in rounds. Prescribers in the CSICU and SICU (87 and 90%, respectively) indicated the ideal pretransfusion hemoglobin (Hb) to be not more than 7 g/dL in nonbleeding and/or nonischemic patients compared to a minority of nurses (8% [p = 0.002] and 42% [p = 0.015], respectively). Prescribers and nurses in both ICUs overestimated the typical pretransfusion Hb in their units (CSICU, p < 0.001; SICU, p = 0.019). During rounds, providers infrequently explicitly discussed Hb monitoring or transfusion thresholds (33%) despite most (60%) reporting significant variation in transfusion thresholds between individual prescribers. Conclusions Our study identified several provider and system barriers to evidence-based transfusion practices including knowledge differences, overly optimistic estimates of current practice, and heterogeneous transfusion practice in each ICU. Further work is necessary to develop targeted interventions to improve evidence-based RBC transfusion practices.

Predictors of transfusion for spinal surgery in Maryland, 1997 to 2000

BACKGROUND: The purpose of this study was to identify preoperative patient, hospital, and surgeon characteristics associated with transfusion for spinal surgery. STUDY DESIGN AND METHODS: Discharge data were obtained from 39 Maryland hospitals for adult patients (n = 3988) who had a primary procedure code for spinal surgery between July 1997 through June 2000, and with these codes, surgeons and hospitals were characterized by annual patient volume. Outcome variables included any allogeneic transfusion, any transfusion, RBCs, autologous blood, FFP, or platelet transfusion. Logistic regression was used for univariate and multivariate analyses. RESULTS: Characteristics independently associated with an increased risk of receiving any allogeneic transfusion (n = 786) included age >54 (OR, 1.6; 95% CI, 1.3-2.1), age >66 (OR, 2.7; 95% CI, 2.0-3.5), female sex (OR, 1.6; 95% CI, 1.2-2.0), diabetes with chronic complications (OR, 2.5; 95% CI, 1.3-4.9), and metastatic tumor (OR, 4.9; 95% CI, 2.3-10.5), emergency room admission (OR, 2.3; 95% CI, 1.4-3.8), and greater hospital volume (OR, 4.0; 95% CI, 1.8-8.6). Characteristics independently associated with increased autologous transfusions (n = 574) included white race (OR, 1.7; 95% CI, 1.2-2.4), female sex (OR, 1.4; 95% CI, 1.1-1.8), and greater surgeon volume (OR, 3.5; 95% CI, 1.4-9.1). DISCUSSION: This information can be used to provide informed risk-benefit discussions with patients regarding the risk for blood transfusion as well as to target high-risk patients and institutions for interventions to reduce the risk of exposure to blood components.

The Research-Treatment Distinction: A Problematic Approach for Determining Which Activities Should Have Ethical Oversight

The rise of quality improvement research and comparative effectiveness research in health care settings constitutes progress toward the goal of what the Institute of Medicine has called a “learning healthcare system,” in which we are “drawing research closer to clinical practice by building knowledge development and application into each stage of the healthcare delivery process.” As clinical research and clinical practice move closer to a deliberately integrated system, the distinction between the two is increasingly blurred, although the sharp distinction in U.S. regulations and research ethics literature remains in place. In the 1970s and for two decades thereafter, this distinction was helpful: for some forms of research, it sheds light on which activities require ethical oversight. Research that is closely integrated with health care—notably, health delivery research—was then uncommon, however. That is no longer the case, and regulations and research ethics need to change to accommodate the new landscape. In this paper, we argue that conceptual, moral, and empirical problems surround the received view that we can and should draw sharp distinctions between clinical research and clinical practice. We start with the history of the research-practice distinction in the reports of a U.S. national commission and in U.S. federal regulations, and then offer a critical assessment of five characterizations of research that have been used in policy documents and the scholarly literature to try to make a sharp distinction between research and practice. We challenge the clarity and the tenability of these characterizations as a way of distinguishing research from practice. We argue that the received view of the research-practice distinction leads to overprotection of the rights and interests of patients in some cases and to underprotection in others. We contend that a new ethical foundation needs to be developed that facilitates both care and research likely to benefit patients, and that provides oversight that, rather than being based on a distinction between research and practice, is commensurate with risk and burden in both realms.

Frailty, hospital volume, and failure to rescue after head and neck cancer surgery

Objectives/Hypothesis We previously reported that high-volume hospital head and neck cancer (HNCA) surgical care is associated with decreased mortality, largely explained by reduced rates of failure to rescue. Frailty is an independent predictor of mortality, but is significantly less likely in patients receiving high-volume care. We investigate whether differences in frailty rates explain the relationship between volume and outcomes in HNCA patients and whether frailty confounds the relationship between failure to rescue and mortality.

National Study of Patient, Visit, and Hospital

Medical Physics Practice Guideline 4.a Development,

Perioperative Nurses and Patient Outcomes—Mortality, Complications, and Length of Stay

ABSTRACT • THE PURPOSE OF THE STUDY described in this article was to identify the relationship between RN staffing factors in the OR and surgical patient outcomes. • THE STUDY ADDRESSED two main questions: whether the level of RN staffing in the OR is related to postoperative complications mortality, and length of stay (LOS) and whether certification, RN agency use, 24-hour staffing, and the performance of multi-disciplinary code drills are related to complications, mortality, and LOS. • ACCORDING TO THIS STUDY, selected organzational factors in ORs had a significant influence on patient outcomes. AORN J 81 (March 2005) 508–528.

Variation in Local Institutional Review Board

Latent risk assessment tool for health care leaders

Efforts to improve quality of care and patient safety have concentrated on provider practice and frontline care processes. Little attention has focused on understanding the role that leadership decisions play in creating risk within a health care system. The framework and tool described in this article builds on Reason's construct of latent organizational failure, by assessing the latent risks of leadership decisions, and identifying appropriate mitigation strategies before the implementation of a change. Stakeholders who will be involved in or impacted by the change are engaged in the assessment to more thoroughly explore both technical and cultural risks.

Robotic Surgery Claims on United States Hospital Websites

To examine the prevalence and content of robotic surgery information presented on websites of U.S. hospitals. We completed a systematic analysis of 400 randomly selected U.S. hospital websites in June of 2010. Data were collected on the presence and location of robotic surgery information on a hospital's website; use of images or text provided by the manufacturer; use of direct link to manufacturer website; statements of clinical superiority; statements of improved cancer outcome; mention of a comparison group for a statement; citation of supporting data and mention of specific risks. Forty-one percent of hospital websites described robotic surgery. Among these, 37% percent presented robotic surgery on their homepage, 73% used manufacturer-provided stock images or text, and 33% linked to a manufacturer website. Statements of clinical superiority were made on 86% of websites, with 32% describing improved cancer control, and 2% described a reference group. No hospital website mentioned risks. Materials provided by hospitals regarding the surgical robot overestimate benefits, largely ignore risks and are strongly influenced by the manufacturer.

Variation in Surgical Site Infection Monitoring and Reporting by State

Abstract Objective Surgical site infections (SSIs) are common, costly, and often preventable. There are no national requirements for measuring or reporting hospital SSI rates and state-level monitoring occurs with little coordination between states. We designed a study to describe the current status of SSI reporting in the United States. Methods We reviewed SSI monitoring and reporting legislation in all 50 states in September 2010. Data collected included whether SSI monitoring and reporting legislation exists, if public reporting is required, how the data are accessible, and for which procedures SSI data are reported. Results Twenty-one (42%) states have legislation for SSI monitoring and reporting. All 21 of these states require public release of findings. Of the states with legislation, eight (38%) currently have SSI data available publicly. A range of two to seven procedures were reported for SSI measurement by individual states. Eighteen (86%) states use state agency websites to make their data publicly available. Conclusion There is wide variation in state monitoring and reporting of SSI rates. Standardized reporting may be needed so that consumers can make informed health choices based on quality metrics.

Towards improving hospital workflows: An evaluation of resources to mobilize patients

Aim To characterize resources to safely mobilize different types of hospitalized patients. Background Current approaches to determine nurse–patient ratios do not always include information regarding the specific demands of patients who require extra resources to mobilize. Workflows must be designed with knowledge of resource requirements to integrate patient mobility into the daily nursing team care plan.

A framework for operationalizing risk: A practical approach to patient safety

The importance of patient safety has grown tremendously; however, there are insufficient resources dedicated to its practical application. We provide an overview of the framework for addressing patient safety within the Johns Hopkins Health System, which approaches patient safety in the context of risk at the patient, provider, unit, and system levels. We present practical examples of how this approach is applied and highlight the resources needed as well as describe how it fits within the broader quality management infrastructure in the health system on its journey toward high reliability.