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Hospital Collaboration With Emergency Medical Services in the Care of Patients With Acute Myocardial Infarction: Perspectives From Key Hospital Staff
Abstract
Study objective:
Evidence suggests that active collaboration between hospitals and emergency medical services (EMS) is significantly associated with lower acute myocardial infarction mortality rates; however, the nature of such collaborations is not well understood. We seek to characterize views of key hospital staff about collaboration with EMS in the care of patients hospitalized with acute myocardial infarction.
Methods:
We performed an exploratory analysis of qualitative data previously collected from site visits and detailed interviews with 11 US hospitals that ranked in the top or bottom 5% of performance on 30-day risk-standardized acute myocardial infarction mortality rates, using Centers for Medicare & Medicaid Services data from 2005 to 2007. We selected all codes from the previous analysis in which EMS was most likely to have been discussed. A multidisciplinary team analyzed the data with the constant comparative method to generate recurrent themes.
Results:
Both higher- and lower-performing hospitals reported that EMS is critical to the provision of timely care for patients with acute myocardial infarction. However, close collaborative relationships with EMS were more apparent in the higher-performing hospitals, which demonstrated specific investment in and attention to EMS through respect for EMS as valued professionals and colleagues, strong communication and coordination with EMS and active engagement of EMS in hospital acute myocardial infarction quality improvement efforts.
Conclusion:
Hospital staff from higher-performing hospitals described broad, multifaceted strategies to support collaboration with EMS in providing acute myocardial infarction care. The association of these strategies with hospital performance should be tested quantitatively in a larger representative study.
... The included articles have mentioned several limitations that can be related to the PD approach even though it is not possible to prove whether it is true or not as many [33,65,83], difficulty of adjusting confounders [30,34,63,68,114], lack of comparison and, or difficulty of doing comparative analysis [24,71,82], and issues of generalizability/transferability [11,30,42,44,64,72,80,82,84,91,96,98,100,102,143] are also reported as common limitations in several articles. In addition, the none-probability sampling methods used to recruit participants [94] and the Hawthorne effect, a type of reactivity in which individuals modify an aspect of their behavior in response to their awareness of being observed as positive deviant are included in many articles as limitations in using the approach of PD [30,32,49,66,71]. ...
... The included articles have mentioned several limitations that can be related to the PD approach even though it is not possible to prove whether it is true or not as many [33,65,83], difficulty of adjusting confounders [30,34,63,68,114], lack of comparison and, or difficulty of doing comparative analysis [24,71,82], and issues of generalizability/transferability [11,30,42,44,64,72,80,82,84,91,96,98,100,102,143] are also reported as common limitations in several articles. In addition, the none-probability sampling methods used to recruit participants [94] and the Hawthorne effect, a type of reactivity in which individuals modify an aspect of their behavior in response to their awareness of being observed as positive deviant are included in many articles as limitations in using the approach of PD [30,32,49,66,71]. ...
... The scoping review findings have supported this statement and depicted that the selection process of PDs appeared to be too complex and dependent on the unique circumstances of each study or project. As a result, different articles and studies have utilized a range of methods and criteria to identify PDs including peer recommendations [25,49,52,106,120,123], and performance-based criteria such as lowest risk-adjusted morbidity [139], mortality [82,87,93,102], timely service [26,32,33,84,95,99,113,116,134], and standardized composite performance measures including high composite quality scores [86,115,137], high composite performance/healthcare service scores [11, 23, 27, 43-45, 53, 62, 65, 69, 75, 78, 109, 110, 117, 118, 122, 124, 131, 138, 140, 144], and better clinical outcome scores [37,38,111,118,125,130]. This justifies the absence of a one-size-fitsall approach to selecting PDs, and the criteria used can vary greatly based on the specific domain and goals of initiatives. ...
... From the literature, positive organisational culture is represented by five characteristics, including 'respect and trust between colleagues at all levels in clinical and nonclinical services'. High performing hospitals demonstrated respect and support between clinical, non-clinical, and support staff, and that the contribution of each staff member to the delivery of care was valued [31,32]. Studies provided evidence to suggest that levels of mutual respect pertained between colleagues, disciplines, and departments [10,33]. ...
... Establishing systems for redesigning clinical processes and providing feedback on physician performance was described as a way of maximising opportunities for physicians to reach quality targets [37]. Good quality, credible data was used at individual, team, and organisational levels to highlight problem areas (e.g., delays), motivate changes, test new methods (e.g., comparison of mattress overlays for patients with high risk of pressure ulcers), support adherence to protocols, promote success amongst peers and senior management, develop action plans, identify gaps in knowledge and skills that can be targeted through specific training, and sustain new processes over the long term [10,32,33,38,40,42,47,48]. ...
... 'Effective dissemination of policy and processes' was another characteristic associated with building and maintaining a proficient workforce. High performing hospitals recognised the need for predetermined, explicit patterns of care that team membersincluding external care providers (e.g., ambulatory services)are aware of [32,33,48], and highlighted the importance of established systems during potentially vulnerable periods (e.g., Fig. 2 Rich picture of high performing hospitals staff rotations) to ensure crucial tasks are managed safely and effectively [43]. ...
High performing hospitals attain excellence across multiple measures of performance and multiple departments. Studying high performing hospitals can be valuable if factors associated with high performance can be identified and applied. Factors leading to high performance are complex and an exclusive quantitative approach may fail to identify richly descriptive or relevant contextual factors. The objective of this study was to undertake a systematic review of qualitative literature to identify methods used to identify high performing hospitals, the factors associated with high performers, and practical strategies for improvement.
Methods used to collect and summarise the evidence contributing to this review followed the 'enhancing transparency in reporting the synthesis of qualitative research' protocol. Peer reviewed studies were identified through Medline, Embase and Cinahl (Jan 2000-Feb 2014) using specified key words, subject terms, and medical subject headings. Eligible studies required the use of a quantitative method to identify high performing hospitals, and qualitative methods or tools to identify factors associated with high performing hospitals or hospital departments. Title, abstract, and full text screening was undertaken by four reviewers, and inter-rater reliability statistics were calculated for each review phase. Risk of bias was assessed. Following data extraction, thematic syntheses identified contextual factors important for explaining success. Practical strategies for achieving high performance were then mapped against the identified themes.
A total of 19 studies from a possible 11,428 were included in the review. A range of process, output, outcome and other indicators were used to identify high performing hospitals. Seven themes representing factors associated with high performance (and 25 sub-themes) emerged from the thematic syntheses: positive organisational culture, senior management support, effective performance monitoring, building and maintaining a proficient workforce, effective leaders across the organisation, expertise-driven practice, and interdisciplinary teamwork. Fifty six practical strategies for achieving high performance were catalogued.
This review provides insights into methods used to identify high performing hospitals, and yields ideas about the factors important for success. It highlights the need to advance approaches for understanding what constitutes high performance and how to harness factors associated with high performance.
... The qualitative data from 158 key staff interviews informed the generation of hypotheses regarding factors potentially associated with better performance (see Table 3) . These hypotheses were used to build an online quantitative survey that was administered in a cross-sectional study of 537 acute care hospitals (91 per- Qualitative component describes features of high quality discharge processes that may be associated with better hospital care for patients with AMI In methods, connected to CMS national database for positive deviance sampling per Aim 1 Resulting paper illustrates staged integration, and analysis expands qualitative findings by showing comprehensive discharge processes may reduce RSMR Qualitative approach describes the nature of the hospital-emergency services relationships in high performance hospitals In methods, connected to the CMS national database using identical positive deviance sampling per Aim 1 Resulting paper illustrates staged integration and analysis expands previous findings by showing that high performing hospitals use multifaceted strategies to support collaboration with EMS in AMI care (Landman et al. 2013) Merge qualitative with quantitative findings. Resulting paper identifies predictors of AMI mortality rates (Bradley et al. 2012b) Through weaving narrative, integrate qualitative findings with quantitative findings that confirm factors influencing RSMRs, and impact on RSMR RSMR-risk-standardized mortality rates AMI-acute myocardial infarction CMS-Center for Medicare and Medicaid Services HSR: Health Services Research cent response rate) Krumholz, Curry, and Bradley 2011;Bradley et al. 2012). ...
... In the multivariable analysis, having an organizational environment where clinicians are encouraged to creatively solve problems was significantly associated with lower RSMRs (0.84 percentage points). Finally, additional analyses of qualitative data examining organizational features related to high-quality discharge planning (point 5, Figure 1) , and examining collaborations with emergency medical services (point 6, Figure 1) (Landman et al. 2013) were also methodologically connected through sampling of highperforming hospitals in the CMS database. ...
... An accompanying editorial (Davidoff 2012) discusses the complementary relationship between the qualitative and quantitative findings, highlighting again the respective purposes of each component. The additional qualitative analyses were published separately Landman et al. 2013) and illustrate staged approach to reporting through narrative with ample referencing to the previous studies. This example also illustrates expansion of the previously published findings (Stange, Crabtree, and Miller 2006). ...
Mixed methods research offers powerful tools for investigating complex processes and systems in health and health care. This article describes integration principles and practices at three levels in mixed methods research and provides illustrative examples. Integration at the study design level occurs through three basic mixed method designs-exploratory sequential, explanatory sequential, and convergent-and through four advanced frameworks-multistage, intervention, case study, and participatory. Integration at the methods level occurs through four approaches. In connecting, one database links to the other through sampling. With building, one database informs the data collection approach of the other. When merging, the two databases are brought together for analysis. With embedding, data collection and analysis link at multiple points. Integration at the interpretation and reporting level occurs through narrative, data transformation, and joint display. The fit of integration describes the extent the qualitative and quantitative findings cohere. Understanding these principles and practices of integration can help health services researchers leverage the strengths of mixed methods.
... Extensive resources are typically used to explore how positive deviants succeed; 10 for example, 158 interviews and 11 one-day or two-day site visits were conducted to explore variation in cardiac mortality rates. [21][22][23] As positive deviance is positioned as a community-driven approach, 24 its methods should be accessible to organisations that are tasked with improvement (eg, improvement bodies, clinical networks and national audits). Building on previous research, 25 26 this study addresses stage 2 of the Bradley et al 9 framework to explore how multidisciplinary teams deliver exceptionally safe care on medical wards for older people (ie, perform best on a broad safety outcome). ...
... Focus groups and brief field notes were used to capture staff perceptions about the modifiable factors that facilitate safety. In line with some previous applications of the approach, 23 28 29 researchers and staff were blinded to ward performance levels in order to maximise confirmability-the extent to which findings were grounded in the data. Although uncommon within qualitative research, blinding may help to minimise bias when implementing the positive deviance approach. ...
Background
The positive deviance approach seeks to identify and learn from those who demonstrate exceptional performance. This study sought to explore how multidisciplinary teams deliver exceptionally safe care on medical wards for older people.
Methods
A qualitative positive deviance study was conducted on four positively deviant and four slightly-above-average matched comparator wards, which had been identified using routinely collected NHS Safety Thermometer data. In total, 70 multidisciplinary staff participated in eight focus groups to explore staff perceptions about how their teams deliver safe patient care. A thematic analysis was conducted in two stages: first to identify the tools, processes, strategies, and cultural and social contexts that facilitated safety across all wards; and second to generate hypotheses about the characteristics that facilitated ‘positively deviant’ patient care.
Results
Based on identifiable qualitative differences between the positively deviant and comparison wards, 14 characteristics were hypothesised to facilitate exceptionally safe care on medical wards for older people. This paper explores five positively deviant characteristics that healthcare professionals considered to be most salient. These included the relational aspects of teamworking, specifically regarding staff knowing one another and working together in truly integrated multidisciplinary teams. The cultural and social context of positively deviant wards was perceived to influence the way in which practical tools (eg, safety briefings and bedside boards) were implemented.
Conclusion
This study exemplifies that there are no ‘silver bullets’ to achieving exceptionally safe patient care on medical wards for older people. Healthcare leaders should encourage truly integrated multidisciplinary ward teams where staff know each other well and work as a team. Focusing on these underpinning characteristics may facilitate exceptional performances across a broad range of safety outcomes.
... 40,41 The methodology was developed to address health problems in developing countries, but has been recently used in the United States to identify effective approaches to improving quality of care. 40,[42][43][44][45][46][47][48] Positive deviants are identified using established performance measures, and then qualitative interviews are conducted with these individuals to develop hypotheses about their distinctive strategies. Some researchers additionally conduct qualitative research with low or average performers, as was done in this study, so that positive deviants' strategies can be distinguished from those used by others. ...
... Some researchers additionally conduct qualitative research with low or average performers, as was done in this study, so that positive deviants' strategies can be distinguished from those used by others. 42,43,45 This study was conducted in collaboration with Fairview Health Services, a Pioneer Accountable Care Organization in Minnesota. Since mid-2010, Fairview has routinely had primary care patients complete the 13-item patient activation measure (PAM). ...
Purpose:
We aimed to identify the strategies used to support patient behavior change by clinicians whose patients had an increase in patient activation.
Methods:
This mixed methods study was conducted in collaboration with Fairview Health Services, a Pioneer Accountable Care Organization. We aggregated data on the change in patient activation measure (PAM) score for 7,144 patients to the primary care clinician level. We conducted in-depth interviews with 10 clinicians whose patients' score increases were among the highest and 10 whose patients' score changes were among the lowest. Transcripts of the interviews were analyzed to identify key strategies that differentiated the clinicians whose patients had top PAM change scores.
Results:
Clinicians whose patients had relatively large activation increases reported using 5 key strategies to support patient behavior change (mean = 3.9 strategies): emphasizing patient ownership; partnering with patients; identifying small steps; scheduling frequent follow-up visits to cheer successes, problem solve, or both; and showing caring and concern for patients. Clinicians whose patients had lesser change in activation were far less likely to describe using these approaches (mean = 1.3 strategies). Most clinicians, regardless of group, reported developing their own approach to support patient behavior change. Those whose patients showed high activation change reported spending more time with patients on counseling and education than did those whose patients showed less improvement in activation.
Conclusions:
Clinicians vary in the strategies they use to promote behavior change and in the time spent with patients on such activities. The 5 key strategies used by clinicians with high patient activation change are promising approaches to supporting patient behavior change that should be tested in a larger sample of clinicians to validate their effectiveness.
... The variability and delays following PCI activation may also be affected by the substantial investment needed to coordinate patient care with EMS, a complex, yet necessary activity among high performing health systems. 22 Delays associated with EMS deployment time may affect the reliability and time to response at transferring EDs. The substantial differences in the structure and performance of EMS systems of STEMI care in the U.S. may also inhibit optimal performance. ...
... Multiple strategies hold promise. For example, activating EMS transportation prior to PCI center activation, 24 using the 911 system to transfer patients, 25 using operations research tools to enhance the operational flexibility of the ED, 26,27 enhancing regionalization efforts to reduce EMS response times, 28,29 standardizing the initial interaction with EMS (eg, patient staying on the stretcher), 24 enhancing hospital-EMS relationships, 22 and appropriate use of ground-based (rather than helicopter) EMS. 19,20 Reducing variability at referring EDs may also be complicated by fewer STEMIs being seen in U.S. EDs. ...
Most US hospitals lack primary percutaneous coronary intervention (PCI) capabilities to treat patients with ST-elevation myocardial infarction (STEMI) necessitating transfer to PCI-capable centers. Transferred patients rarely meet the 120-minute benchmark for timely reperfusion, and referring emergency departments (EDs) are a major source of preventable delays. We sought to use more granular data at transferring EDs to describe the variability in length of stay at referring EDs.
We retrospectively analyzed a secondary data set used for quality improvement for patients with STEMI transferred to a single PCI center between 2008 and 2012. We conducted a descriptive analysis of the total time spent at each referring ED (door-in-door-out [DIDO] interval), periods that comprised DIDO (door to electrocardiogram [EKG], EKG-to-PCI activation, and PCI activation to exit), and the relationship of each period with overall time to reperfusion (medical contact-to-balloon [MCTB] interval).
We identified 41 EDs that transferred 620 patients between 2008 and 2012. Median MCTB was 135 minutes (interquartile range [IQR] 114,172). Median overall ED DIDO was 74 minutes (IQR 56,103) and was composed of door to EKG, 5 minutes (IQR 2,11); EKG-to-PCI activation, 18 minutes (IQR 7,37); and PCI activation to exit, 44 minutes (IQR 34,56). Door-in door-out accounted for the largest proportion (60%) of overall MCTB and had the largest variability (coefficient of variability, 1.37) of these intervals.
In this cohort of transferring EDs, we found high variability and substantial delays after EKG performance for patients with STEMI. Factors influencing ED decision making and transportation coordination after PCI activation are a potential target for intervention to improve the timeliness of reperfusion in patients with STEMI.
Copyright © 2015 Elsevier Inc. All rights reserved.
... Previous research has identified hospital strategies that have been associated with lower hospital RSMRs and has highlighted key features of organizational culture that are prominent among hospitals with top performance as measured by RSMR [5][6][7][8]. Although the presence of these strategies and features of organizational cultural were somewhat limited in 2010, substantial efforts have been made nationally to improve quality, particularly in the wake of public reporting on 30-day mortality rates after AMI [9]. ...
... Several hospital strategies associated with lower AMI RSMR in previous research highlight room for further improvement, with levels of adoption under 60% at baseline and at follow up. These strategies largely pertained to inpatient care including having both physician and nurse champions focused on improving AMI mortality [5,10], having cardiologists or cardiology fellows on site 24 hours a day, 7 days a week [5,11,12] (or among hospitals without such cardiologist coverage, having pharmacists round on all patients with AMI [5]), and having clinicians meet with EMS providers monthly for training and to review AMI care [5,8,13]. Notably, these strategies are complex interventions that require coordination among units or organizations, and in some cases require substantial investment by hospitals. ...
Survival rates after acute myocardial infarction (AMI) vary markedly across U.S. hospitals. Although substantial efforts have been made to improve hospital performance, we lack contemporary evidence about changes in hospital strategies and features of organizational culture that might contribute to reducing hospital AMI mortality rates. We sought to describe current use of several strategies and features of organizational culture linked to AMI mortality in a national sample of hospitals and examine changes in use between 2010 and 2013.
We conducted a cross-sectional survey of 543 hospitals (70% response rate) in 2013, and longitudinal analysis of a subsample of 107 hospitals that had responded to a survey in 2010 (67% response rate).
Between 2010 and 2013, the use of many strategies increased, but the use of only two strategies increased significantly: the percentage of hospitals providing regular training to Emergency Medical Service (EMS) providers about AMI care increased from 36% to 71% (P-value < 0.001) and the percentage of hospitals using computerized assisted physician order entry more than doubled (P-value < 0.001). Most, but not all, hospitals reported having environments conducive to communication, coordination and problem solving.
We found few significant changes between 2010 and 2013 in hospital strategies or in key features of organizational culture that have been associated with lower AMI mortality rates. Findings highlight several opportunities to help close remaining performance gaps in AMI mortality among hospitals.
... Proper first aid training, basic life support tools (e.g., AEDs, eyewash stations), and specialized equipment can save lives [34]. Collaboration with external responders improves triage and treatment [35]. Table 3 highlights key immediate-response actions. ...
This review aims to provide a general resource for occupational health stakeholders. It also serves as a clinical guide for frontline providers and a policy framework for employers and regulators. Medical and surgical emergencies in occupational settings can cause serious harm if not identified and managed early. This review covers trauma, chemical exposures, thermal injuries, respiratory distress, and infectious hazards. We outline clinical signs, diagnostic steps, initial care, and follow-up plans. We also discuss preventive strategies such as hazard assessments and safety protocols. Evidence-based guidelines and practical methods can lower injury and death rates. Our objective is to help stakeholders recognize risks, respond fast, and improve outcomes. Future studies should monitor and examine new threats, such as novel industrial processes and evolving pathogens, to optimize workplace safety.
... This study aims to investigate and compare the current level of EMSrelated knowledge between emergency medicine resident physicians and residents of other specialties that regularly interact with EMS. As per the Accreditation Council for Graduate Medical Education (ACGME), EMS is a core competency of emergency medicine, and documented experience with EMS is required for the completion of an emergency medicine residency [3]. However, this is not a requirement for the other specialties included in this study; hence, it was hypothesized that emergency medicine residents would have a greater understanding and knowledge related to EMS than residents of other specialties due to this EMS education requirement. ...
Background and objective
Emergency medical services (EMS) are often assumed to only involve bringing patients to physicians for treatment in the emergency department. However, EMS staff are also responsible for responding to physicians in the primary care setting when medical emergencies arise. While emergency medicine (EM) residents are exposed to EMS as part of their curriculum, little is known about the knowledge of other resident physicians who may interact with EMS. In light of this, we conducted this study to address the scarcity of data related to this topic.
Methods
A quantitative cross-sectional knowledge assessment was conducted among resident physicians in emergency medicine, internal medicine, family medicine, pediatric, and combined medicine and pediatric residencies at the Penn State Milton S. Hershey Medical Center.
Results
Eighteen EM residents and 26 non-EM residents completed the assessment. The EM residents had a higher average score when compared to non-emergency medicine residents (69.2% vs. 53.8%, p=0.0012).
Conclusion
Variations in scores between EM and other specialties that interact with EMS highlight the need for further training and familiarization related to EMS for residents in non-EM specialties.
... A retrospective study showed that the HINTS exam was wrongly any (McClelland et al., 2017). It has also been shown that high-performing hospitals with low mortality rates from acute MI have close collaborative relationships with EMS, investing in 'bi-directional communication' to learn from cases and discuss potential improvements (Landman et al., 2013). Investing in something similar for stroke patients may yield similar improvements. ...
Introduction: The main pre-hospital screening tool used for stroke in Ireland and the United Kingdom is the FAST (face, arms, speech, time) test. However, posterior circulation stroke (PCS) patients may be FAST negative on exam, presenting with sudden dizziness, headaches, visual problems, nausea and vomiting and balance/co-ordination problems. There is a lack of research into paramedic recognition of PCS, and this study sought to evaluate recognition rates among paramedics (Ps) and advanced paramedics (APs) in Ireland.
Methods: A cross-sectional sequential exploratory design was chosen. An anonymous online survey was carried out, which informed focus group discussions. The survey contained six clinical vignettes, two of which were PCS presentations. Correct diagnosis, hospital destination and type of pre-alert were recorded. Focus groups were chaired by an independent moderator via Zoom. Recordings were transcribed and thematic analysis was carried out to create codes and themes.
Results: One hundred and fifty-one staff members (91 Ps, 60 APs) completed the survey (response rate 40%). Of these, 67% did not recognise PCS symptoms and 77% did not choose to transport to a stroke unit. For those correctly suspecting PCS, 42% requested resus at the stroke unit and 18% requested resus in the local emergency department (ED). Two focus groups of four practitioners (n = 8) took place. Three main themes were created: (1) comfort levels with posterior stroke, with subthemes of recognition and personal experiences; (2) education, with subthemes of clinical practice guideline (CPG) issues and training issues; and (3) hospital factors, with subthemes of pre-alerting and disconnect between hospital and emergency medical services. Participants were uncomfortable with PCS recognition and bypassing their local ED. More training was called for, with a dedicated CPG. Relationships with hospital staff affected willingness to pre-alert.
Conclusions: In this sample group, recognition of PCS and onward transfer to a stroke unit was low. Focus groups showed that practitioners were uncomfortable recognising PCS and bypassing a local ED without adequate training and a dedicated CPG. Relationships with hospital staff also affected pre-alert decisions.
... In Taylor & al. 's [1] systematic review study of factors and strategies associated with high performing hospitals, trustful relationships was found to be one of the more important factors. High performing hospitals demonstrated respectful and valued relations between staff members [3,4]. ...
Background
Trustful relationships play a vital role in successful organisations and well-functioning hospitals. While the trust relationship between patients and providers has been widely studied, trust relations between healthcare professionals and their supervisors have not been emphasised. A systematic literature review was conducted to map and provide an overview of the characteristics of trustworthy management in a hospital setting.
Methods
We searched Web of Science, Embase, MEDLINE, APA PsycInfo, CINAHL, Scopus, EconLit, Taylor & Francis Online, SAGE Journals and Springer Link from database inception up until Aug 9, 2021. Empirical studies written in English undertaken in a hospital or similar setting and addressed trust relationships between healthcare professionals and their supervisors were included, without date restrictions. Records were independently screened for eligibility by two researchers. One researcher extracted the data and another one checked the correctness. A narrative approach, which involves textual and tabular summaries of findings, was undertaken in synthesising and analysing the data. Risk of bias was assessed independently by two researchers using two critical appraisal tools. Most of the included studies were assessed as acceptable, with some associated risk of bias.
Results
Of 7414 records identified, 18 were included. 12 were quantitative papers and 6 were qualitative. The findings were conceptualised in two categories that were associated with trust in management, namely leadership behaviours and organisational factors. Most studies (n = 15) explored the former, while the rest (n = 3) additionally explored the latter. Leadership behaviours most commonly associated with employee’s trust in their supervisors include (a) different facets of ethical leadership, such as integrity, moral leadership and fairness; (b) caring for employee’s well-being conceptualised as benevolence, supportiveness and showing concern and (c) the manager’s availability measured as being accessible and approachable. Additionally, four studies found that leaders’ competence were related to perceptions of trust. Empowering work environments were most commonly associated with trust in management.
Conclusions
Ethical leadership, caring for employees’ well-being, manager’s availability, competence and an empowering work environment are characteristics associated with trustworthy management. Future research could explore the interplay between leadership behaviours and organisational factors in eliciting trust in management.
... Es erscheint daher empfehlenswert, dass Primärkliniken Prozessänderungen erwägen, die eine strukturiertere prähospitale Ankündigung und ein persönliches Gespräch zwischen Rettungsdienstmitarbeitenden und zuständigen Ärzt*innen ermöglichen. Dies könnte durch gemeinsame Fallbesprechungen oder Fortbildungen unterstützt werden [10]. Zusätzlich sollte bei Implementierung neuer (digitaler) Systeme berücksichtigt werden, dass diese ausreichend in den Klinikalltag integriert werden, damit sie nicht disruptiv sind. ...
Background:
In stroke networks, hospitals that do not provide thrombectomy (referring hospitals) refer patients to specialized hospitals (receiving hospitals) for this specific intervention. In order to improve the access and management of thrombectomy, the focus of research needs to be not only on the receiving hospitals but also on the prior stroke care pathways in referring hospitals.
Objective:
The purpose of this study was to investigate the stroke care pathways in different referring hospitals as well as the advantages and disadvantages associated with these pathways.
Methods:
A qualitative multicenter study was carried out in three referring hospitals of a stroke network. Stroke care was assessed and analyzed by using non-participant observations and 15 semi-structured interviews with employees in various health professions.
Results:
The following aspects were reported as advantageous within the stroke care pathways: (1) a structured and personal prenotification of the patient by the emergency medical service (EMS) members; (2) a more efficiently organized teleneurology workflow; (3) the provision of the secondary referral to thrombectomy by the same EMS members of the primary referral and (4) the integration of external neurologists into in-house structures.
Conclusion:
The study provides insights into different stroke care pathways of three different referring hospitals of a stroke network. The results can be used to derive potentials for improvement of other referring hospitals; however, this study is too small to provide reliable information about their potential effectiveness. Future studies should investigate whether implementation of these recommendations actually leads to improvements and under which conditions they are successful. To ensure patient-centeredness, the perspectives of patients and relatives should also be included.
... Based on the clinical care approaches, the emergency care formulates targeted care and treatment measures according to the AMI patients' conditions, which actively stimulates the medical staff's initiative, saves the lives of patients to the greatest extent from the perspective of the patients, and completes the first aid task with high quality [17]. In this study, the effects of routine care and emergency care in AMI were compared. ...
Objective:
To evaluate the effect of emergency care on the mental health and recovery of limb function in myocardial infarction (MI) patients.
Methods:
We recruited 106 MI patients consecutively admitted to the emergency center of our hospital from June, 2016 to January, 2019. Among them, 51 underwent routine care (the control group) and 55 underwent emergency care (the observation group). The rescue success rates, the pre-hospital times, the emergency rescue times, and the door-to-balloon times were recorded and compared. The patients' heart rates, respiratory frequencies, and blood pressure levels were monitored after the care. The self-rating anxiety scale (SAS) and the self-rating depression scale (SDS) were used to evaluate the patients' psychological states. The patients' limb function and activities of daily living (ADL) were evaluated using the Fugl-Meyer assessment (FMA) and the modified Barthel index (MBI), respectively. The incidences of complications were compared between the two groups. The Short-Form 36 Item Health Survey (SF-36) was used to evaluate the patients' quality of life (QOL), and a self-made satisfaction questionnaire was developed to evaluate the patient satisfaction.
Results:
After the emergency care, there was a higher rescue success rate and shorter pre-hospital times, emergency rescue times, and door-to-balloon times in the observation group. The heart rates, respiratory frequencies, and blood pressure levels in the observation group were more stable than they were in the control group. The patients in the observation group had lower SAS and SDS scores (P<0.05), lower FMA and lower MBI (P<0.05), as well as a lower incidence of complications (P<0.05). The QOL was greatly improved in the observation group after two weeks of care. The patients in the observation group were more satisfied with the nursing service than the patients in the control group (P<0.05).
Conclusion:
Emergency care contributes to the improvement of mental health and limb function, as well as MI patient prognosis, so it is well worthy of promoting.
... Hospital systems must increasingly work with EMS agencies to form regional systems that can provide timely access to percutaneous coronary intervention. 40 It is important to address systemic barriers with teamwork, technology, and training and identify countermeasures for effective pre-hospital STEMI triage. Table 5 answers RQ3 by identifying various countermeasures for improving pre-hospital STEMI triage. ...
Residents in rural communities have a higher incidence of cardiac death and risk factors associated with cardiac disease. Living in a rural region can add precious time that amplifies cardiac death during an ST-elevated myocardial infarction (STEMI) episode. The consensus is that improved efficiencies can increase myocardial salvage and decrease STEMI mortality rates. This article identifies issues that may impact pre-hospital STEMI triage of patients in a rural region of the United States (U.S.). A qualitative research design was chosen to gain insight into emergency personnel perceptions of pre-hospital STEMI triage. The participants (n = 18) were obtained from a convenience sample in rural Northeast Texas, U.S. Data were gathered by individual and group semi-structured interviews. Themes were identified, synthesized, and oriented to offer a basis for understanding opportunities to improve the delivery of rural STEMI care. This study demonstrated that quality improvement initiatives aimed at achieving pre-hospital STEMI triage efficiencies have dependencies on teamwork, technology, and training in the context of 3 stages (a) pre-transport, (b) door-to-door, and (c) post-transport. A pre-hospital STEMI triage model is offered based on the findings. By incorporating this model, emergency medical coordinators in rural communities have a better opportunity to facilitate timely reperfusion therapy for this high-risk population.
... Trabalhar com um número menor de pacientes por profissional permitiu uma melhor visão do todo, possibilitou a visualização dos resultados do próprio trabalho e um diálogo com os pacientes para aliviar sua ansiedade, além disso, foi considerado menos estressante pelos profissionais(Frykman et al., 2014). Um quantitativo de profissionais com qualificação de pós-graduação, que tinham papéis bem definidos e que fossem alocados na função de líder da equipe propiciou o trabalho colaborativo(Grover et al., 2017).O bom relacionamento interprofissional foi identificado em quatro estudos(Landman et al., 2013;Grover et al., 2017; Chaves et al., 2018;Whalen et al., 2018). Manter boas relações de trabalho entre as equipes de emergência exigiu um compromisso persistente e investimento de tempo e recursos. ...
Objective: To identify the evidence available in the literature on the process of interprofessional collaboration between health teams of emergency services. Methodology: integrative review. The search for primary studies was performed in four relevant health databases, with a sample of 22 studies. Results: The synthesis of the primary articles originated two categories: a) Interprofessional collaboration: specific and shared attributions of professionals working in emergency services teams b) Facilitators and barriers to collaborative practical implementation in emergency services. Private and shared attributions of professionals working in emergency and emergency services, as well as intervening factors in interprofessional collaboration, such as: communication, physical structure, human resources and materials and professional experience were evidenced. Conclusion: interprofessional articulation is not easy to reach, because the professions are still very rooted in the knowledge of their field and with difficulties in promoting articulation.
... Additionally, further study will be needed to assess the financial feasibility of this and similar programs. Overall, it appears that when hospitals learn to collaborate effectively with their EMS partners, the effects are almost uniformly positive for patients (27). Proactive destination control is one such collaborative enterprise, and it is our hope that such programs will ultimately confer real-life benefits to patients and their families. ...
Background: Implemented in September 2017, the “nurse navigator program” identified the preferred ED destination within a single healthcare system using real-time assessment of hospital and emergency department (ED) capacity and crowding metrics. The primary objective of the navigator program was to improve load-balancing between two closely situated emergency departments, both of which feed into the same inpatient facilities of a single healthcare system. A registered nurse in the hospital command center made real-time recommendations to EMS providers via radio, identifying the preferred destination for each transported patient based on such factors as chief complaint, ED volume and waiting room census. The destination decision was made via the utilization of various real-time measures of health system capacity conjunction with existing protocols dictating campus-specific clinical service availability. The objective of this study was to evaluate the efficacy of this real-time ambulance destination direction program as reflected in changes to emergency medical services (EMS) turnaround time and the incidence of intercampus transports.
Methods: A before-and-after time series was performed to determine if program implementation resulted in a change in EMS turnaround time or incidence of intercampus transfers.
Results: Implementation of the nurse navigator program was associated with a statistically significant decrease in EMS turnaround times for all levels of dispatch and transport at both hospital campuses. Intercampus transfers also showed significant improvement following implementation of the intervention, though this effect lagged behind implementation by several months.
Conclusion: A proactive approach to EMS destination control using a nurse navigator with access to real-time hospital and ED capacity metrics appears to be an effective method of decreasing EMS turnaround time.
... Os resultados desta pesquisa são consistentes com o estudo de Landman et al. (2013) e Leever et al. (2010) ao mencionarem que os médicos que possuem respeito mútuo, confiança, profissionalismo e percebem a competência dos seus colegas, são mais dispostos a estabelecer contato e assegurar uma compreensão comum com outros profissionais da saúde. ...
O objetivo dessa pesquisa é evidenciar os motivadores no compartilhamento do conhecimento tácito, de acordo com a percepção de radiologistas integrantes de grupos de trabalhos de organizações intensivas em conhecimento. É uma pesquisa aplicada, com abordagem qualitativa e, ainda, descritiva. Como procedimento técnico para a sua realização, utilizou-se o estudo multicaso, tendo como universo de pesquisa três organizações intensivas em conhecimento de Santa Catarina. Para a coleta de dados utilizou-se a observação e entrevistas, procedendo à análise dos dados, orientada pela análise temática. Os resultados contribuem para o avanço da teoria existente e apontam que o quando o indivíduo percebe um ambiente favorável ao compartilhamento do conhecimento, onde é reconhecido pelo seu conhecimento, ele é motivado a compartilhar, pois identifica oportunidades de aprender ao discutir casos desafiadores com seus colegas por meio de práticas que são efetivas devido às características peculiares dos grupos e da percepção que os mesmos possuem da ação de compartilhar conhecimento tácito. Conclui-se que o feedback direto e práticas apropriadas, como revisão por pares, storytelling, mapa de conhecimentos e mentoring agem na criação de um comportamento recíproco de cooperação e pertencimento, favorecendo o compartilhamento de conhecimento tácito.
... Feedback to paramedics by the hospital team was considered important but was not compared against future health outcomes. 148 hospital staff involved with MI patients were interviewed about their relationship with EMS services [49] and those from high performing hospitals (upper 5% of hospitals based on 30-day standardised risk of mortality) described provision of feedback as important. Other strategies were a high level of respect for emergency medical services as valued professionals/colleagues; employing a hospital-based liaison to deliver training and facilitate communication between pre-hospital and in-hospital teams; and involvement of emergency medical services providers in care improvement initiatives. ...
Background
Ambulance paramedics play a critical role expediting patient access to emergency treatments. Standardised handover communication frameworks have led to improvements in accuracy and speed of information transfer but their impact upon time-critical scenarios is unclear. Patient outcomes might be improved by paramedics staying for a limited time after handover to assist with shared patient care. We aimed to categorize and synthesise data from studies describing development/extension of the ambulance-based paramedic role during and after handover for time-critical conditions (trauma, stroke and myocardial infarction). Methods
We conducted an electronic search of published literature (Jan 1990 to Sep 2016) by applying a structured strategy to eight bibliographic databases. Two reviewers independently assessed eligible studies of paramedics, emergency medical (or ambulance) technicians that reported on the development, evaluation or implementation of (i) generic or specific structured handovers applied to trauma, stroke or myocardial infarction (MI) patients; or (ii) paramedic-initiated care processes at handover or post-handover clinical activity directly related to patient care in secondary care for trauma, stroke and MI. Eligible studies had to report changes in health outcomes. ResultsWe did not identify any studies that evaluated the health impact of an emergency ambulance paramedic intervention following arrival at hospital. A narrative review was undertaken of 36 studies shortlisted at the full text stage which reported data relevant to time-critical clinical scenarios on structured handover tools/protocols; protocols/enhanced paramedic skills to improve handover; or protocols/enhanced paramedic skills leading to a change in in-hospital transfer location. These studies reported that (i) enhanced paramedic skills (diagnosis, clinical decision making and administration of treatment) might supplement handover information; (ii) structured handover tools and feedback on handover performance can impact positively on paramedic behaviour during clinical communication; and (iii) additional roles of paramedics after arrival at hospital was limited to ‘direct transportation’ of patients to imaging/specialist care facilities. Conclusions
There is insufficient published evidence to make a recommendation regarding condition-specific handovers or extending the ambulance paramedic role across the secondary/tertiary care threshold to improve health outcomes. However, previous studies have reported non-clinical outcomes which suggest that structured handovers and enhanced paramedic actions after hospital arrival might be beneficial for time-critical conditions and further investigation is required.
... Second, the list of system practices may be incomplete. Third, additional factors not captured in our survey -such as collaborative relationships between EMS agencies, STEMI referral hospitals, and STEMI receiving centers 13,14 and decision-making processes at the STEMI referral hospital 15 -may influence DIDO and first-DTB times. Finally, our sample size may have been insufficient to detect a more subtle relationship between system practices and DIDO and FIRST-DTB times. ...
Background:
Current guidelines suggest a "door-in-door-out" (DIDO) time of 30 minutes or shorter for patients with ST-segment elevation myocardial infarction (STEMI) who arrive at a STEMI referral hospital and are transferred to a STEMI-receiving center for primary percutaneous coronary intervention. Experts previously identified 18 system practices as critical for reducing DIDO times. The objective of this study was to describe how frequently these critical practices are used and to determine whether their use was associated with shorter DIDO times.
Methods:
We surveyed 18 STEMI referral hospitals for 4 STEMI-receiving centers regarding their use of these 18 practices. The median number used was 14 practices (interquartile range 12-15). We then evaluated their association with DIDO times in all patients (n = 93) transferred from these STEMI referral hospitals to the 4 STEMI-receiving centers for primary percutaneous coronary intervention.
Results:
In univariate linear regression analyses, system-wide quality improvement programs with leaders in the emergency medical services agencies and STEMI referral hospitals were associated with shorter DIDO times (P < 0.001 for all). Overall use of system practices was not associated with DIDO times (P = 0.143). The majority (76%, 95% confidence interval: 66%-85%) of DIDO times did not meet the 30-minute goal.
Conclusions:
These findings highlight the difficulty in achieving the 30-minute DIDO goal and the need for continued focus on strategies for reducing DIDO time, including system-wide quality improvement programs.
... 12 Other factors such as hospital culture, organizational structure, and collaboration across providers may explain more of the variation. [27][28][29][30][31] This study has several limitations. First, we applied several patient and hospital exclusion criteria in this study to calculate risk-standardized mortality rates. ...
Background
Thirty-day risk-standardized mortality rates after acute myocardial infarction are commonly used to evaluate and compare hospital performance. However, it is not known whether differences among hospitals in the early survival of patients with acute myocardial infarction are associated with differences in long-term survival.
Methods
We analyzed data from the Cooperative Cardiovascular Project, a study of Medicare beneficiaries who were hospitalized for acute myocardial infarction between 1994 and 1996 and who had 17 years of follow-up. We grouped hospitals into five strata that were based on case-mix severity. Within each case-mix stratum, we compared life expectancy among patients admitted to high-performing hospitals with life expectancy among patients admitted to low-performing hospitals. Hospital performance was defined by quintiles of 30-day risk-standardized mortality rates. Cox proportional-hazards models were used to calculate life expectancy.
Results
The study sample included 119,735 patients with acute myocardial infarction who were admitted to 1824 hospitals. Within each case-mix stratum, survival curves of the patients admitted to hospitals in each risk-standardized mortality rate quintile separated within the first 30 days and then remained parallel over 17 years of follow-up. Estimated life expectancy declined as hospital risk-standardized mortality rate quintile increased. On average, patients treated at high-performing hospitals lived between 0.74 and 1.14 years longer, depending on hospital case mix, than patients treated at low-performing hospitals. When 30-day survivors were examined separately, there was no significant difference in unadjusted or adjusted life expectancy across hospital risk-standardized mortality rate quintiles.
Conclusions
In this study, patients admitted to high-performing hospitals after acute myocardial infarction had longer life expectancies than patients treated in low-performing hospitals. This survival benefit occurred in the first 30 days and persisted over the long term. (Funded by the National Heart, Lung, and Blood Institute and the National Institute of General Medical Sciences Medical Scientist Training Program.)
... The method was developed in the global health arena, and it is increasingly being used for quality improvement related-research in the United States. [27][28][29][30] The positive deviance process involves several steps. Initially quantitative data is used to identify top performers on specific performance measures and often on a comparator group of average or low performers. ...
Background:
Primary care provider (PCP) support of patient self-management may be important mechanism to improving patient health outcomes. In this paper we develop a PCP-reported measure of clinician strategies for supporting patient self-management, and we psychometrically test and validate the measure.
Methods:
We developed survey items based upon effective self-management support strategies identified in a prior mixed methods study. We fielded a survey in the fall of 2014 with 139 Fairview Health Services PCPs, and conducted exploratory factor analysis and Cronbach's Alpha to test for scale reliability. To validate the measure, we examined the Self-Management Support (SMS) scale's relationship to survey items on self-management support, as well as clinicians' patient panel rates of smoking cessation and weight loss.
Results:
Nine survey items clustered reliably to create a single factor (Cronbach's Alpha=0.73). SMS scores ranged from 2.1 to 4.9. The SMS was related to each of the validation variables. PCPs who reported spending 60% percent or more of their time counseling, educating, and coaching patients had a mean SMS score of 4.0, while those who reported spending less than 30% of their time doing so had mean SMS scores 15% lower. PCPs' SMS scores exhibited significant but modest associations with their patients' smoking cessation and weight loss (among obese patients) (r=0.21 and r=0.13 respectively).
Conclusions:
This study develops and tests a promising measure of PCPs' strategies to support patient self-management. It highlights variation across PCPs. Future work should examine whether increasing scores of PCPs low on the SMS improves chronic care quality outcomes.
... Given the importance of paramedic to nurse interaction during times such as clinical handover (1,6,23,24), it is critical that practitioners develop strong communication skills and interprofessional relationships early, ideally during undergraduate education (26). Where do these good interprofessional communication skills originate and how are they fostered? ...
p> Introduction
The literature emphasises the vital importance of interprofessional communication during clinical handover as being paramount to patient safety. At Charles Sturt University we explored how simulation can be employed in an interprofessional education (IPE) exercise exposing paramedic and nursing students to a high-pressure emergency department wherein they must engage in patient handover.
Methods
Over a 4-day period in April 2012, 200 paramedic and nursing students participated in an intensive simulation exercise where they practised interprofessional communication. The project team subsequently debriefed all student and staff members to gain insight through the participants’ experiences.
Results
Our results demonstrated that students become more comfortable interacting and communicating with other team members during scenarios. In addition to experiencing first hand that IPE is an effective tool for developing communication skills, we determined that this could be successfully facilitated in a large-scale simulated IPE to help students develop a shared understanding between disciplines.
Conclusion
Academics can work horizontally across disciplines to employ IPE in simulation as an educational tool to teach vital communication skills; and with paramedicine now being taught alongside nursing in tertiary centres, universities are well positioned to support collaborative interprofessional practice and communication. </p
... Only a few studies explicitly define positively deviant behaviours as being 'deviant' or going against cultural norms. [30][31][32] 'Positive deviance inquiries focus on individuals who behave differently from the rest of the community and, in so doing, succeed where others fail' (ref. 11, p.1413) 'The group that faces the problem determines the desired outcome; identifies the most effective behaviours, resources, and actions; and searches for the best solutions using unique strategies' (ref. ...
Background The positive deviance approach focuses on those who demonstrate exceptional performance, despite facing the same constraints as others. ‘Positive deviants’ are identified and hypotheses about how they succeed are generated. These hypotheses are tested and then disseminated within the wider community. The positive deviance approach is being increasingly applied within healthcare organisations, although limited guidance exists and different methods, of varying quality, are used. This paper systematically reviews healthcare applications of the positive deviance approach to explore how positive deviance is defined, the quality of existing applications and the methods used within them, including the extent to which staff and patients are involved.
Methods Peer-reviewed articles, published prior to September 2014, reporting empirical research on the use of the positive deviance approach within healthcare, were identified from seven electronic databases. A previously defined four-stage process for positive deviance in healthcare was used as the basis for data extraction. Quality assessments were conducted using a validated tool, and a narrative synthesis approach was followed.
Results 37 of 818 articles met the inclusion criteria. The positive deviance approach was most frequently applied within North America, in secondary care, and to address healthcare-associated infections. Research predominantly identified positive deviants and generated hypotheses about how they succeeded. The approach and processes followed were poorly defined. Research quality was low, articles lacked detail and comparison groups were rarely included. Applications of positive deviance typically lacked staff and/or patient involvement, and the methods used often required extensive resources.
Conclusion Further research is required to develop high quality yet practical methods which involve staff and patients in all stages of the positive deviance approach. The efficacy and efficiency of positive deviance must be assessed and compared with other quality improvement approaches.
PROSPERO registration number CRD42014009365.
... No one would argue that cardiologists should not play a central role in the evaluation of chest pain after PCI. Furthermore, collaborating with emergency medicine physicians on this issue builds on the relationships and past successes of efforts to reduce door-to-balloon times, 14,15 and these efforts may, in turn, promote additional collaborative efforts to reduce readmissions more broadly. ...
Is it too early to call this the Readmission Decade? Readmissions are on everybody’s mind—identifying readmissions, preventing readmissions, considering the financial repercussions of having too many readmissions, lamenting the injustice of being held accountable for readmissions. Only time will tell whether this is a passing storm or here to stay, but for the moment the issue of readmissions is having its moment in the sun.
Article see p 97
Prior research has shown that a substantial proportion of patients undergoing percutaneous coronary intervention (PCI) are readmitted to the hospital within 30 days of discharge, ranging from 8% to 16%.1–7 Early readmissions are often unplanned and potentially preventable events that are associated with increased 30-day and 1-year mortality.2,6,8,9 To date, however, the interventional community at large has not had to fully engage in efforts to prevent unplanned readmission. Although many of the heart failure and acute myocardial infarction patients included in the publicly reported hospital readmission measures10,11 undergo PCIs, we have for the most part avoided being held accountable for readmissions after PCI. That privileged position may be in jeopardy, as recent events make it unlikely we will be able to remain above the fray much longer.
In December 2013, the Centers for Medicare and Medicaid Services began publicly reporting what …
... A s far back as 1973, the Emergency Medical Services Systems Act (EMSSA) defined "access to care" as one of the 15 core areas of emergency medical services (EMS) systems, recognizing the important role of EMS, both ground and air, in providing transport to definitive care. 1 Rapid, evidence-based emergency intervention has since been shown to reduce morbidity and mortality in time-sensitive conditions, such as acute myocardial infarction, stroke, and trauma. 2 EMS providers are critically important for quickly recognizing these conditions, administering initial treatment, and rapidly transporting patients to the most appropriate receiving centers. 3,4 A 2006 Institute of Medicine report on the future of emergency care noted widespread fragmentation and limited regional coordination of patients transported to the optimal, ready facility; it recommended more integrated, coordinated, and regionalized prehospital care. 5 To meet these objectives, EMS resources must be allocated and available to serve patients in all geographic areas and be held accountable for performance. ...
... This can be partially explained by the following: First, a higher number of cardiologists are likely to improve communication and coordination among themselves and with other staff, which may result in better quality of care and a reduction in mortality [7]. Furthermore, hospitals with more cardiologists have been shown to be more likely to support collaborations with emergency medical services and to have a system offering round-the-clock care to patients with acute diseases [10]. ...
... Within the past few years, the studies supported by AHRQ's grant mechanisms have addressed a wide area of topics of importance to emergency medicine, including the racial composition of hospital service area and the use of ambulance diversion, 3 transfer from the ED to the ICU, 4,5 differences in care provided to patients with joint dislocation in the ED across racial and ethnic groups, 6 treatment of pediatric syncope, 7 differential mortality in injured patients treated in Level I and II trauma centers, the exchange of electronic information between 580 Annals of Emergency Medicine Volume 63, no. 5 : May 2014 poison control centers and EDs, 8 the association between the occurrence of preventable medical errors and ED crowding, 9 the use of evidence-based care for injured patients, 10,11 and the association between availability of patient information in an electronic health record and treatment intensity and outcomes for heart failure patients seen in the ED. 12 In recognition of the effect that care delivered in the out-of-hospital environment can have on patient safety, costs, and outcomes, AHRQ has also invested in EMS research. Recent AHRQ-funded studies have demonstrated that high-performing hospitals collaborate closely with EMS professionals in the care of patients with acute myocardial infarction, 13 suggested strategies for the discovery of medical errors in the out-of-hospital setting, 14 examined the safety of using fentanyl in adult trauma patients, 15 and identified the characteristics of EMS systems that chose to participate in the Cardiac Arrest Registry to Enhance Survival. 16 ...
Objective:
Emergency Medical Services (EMS) clinicians desire performance feedback (PF) and patient outcome follow-up (POF). Within our agency, both a peer-review and feedback/outcome (PF/POF) process exist. Our objective was to determine whether receiving feedback and outcome data improved future clinical care amongst EMS, based upon peer-review scores.
Methods:
This retrospective cohort study took place between 1/1/2020 and 6/7/2023 within an EMS agency site with 22,000 average annual 9-1-1 calls. Requests for PF/POF were submitted on an individual basis beginning June 2020 and completed by a dedicated EMS nurse, EMS physician, or emergency medicine (EM) resident. Peer-review of select high-acuity cases were scored by two Quality Assurance (QA) specialists within the categories of assessment, treatment, disposition/outcome and process/administrative guidelines. Association between overall peer-review score and number of PF/POF requests at time of assessment was evaluated by linear regression.
Results:
A total of 378 PF/POF requests were received, with the most common patient complaints being cardiac (n = 105; 27.8%, including 49 (13.0%) out of hospital cardiac arrests), altered mental status/neurologic (n = 103; 27.2%), trauma (n = 61; 16.1%, including 2 (0.5%) traumatic arrests); and respiratory distress (n = 47; 12.4%). A total of 378 runs meeting QA criteria were peer-reviewed post-PF/POF process implementation, including 337 (89.2%) cardiac/respiratory arrests, 27 (7.1%) with difficult airway management, and 14 (3.7%) major trauma/traumatic arrests. The number of prior PF/POF requests made by the team leader was associated with higher overall peer-review scores. Team leaders with >5 prior PF/POF requests had a peer-review score 0.39 points greater (95% CI: 0.16 - 0.62, p = 0.001) than those with <5 prior requests. The number of prior PF/POF requests amongst the entire crew was also associated with higher peer-review scores. Crews that collectively had >5 prior PF/POF requests had an increase in peer-review score 0.32 points greater (95% CI: 0.14 - 0.50, p < 0.001) than those with <5 prior requests.
Conclusion:
Providing performance feedback and patient outcome follow-up to EMS is associated with improved peer-review scores of clinical performance. Future studies should assess if those that are submitting cases for feedback/outcome are higher performers at baseline or if the process of receiving feedback/outcome improves their performance.
Background
Quality has been a persistent challenge in the healthcare system, particularly in resource-limited settings. As a result, the utilization of innovative approaches is required to help countries in their efforts to enhance the quality of healthcare. The positive deviance (PD) approach is an innovative approach that can be utilized to improve healthcare quality. The approach assumes that solutions to problems are already available within the community and identifying and sharing those solutions can help others to resolve existing issues. Therefore, this scoping review aimed to synthesize the evidence regarding the use of the PD approach in healthcare system service delivery and quality improvement programs.
Methods
Articles were retrieved from six international databases. The last date for article search was June 02, 2023, and no date restriction was applied. All articles were assessed for inclusion through a title and/or abstract read. Then, articles that passed the title and abstract review were screened by reading their full texts. In case of duplication, only the full-text published articles were retained. A descriptive mapping and evidence synthesis was done to present data with the guide of the Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for Scoping Reviews checklist and the results are presented in text, table, and figure formats.
Results
A total of 125 articles were included in this scoping review. More than half, 66 (52.8%), of the articles were from the United States, 11(8.8%) from multinational studies, 10 (8%) from Canada, 8 (6.4%) from the United Kingdom and the remaining, 30 (24%) are from other nations around the world. The scoping review indicates that several types of study designs can be applied in utilizing the PD approach for healthcare service and quality improvement programs. However, although validated performance measures are utilized to identify positive deviants (PDs) in many of the articles, some of the selection criteria utilized by authors lack clarity and are subject to potential bias. In addition, several limitations have been mentioned in the articles including issues in operationalizing PD, focus on leaders and senior managers and limited staff involvement, bias, lack of comparison, limited setting, and issues in generalizability/transferability of results from prospects perspective. Nevertheless, the limitations identified are potentially manageable and can be contextually resolved depending on the nature of the study. Furthermore, PD has been successfully employed in healthcare service and quality improvement programs including in increasing surgical care quality, hand hygiene practice, and reducing healthcare-associated infections.
Conclusion
The scoping review findings have indicated that healthcare systems have been able to enhance quality, reduce errors, and improve patient outcomes by identifying lessons from those who exhibit exceptional practices and implementing successful strategies in their practice. All the outcomes of PD-based research, however, are dependent on the first step of identifying true PDs. Hence, it is critical that PDs are identified using objective and validated measures of performance as failure to identify true PDs can subsequently lead to failure in identifying best practices for learning and dissemination to other contextually similar settings.
Introduction
Planning adequate nurse staffing in the emergency department (ED) is challenging. Although there are models to determine nurse staffing in EDs, these models do not consider all the factors. Inadequate nurse staffing causes overcrowding, poor quality of patient care, increased hospital costs, poor patient outcomes and high levels of burnout amongst nurses. In this paper, we report stakeholders’ perceptions of important factors to be considered when planning ED nursing ratios.
Methods
We applied a consensus research design. The data was generated from modified nominal group techniques followed by an e-Delphi with two rounds. The factors were generated during two nominal groups by 19 stakeholders which included management and healthcare professionals working in EDs. The generated factors were then put on a survey format for use in an e-Delphi. Using purposive and snowball sampling the survey was distributed to 74 national and international experts for consensus.
Results
Ultimately, 43 experts agreed (a validity index of ≥ 80%) on four categories namely: hospital, staff, patient and additional categories which included 17 related factors.
Conclusion
Ideal nurse staffing ratios are influenced by the complexity of the environment and interactions between multiple factors. The categories and factors identified emphasised the need for extensive further research to ensure a financially viable model that will be accepted by both staff and patient, and thus promote optimal outcomes.
Introduction
Out-of-hospital cardiac arrest (OHCA) is a common, life-threatening event encountered routinely by first responders, including police, fire and emergency medical services (EMS). Current literature suggests that there is significant regional variation in outcomes, some of which may be related to modifiable factors. Yet, there is a persistent knowledge gap regarding strategies to guide quality improvement efforts in OHCA care and, by extension, survival. The Enhancing Prehospital Outcomes for Cardiac Arrest (EPOC) study aims to fill these gaps and to improve outcomes.
Methods and analysis
This mixed-methods study includes three aims. In aim I, we will define variation in OHCA survival to the emergency department (ED) among EMS agencies that participate in the Michigan Cardiac Arrest Registry to Enhance Survival (CARES) in order to sample EMS agencies with high-survival and low-survival outcomes. In aim II, we will conduct site visits to emergency medical systems—including 911/dispatch, police, non-transport fire, and EMS agencies—in approximately eight high-survival and low-survival communities identified in aim I. At each site, key informant interviews and a multidisciplinary focus group will identify themes associated with high OHCA survival. Transcripts will be coded using a structured codebook and analysed through thematic analysis. Results from aims I and II will inform the development of a survey instrument in aim III that will be administered to all EMS agencies in Michigan. This survey will test the generalisability of factors associated with increased OHCA survival in the qualitative work to ultimately build an EPOC Toolkit which will be distributed to a broad range of stakeholders as a practical ‘how-to’ guide to improve outcomes.
Ethics and dissemination
The EPOC study was deemed exempt by the University of Michigan Institutional Review Board. Findings will be compiled in an ‘EPOC Toolkit’ and disseminated in the USA through partnerships including, but not limited to, policymakers, EMS leadership and health departments.
Objective
To identify modifiers of emergency medical services (EMS) oversight quality, including facilitators and barriers, and inform best practices and policy related to EMS oversight and system performance.
Methods
We used a qualitative design, including 4 focus groups and 10 in-depth, 1-on-1 interviews. Primary data were collected from EMS stakeholders in Michigan from June to July 2016. Qualitative data were analyzed using the rapid assessment technique.
Results
Emergent themes included organizational structure, oversight and stakeholder leadership, interorganizational communication and relationships, competition or collaboration among MCA stakeholders, quality improvement practices, resources, and needs specific to rural communities.
Conclusions
EMS is a critical component of disaster response. This study revealed salient themes and modifiers, including facilitators and barriers, of EMS oversight quality. These findings were evaluated in the context of current evidence and informed state policy to improve the quality of EMS oversight and prehospital care for both routine and disaster settings. Some were particular to geographic regions and communities, whereas others were generalizable.
Background
Identifying characteristics associated with struggling healthcare organisations may help inform improvement. Thus, we systematically reviewed the literature to: (1) Identify organisational factors associated with struggling healthcare organisations and (2) Summarise these factors into actionable domains.
Methods
Systematic review of qualitative studies that evaluated organisational characteristics of healthcare organisations that were struggling as defined by below-average patient outcomes (eg, mortality) or quality of care metrics (eg, Patient Safety Indicators). Searches were conducted in MEDLINE (via Ovid), EMBASE, Cochrane Library, CINAHL, and Web of Science from database inception through February 8 2018. Qualitative data were analysed using framework-based synthesis and summarised into key domains. Study quality was evaluated using the Critical Appraisal Skills Program tool.
Results
Thirty studies (33 articles) from multiple countries and settings (eg, acute care, outpatient) with a diverse range of interviewees (eg, nurses, leadership, staff) were included in the final analysis. Five domains characterised struggling healthcare organisations: poor organisational culture (limited ownership, not collaborative, hierarchical, with disconnected leadership), inadequate infrastructure (limited quality improvement, staffing, information technology or resources), lack of a cohesive mission (mission conflicts with other missions, is externally motivated, poorly defined or promotes mediocrity), system shocks (ie, events such as leadership turnover, new electronic health record system or organisational scandals that detract from daily operations), and dysfunctional external relations with other hospitals, stakeholders, or governing bodies.
Conclusions
Struggling healthcare organisations share characteristics that may affect their ability to provide optimal care. Understanding and identifying these characteristics may provide a first step to helping low performers address organisational challenges to improvement.
Systematic review registration
PROSPERO: CRD42017067367.
Le travail collectif est un défi considérable pour les organisations de santé, en particulier les hôpitaux publics. La complexité des structures, la pluralité des mains qui agissent et la variabilité des pratiques médicales suggestionnent la pratique collaborative. Dans un tel contexte, il convient de se pencher sur les dimensions de la collaboration interprofessionnelle permettant l’unicité de l’activité médicale. Ce concept prend une importance particulière si l’on considère que la dispensation des services de santé appelle de plus en plus à un haut degré de coordination entre les différents professionnels. Ce travail de recherche analyse la concrétisation de la collaboration interprofessionnelle dans le cas d’un CHU moyennant une méthodologie qualitative. En se basant sur les travaux précurseurs de D’Amour (1997), cette présente thèse identifie les principales dimensions de la collaboration interprofessionnelle ainsi que leur lien d’'interdépendance.
Introduction
In a 2015 report, the Institute of Medicine (IOM; Washington, DC USA), now the National Academy of Medicine (NAM; Washington, DC USA), stated that the field of Emergency Medical Services (EMS) exhibits signs of fragmentation; an absence of system-wide coordination and planning; and a lack of federal, state, and local accountability. The NAM recommended clarifying what roles the federal government, state governments, and local communities play in the oversight and evaluation of EMS system performance, and how they may better work together to improve care.
Objective
This systematic literature review and environmental scan addresses NAM’s recommendations by answering two research questions: (1) what aspects of EMS systems are most measured in the peer-reviewed and grey literatures, and (2) what do these measures and studies suggest for high-quality EMS oversight?
Methods
To answer these questions, a systematic literature review was conducted in the PubMed (National Center for Biotechnology Information, National Institutes of Health; Bethesda, Maryland USA), Web of Science (Thomson Reuters; New York, New York USA), SCOPUS (Elsevier; Amsterdam, Netherlands), and EMBASE (Elsevier; Amsterdam, Netherlands) databases for peer-reviewed literature and for grey literature; targeted web searches of 10 EMS-related government agencies and professional organizations were performed. Inclusion criteria required peer-reviewed literature to be published between 1966-2016 and grey literature to be published between 1996-2016. A total of 1,476 peer-reviewed titles were reviewed, 76 were retrieved for full-text review, and 58 were retained and coded in the qualitative software Dedoose (Manhattan Beach, California USA) using a codebook of themes. Categorizations of measure type and level of application were assigned to the extracted data. Targeted websites were systematically reviewed and 115 relevant grey literature documents were retrieved.
Results
A total of 58 peer-reviewed articles met inclusion criteria; 46 included process, 36 outcomes, and 18 structural measures. Most studies applied quality measures at the personnel level (40), followed by the agency (28) and system of care (28), and few at the oversight level (5). Numerous grey literature articles provided principles for high-quality EMS oversight.
Conclusions
Limited quality measurement at the oversight level is an important gap in the peer-reviewed literature. The grey literature is ahead in this realm and can guide the policy and research agenda for EMS oversight quality measurement.
TaymourRK , AbirM , ChamberlinM , DunneRB , LowellM , WahlK , ScottJ . Policy, practice, and research agenda for Emergency Medical Services oversight: a systematic review and environmental scan .
This research studied a patient referral problem among multiple cooperative hospitals for sharing imaging services’ referrals. The proposed problem consisted of many types of patients and the uncertainty associated with the number of patients of each type, patients’ arrival time, and patients’ medical operation time, leading to a difficulty in finding solutions due to the uncertain environment. This research used system simulation to construct a model and develop a simulation optimization method, combining the heuristic algorithm (patient referral mechanism) with the particle swarm optimization (PSO) method, to determine a better way to refer patients from one hospital (referring hospital) to another (recipient hospital) to receive certain imaging services. After the simulated model was verified and validated, three patient referral mechanisms to dispatch referring patients to the appropriate recipient hospitals were proposed. Based on the numerical results, the findings showed that Mechanism 2, transferring patients to the hospital with the shortest waiting time, had good performance in both scenarios: allowing patient referrals among all hospitals and limiting the patients’ waiting time. Finally, this study presents the conclusions and some directions for future research.
Introduction:
Feedback to EMS professionals is a critical component for optimizing patient care and outcomes in the prehospital setting. There is a paucity of data concerning the feedback received by prehospital providers.
Objectives:
The objective of this study was to describe the prevalence of feedback received by EMS professionals in the past 30 days including the types, sources, modes, and utility of feedback. The secondary objective was to identify factors associated with receiving any feedback and, specifically, feedback regarding medical care provided.
Methods:
This was a cross-sectional survey examining currently practicing nationally certified EMS patient care providers (EMT or higher) in non-military and non-tribal settings. Data were collected on provider characteristics along with feedback received. Descriptive statistics were calculated, and multivariable logistic regression models were constructed to assess the relationship between EMS provider characteristics and receiving feedback. A non-respondent survey was administered to assess for non-response bias.
Results:
Responses from 32,314 EMS providers were received (response rate = 10.4%) with 15,766 meeting inclusion criteria. In the 30 days preceding the survey, 69.4% (n = 10,924) of respondents received at least one type of feedback with 54.7% (n = 8,592) reporting receiving medical care feedback. Multivariable logistic regression modeling indicated that higher certification level, fewer years of experience in EMS, working for a hospital-based agency, air medical service, and higher weekly call volumes were significantly associated with increased odds of having received at least one type of feedback, and specifically medical care feedback. Additionally, providing primarily medical/convalescent transport and more years of EMS experience were significantly associated with decreased odds of receiving feedback.
Conclusion:
Feedback to EMS providers is critical to improving prehospital care. In this study, nearly a third of providers did not receive any feedback in a 30-day period, and nearly half reported not receiving medical care feedback. Disparities in the frequency of feedback exist between different provider levels and service settings, while reported feedback decreased with years of experience in the profession. Future work is needed to assess the content of feedback and role in improving patient care and safety.
Dr. Becker has a relationship with Philips Medical Systems, National Institutes of Health, Zoll Medical Corporation, and Nihon Kohden. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Background
Electronic health records (EHRs), when linked across primary and secondary care and curated for research use, have the potential to improve our understanding of care quality and outcomes.
Objective
To evaluate new opportunities arising from linked EHRs for improving quality of care and outcomes for patients at risk of or with coronary disease across the patient journey.
Design
Epidemiological cohort, health informatics, health economics and ethnographic approaches were used.
Setting
230 NHS hospitals and 226 general practices in England and Wales.
Participants
Up to 2 million initially healthy adults, 100,000 people with stable coronary artery disease (SCAD) and up to 300,000 patients with acute coronary syndrome.
Main outcome measures
Quality of care, fatal and non-fatal cardiovascular disease (CVD) events.
Data platform and methods
We created a novel research platform [ClinicAl disease research using LInked Bespoke studies and Electronic health Records (CALIBER)] based on linkage of four major sources of EHR data in primary care and national registries. We carried out 33 complementary studies within the CALIBER framework. We developed a web-based clinical decision support system (CDSS) in hospital chest pain clinics. We established a novel consented prognostic clinical cohort of SCAD patients.
Results
CALIBER was successfully established as a valid research platform based on linked EHR data in nearly 2 million adults with > 600 EHR phenotypes implemented on the web portal (see https://caliberresearch.org/portal ). Despite national guidance, key opportunities for investigation and treatment were missed across the patient journey, resulting in a worse prognosis for patients in the UK compared with patients in health systems in other countries. Our novel, contemporary, high-resolution studies showed heterogeneous associations for CVD risk factors across CVDs. The CDSS did not alter the decision-making behaviour of clinicians in chest pain clinics. Prognostic models using real-world data validly discriminated risk of death and events, and were used in cost-effectiveness decision models.
Conclusions
Emerging ‘big data’ opportunities arising from the linkage of records at different stages of a patient’s journey are vital to the generation of actionable insights into the diagnosis, risk stratification and cost-effective treatment of people at risk of, or with, CVD.
Future work
The vast majority of NHS data remain inaccessible to research and this hampers efforts to improve efficiency and quality of care and to drive innovation. We propose three priority directions for further research. First, there is an urgent need to ‘unlock’ more detailed data within hospitals for the scale of the UK’s 65 million population. Second, there is a need for scaled approaches to using EHRs to design and carry out trials, and interpret the implementation of trial results. Third, large-scale, disease agnostic genetic and biological collections linked to such EHRs are required in order to deliver precision medicine and to innovate discovery.
Study registration
CALIBER studies are registered as follows: study 2 – NCT01569139, study 4 – NCT02176174 and NCT01164371, study 5 – NCT01163513, studies 6 and 7 – NCT01804439, study 8 – NCT02285322, and studies 26–29 – NCT01162187. Optimising the Management of Angina is registered as Current Controlled Trials ISRCTN54381840.
Funding
The National Institute for Health Research (NIHR) Programme Grants for Applied Research programme (RP-PG-0407-10314) (all 33 studies) and additional funding from the Wellcome Trust (study 1), Medical Research Council Partnership grant (study 3), Servier (study 16), NIHR Research Methods Fellowship funding (study 19) and NIHR Research for Patient Benefit (study 33).
Background:
Emergency Medical Service (EMS) providers are tasked with rapid evaluation, stabilization, recognition, and transport of acute stroke patients. Although prehospital stroke scales were developed to assist with stroke recognition, unrecognized challenges exist in the prehospital setting that hinder accurate assessment of stroke. The goal of this qualitative study was to systematically understand the challenges and barriers faced by paramedics in recognizing stroke presentations in the field.
Methods:
Paramedics from 12 EMS agencies serving a mix of rural, suburban, and urban communities in the State of California participated in five focus group discussions. Group size ranged from 3-8, with a total of 28 participants. Demographics of the participants were collected and focus group recordings were transcribed verbatim. Transcripts were subjected to deductive and inductive coding, which identified recurrent and divergent themes.
Results:
Strong consensus existed around constraints to prehospital stroke recognition; participants cited the diversity of stroke presentations, linguistic diversity, and exam confounded by alcohol and or drug use as barriers to initial evaluation. Also, lack of educational feedback from hospital staff and physicians and continuing medical education on stroke were reported as major deterrents to enhancing their diagnostic acumen. Across groups, participants reported attempting to foster relationships with hospital personnel to augment their educational needs, but this was easier for rural than urban providers.
Conclusions:
While challenges to stroke recognition in the field were slightly different for rural and urban EMS, participants concurred that timely, systematic feedback on individual patients and case-based training would strengthen early stroke recognition skills.
This research takes three-hospital collaboration as a case study. For the case hospital collaboration, each hospital has different computed tomography (CT) patients and CT scanners. This research formulates a mathematical model and uses system simulation to construct a collaborative CT patient-referring mechanism among the three hospitals. The objective of this study is to apply the simulation optimization method to obtain an optimal solution of daily referring CT patients among hospitals in order to satisfy the patient waiting time constraint and the hospitals’ budget constraints. Further, this study performs sensitivity analyses on key parameters and discusses their managerial implications. The results of this research will provide hospitals with a reference for developing collaborative patient-referring mechanisms.
Background and purpose:
A potential way to improve prehospital stroke care and patient handoff is hospital-directed feedback for emergency medical service (EMS) providers. We evaluated whether a hospital-directed EMS stroke follow-up tool improved documentation of adherence to the Rhode Island state prehospital stroke protocol for EMS providers.
Methods:
A standardized, 10-item feedback tool was developed in 2012 and sent to EMS directors for every transported patient with a discharge diagnosis of ischemic stroke. We reviewed patient charts meeting these criteria between January 2008 and December 2013. Performance on the tool was compared between the preintervention (January 2008 through January 2012) and postintervention (February 2012 through December 2013) periods.
Results:
We identified 1176 patients with ischemic stroke who arrived by EMS in the study period: 668 in the preintervention period and 508 in the postintervention period. The overall score for the preintervention group was 5.31 and for the postintervention group 6.42 (P<0.001). Each of the 10 items, except checking blood glucose, showed statistically significant improvement in the postintervention period compared with the preintervention period.
Conclusions:
Hospital-directed feedback to EMS was associated with improved overall compliance with state protocols and documentation of 9 out of 10 individual items. Future confirmatory studies in different locales and studies on the impact of this intervention on actual tissue-type plasminogen activator administration rates and EMS personnel knowledge and behavior are needed.
A tremendous growth in the use of multi-item scales in marketing research has occurred over the past two decades. Concurrently, there is increasing concern about the quality of these measures. Although the majority of marketing-related articles now discuss the reliability of the scales administered, few address the issue of scale validity. One aspect of scale validity, which should be of particular concern to marketing researchers, is the potential threat of contamination due to social-desirability response bias. However, a careful review of nearly 20 years of published research suggests that social-desirability bias has been consistently neglected in scale construction, evaluation, and implementation. The purpose of this article is to discuss the nature of such a bias, methods for identifying, testing for and/or preventing it, and how these methods can and should be implemented in consumer-related research. ©: 2000 John Wiley & Sons, Inc.
Despite recent improvements in survival after acute myocardial infarction (AMI), U.S. hospitals vary 2-fold in their 30-day risk-standardized mortality rates (RSMRs). Nevertheless, information is limited on hospital-level factors that may be associated with RSMRs.
To identify hospital strategies that were associated with lower RSMRs.
Cross-sectional survey of 537 hospitals (91% response rate) and weighted multivariate regression by using data from the Centers for Medicare & Medicaid Services to determine the associations between hospital strategies and hospital RSMRs.
Acute care hospitals with an annualized AMI volume of at least 25 patients.
Patients hospitalized with AMI between 1 January 2008 and 31 December 2009.
Hospital performance improvement strategies, characteristics, and 30-day RSMRs.
In multivariate analysis, several hospital strategies were significantly associated with lower RSMRs and in aggregate were associated with clinically important differences in RSMRs. These strategies included holding monthly meetings to review AMI cases between hospital clinicians and staff who transported patients to the hospital (RSMR lower by 0.70 percentage points), having cardiologists always on site (lower by 0.54 percentage points), fostering an organizational environment in which clinicians are encouraged to solve problems creatively (lower by 0.84 percentage points), not cross-training nurses from intensive care units for the cardiac catheterization laboratory (lower by 0.44 percentage points), and having physician and nurse champions rather than nurse champions alone (lower by 0.88 percentage points). Fewer than 10% of hospitals reported using at least 4 of these 5 strategies.
The cross-sectional design demonstrates statistical associations but cannot establish causal relationships.
Several strategies, which are currently implemented by relatively few hospitals, are associated with significantly lower 30-day RSMRs for patients with AMI.
The Agency for Healthcare Research and Quality, the United Health Foundation, and the Commonwealth Fund.
As the United States embraces electronic health records (EHRs), improved emergency medical services (EMS) information systems are also a priority; however, little is known about the experiences of EMS agencies as they adopt and implement electronic patient care report (e-PCR) systems. We sought to characterize motivations for adoption of e-PCR systems, challenges associated with adoption and implementation, and emerging implementation strategies.
We conducted a qualitative study using semi-structured in-depth interviews with EMS agency leaders. Participants were recruited through a web-based survey of National Association of EMS Physicians (NAEMSP) members, a didactic session at the 2010 NAEMSP Annual Meeting, and snowball sampling. Interviews lasted approximately 30 minutes, were recorded and professionally transcribed. Analysis was conducted by a five-person team, employing the constant comparative method to identify recurrent themes.
Twenty-three interviewees represented 20 EMS agencies from the United States and Canada; 14 EMS agencies were currently using e-PCR systems. The primary reason for adoption was the potential for e-PCR systems to support quality assurance efforts. Challenges to e-PCR system adoption included those common to any health information technology project, as well as challenges unique to the prehospital setting, including: fear of increased ambulance run times leading to decreased ambulance availability, difficulty integrating with existing hospital information systems, and unfunded mandates requiring adoption of e-PCR systems. Three recurring strategies emerged to improve e-PCR system adoption and implementation: 1) identify creative funding sources; 2) leverage regional health information organizations; and 3) build internal information technology capacity.
EMS agencies are highly motivated to adopt e-PCR systems to support quality assurance efforts; however, adoption and implementation of e-PCR systems has been challenging for many. Emerging strategies from EMS agencies and others that have successfully implemented EHRs may be useful in expanding e-PCR system use and facilitating this transition for other EMS agencies.
Critical access hospitals (CAHs) play a crucial role in the US rural safety net. Current policy efforts have focused primarily on helping these small, isolated hospitals remain financially viable to ensure access for individuals living in rural areas in the United States; however, little is known about the quality of care they provide or the outcomes their patients achieve.
To examine the quality of care and patient outcomes at CAHs and to understand why patterns of care might differ for CAHs vs non-CAHs.
A retrospective analysis in 4738 US hospitals of Medicare fee-for-service beneficiaries with acute myocardial infarction (AMI) (10,703 for CAHs vs 469,695 for non-CAHs), congestive heart failure (CHF) (52,927 for CAHs vs 958,790 for non-CAHs), and pneumonia (86,359 for CAHs vs 773,227 for non-CAHs) who were discharged in 2008-2009.
Clinical capabilities, performance on processes of care, and 30-day mortality rates, adjusted for age, sex, race, and medical comorbidities.
Compared with other hospitals (n = 3470), 1268 CAHs (26.8%) were less likely to have intensive care units (380 [30.0%] vs 2581 [74.4%], P < .001), cardiac catheterization capabilities (6 [0.5%] vs 1654 [47.7%], P < .001), and at least basic electronic health records (80 [6.5%] vs 445 [13.9%], P < .001). The CAHs had lower performance on processes of care than non-CAHs for all 3 conditions examined (concordance with Hospital Quality Alliance process measures for AMI, 91.0% [95% CI, 89.7%-92.3%] vs 97.8% [95% CI, 97.7%-97.9%]; for CHF, 80.6% [95% CI, 79.2%-82.0%] vs 93.5% [95% CI, 93.3%-93.7%]; and for pneumonia, 89.3% [95% CI, 88.6%-90.0%] vs 93.7% [95% CI, 93.6%-93.9%]; P < .001 for each). Patients admitted to CAHs had higher 30-day mortality rates for each condition than those admitted to non-CAHs (for AMI: 23.5% vs 16.2%; adjusted odds ratio [OR], 1.70; 95% confidence interval [CI], 1.61-1.80; P < .001; for CHF: 13.4% vs 10.9%; adjusted OR, 1.28; 95% CI, 1.23-1.32; P < .001; and for pneumonia: 14.1% vs 12.1%; adjusted OR, 1.20; 95% CI, 1.16-1.24; P < .001).
Compared with non-CAHs, CAHs had fewer clinical capabilities, worse measured processes of care, and higher mortality rates for patients with AMI, CHF, or pneumonia.
Qualitative methods are now widely used and increasingly accepted in health research, but quality in qualitative research is a mystery to many health services researchers. There is considerable debate over the nature of the knowledge produced by such methods and how such research should be judged. Antirealists argue that qualitative and quantitative research are very different and that it is not possible to judge qualitative research by using conventional criteria such as reliability, validity, and generalisability. Quality in qualitative research can be assessed with the same broad concepts of validity and relevance used for quantitative research, but these need to be operationalised differently to take into account the distinctive goals of qualitative research.
Mortality rates for patients with acute myocardial infarction (AMI) vary substantially across hospitals, even when adjusted for patient severity; however, little is known about hospital factors that may influence this variation.
To identify factors that may be related to better performance in AMI care, as measured by risk-standardized mortality rates.
Qualitative study that used site visits and in-depth interviews.
Eleven U.S. hospitals that ranked in either the top or the bottom 5% in risk-standardized mortality rates for 2 recent years of data from the Centers for Medicare & Medicaid Services (2005 to 2006 and 2006 to 2007), with diversity among hospitals in key characteristics.
158 members of hospital staff, all of whom were involved with AMI care at the 11 hospitals.
Site visits and in-depth interviews conducted with hospital staff during 2009. A multidisciplinary team performed analyses by using the constant comparative method.
Hospitals in the high-performing and low-performing groups differed substantially in the domains of organizational values and goals, senior management involvement, broad staff presence and expertise in AMI care, communication and coordination among groups, and problem solving and learning. Participants described diverse protocols or processes for AMI care (such as rapid response teams, clinical guidelines, use of hospitalists, and medication reconciliation); however, these did not systematically differentiate high-performing from low-performing hospitals.
The qualitative design informed the generation of hypotheses, and statistical associations could not be assessed.
High-performing hospitals were characterized by an organizational culture that supported efforts to improve AMI care across the hospital. Evidence-based protocols and processes, although important, may not be sufficient for achieving high hospital performance in care for patients with AMI.
Agency for Healthcare Research and Quality, United Health Foundation, and the Commonwealth Fund.
Despite decades of efforts to improve quality of health care, poor performance persists in many aspects of care. Less than 1% of the enormous national investment in medical research is focused on improving health care delivery. Furthermore, when effective innovations in clinical care are discovered, uptake of these innovations is often delayed and incomplete. In this paper, we build on the established principle of 'positive deviance' to propose an approach to identifying practices that improve health care quality.
We synthesize existing literature on positive deviance, describe major alternative approaches, propose benefits and limitations of a positive deviance approach for research directed toward improving quality of health care, and describe an application of this approach in improving hospital care for patients with acute myocardial infarction.
The positive deviance approach, as adapted for use in health care, presumes that the knowledge about 'what works' is available in existing organizations that demonstrate consistently exceptional performance. Steps in this approach: identify 'positive deviants,' i.e., organizations that consistently demonstrate exceptionally high performance in the area of interest (e.g., proper medication use, timeliness of care); study the organizations in-depth using qualitative methods to generate hypotheses about practices that allow organizations to achieve top performance; test hypotheses statistically in larger, representative samples of organizations; and work in partnership with key stakeholders, including potential adopters, to disseminate the evidence about newly characterized best practices. The approach is particularly appropriate in situations where organizations can be ranked reliably based on valid performance measures, where there is substantial natural variation in performance within an industry, when openness about practices to achieve exceptional performance exists, and where there is an engaged constituency to promote uptake of discovered practices.
The identification and examination of health care organizations that demonstrate positive deviance provides an opportunity to characterize and disseminate strategies for improving quality.
Various strategies are available within qualitative research to protect against bias and enhance the reliability of findings. This paper gives examples of the principal approaches anti summarises them into a methodological checklist to help readers of reports of qualitative projects to assess the quality of the research.
Effective communication and teamwork is essential for the delivery of high quality, safe patient care. Communication failures are an extremely common cause of inadvertent patient harm. The complexity of medical care, coupled with the inherent limitations of human performance, make it critically important that clinicians have standardised communication tools, create an environment in which individuals can speak up and express concerns, and share common "critical language" to alert team members to unsafe situations. All too frequently, effective communication is situation or personality dependent. Other high reliability domains, such as commercial aviation, have shown that the adoption of standardised tools and behaviours is a very effective strategy in enhancing teamwork and reducing risk. We describe our ongoing patient safety implementation using this approach within Kaiser Permanente, a non-profit American healthcare system providing care for 8.3 million patients. We describe specific clinical experience in the application of surgical briefings, properties of high reliability perinatal care, the value of critical event training and simulation, and benefits of a standardised communication process in the care of patients transferred from hospitals to skilled nursing facilities. Additionally, lessons learned as to effective techniques in achieving cultural change, evidence of improving the quality of the work environment, practice transfer strategies, critical success factors, and the evolving methods of demonstrating the benefit of such work are described.
Prompt reperfusion treatment is essential for patients who have myocardial infarction with ST-segment elevation. Guidelines recommend that the interval between arrival at the hospital and intracoronary balloon inflation (door-to-balloon time) during primary percutaneous coronary intervention should be 90 minutes or less. However, few hospitals meet this objective. We sought to identify hospital strategies that were significantly associated with a faster door-to-balloon time.
We surveyed 365 hospitals to determine whether each of 28 specific strategies was in use. We used hierarchical generalized linear models and data on patients from the Centers for Medicare and Medicaid Services to determine the association between hospital strategies and the door-to-balloon time.
In multivariate analysis, six strategies were significantly associated with a faster door-to-balloon time. These strategies included having emergency medicine physicians activate the catheterization laboratory (mean reduction in door-to-balloon time, 8.2 minutes), having a single call to a central page operator activate the laboratory (13.8 minutes), having the emergency department activate the catheterization laboratory while the patient is en route to the hospital (15.4 minutes), expecting staff to arrive in the catheterization laboratory within 20 minutes after being paged (vs. >30 minutes) (19.3 minutes), having an attending cardiologist always on site (14.6 minutes), and having staff in the emergency department and the catheterization laboratory use real-time data feedback (8.6 minutes). Despite the effectiveness of these strategies, only a minority of hospitals surveyed were using them.
Several specific hospital strategies are associated with a significant reduction in the door-to-balloon time in the management of myocardial infarction with ST-segment elevation.
Hospital-based clinicians and educators face a difficult challenge trying to simultaneously improve measurable quality, educate residents in line with ACGME core competencies, while also attending to fiscal concerns such as hospital length of stay (LOS).
The purpose of this study was to determine the effect of multidisciplinary rounds (MDR) on quality core measure performance, resident education, and hospital length of stay.
Pre and post observational study assessing the impact of MDR during its first year of implementation.
The Norwalk Hospital is a 328-bed, university-affiliated community teaching hospital in an urban setting with a total of 44 Internal Medicine residents.
Joint Commission on Accreditation of Healthcare Organizations (JCAHO) core measure performance was obtained on a monthly basis for selected heart failure (CHF), pneumonia, and acute myocardial infarction (AMI) measures addressed on the general medical service. Resident knowledge and attitudes about MDR were determined by an anonymous questionnaire. LOS and monthly core measure performance rates were adjusted for patient characteristics and secular trends using linear spline logistic regression modeling.
Institution of MDR was associated with a significant improvement in quality core measure performance in targeted areas of CHF from 65% to 76% (p < .001), AMI from 89% to 96% (p = .004), pneumonia from 27% to 70% (p < .001), and all combined from 59% to 78% (p < .001). Adjusted overall monthly performance rates also improved during MDR (odds ratio [OR] 1.09, CI 1.06-1.12, p < .001). Residents reported substantial improvements in core measure knowledge, systems-based care, and communication after institution of MDR (p < .001). Residents also agreed that MDR improved efficiency, delivery of evidence-based care, and relationships with involved disciplines. Adjusted average LOS decreased 0.5 (95% CI 0.1-0.8) days for patients with a target core measure diagnosis of either CHF, pneumonia, or AMI (p < .01 ) and by 0.6 (95% CI 0.5-0.7) days for all medicine DRGs (p < .001).
Resident-centered MDR is an effective process using no additional resources that simultaneously improves quality of care while enhancing resident education and is associated with shortened length of stay.
................ ................ ................ ................ ................ ................ ................ ............... Effective communication and teamwork is essential for the delivery of high quality, safe patient care. Communication failures are an extremely common cause of inadvertent patient harm. The complexity of medical care, coupled with the inherent limitations of human performance, make it critically important that clinicians have standardised communication tools, create an environment in which individuals can speak up and express concerns, and share common ‘‘critical language’’ to alert team members to unsafe situations. All too frequently, effective communication is situation or personality dependent. Other high reliability domains, such as commercial aviation, have shown that the adoption of standardised tools and behaviours is a very effective strategy in enhancing teamwork and reducing risk. We describe our ongoing patient safety implementation using this approach within Kaiser Permanente, a non-profit American healthcare system providing care for 8.3 million patients. We describe specific clinical experience in the application of surgical briefings, properties of high reliability perinatal care, the value of critical event training and simulation, and benefits of a standardised communication process in the care of patients transferred from hospitals to skilled nursing facilities. Additionally, lessons learned as to effective techniques in achieving cultural change, evidence of improving the quality of the work environment, practice transfer strategies, critical success factors, and the evolving methods of demonstrating the benefit of such work are described.
Background
Despite recent improvements in survival after acute myocardial infarction (AMI), U.S. hospitals vary 2-fold in their 30-day risk-standardized mortality rates (RSMRs). Nevertheless, information is limited on hospital-level factors that may be associated with RSMRs.
National guidelines call for participation in systems to rapidly diagnose and treat ST-segment-elevation myocardial infarction (STEMI). In order to characterize currently implemented STEMI reperfusion systems and identify practices common to system organization, the American Heart Association surveyed existing systems throughout the United States.
A STEMI system was defined as an integrated group of separate entities focused on reperfusion therapy for STEMI within a geographic region that included at least 1 hospital that performs percutaneous coronary intervention and at least 1 emergency medical service agency. Systems meeting this definition were invited to participate in a survey of 42 questions based on expert panel opinion and knowledge of existing systems. Data were collected through the American Heart Association Mission: Lifeline website. Between April 2008 and January 2010, 381 unique systems involving 899 percutaneous coronary intervention hospitals in 47 states responded to the survey, of which 255 systems (67%) involved urban regions. The predominant funding sources for STEMI systems were percutaneous coronary intervention hospitals (n = 320, 84%) and /or cardiology practices (n = 88, 23%). Predominant system characteristics identified by the survey included: STEMI patient acceptance at percutaneous coronary intervention hospital regardless of bed availability (N = 346, 97%); single phone call activation of catheterization laboratory (N = 335, 92%); emergency department physician activation of laboratory without cardiology consultation (N = 318, 87%); data registry participation (N = 311, 84%); and prehospital activation of the laboratory through emergency department notification without cardiology notification (N = 297, 78%). The most common barriers to system implementation were hospital (n = 139, 37%) and cardiology group competition (n = 81, 21%) and emergency medical services transport and finances (n = 99, 26%).
This survey broadly describes the organizational characteristics of collaborative efforts by hospitals and emergency medical services to provide timely reperfusion in the United States. These findings serve as a benchmark for existing systems and should help guide healthcare teams in the process of organizing care for patients with STEMI.
In the United States, emergency physicians and hospitalists are increasingly responsible for managing hospitalized patients. These specialists share a common practice space and similar shift work schedules. Together they govern decisions about use of the most expensive care setting in medicine--the hospital.
Unfortunately, in most institutions there is little collaboration between emergency physicians and hospitalists, resulting in missed opportunities to improve the quality of care and reduce its cost. In this call to action, we challenge emergency physicians and hospitalists to work together to develop protocols for consistent, evidence-based, and expeditious care of patients admitted from the ED; to collaborate in the care of ED patients who can safely be discharged home; to pursue joint quality, hospital leadership, and cost-effectiveness projects; to work in partnership to assure adequate staffing of hospital-based specialists; and to cooperate in the professional, front-line assessment of clinically and fiscally driven policies aimed at assessing the appropriateness of hospital admissions and readmissions.
Hospital care is increasingly driven by emergency physicians and hospitalists. We envision a vital role for ongoing collaboration between them in achieving the goals of patient care, education, and quality and safety outcomes.
Foreword - Larry Culpepper Introduction - William L Miller and Benjamin F Crabtree PART ONE: OVERVIEW OF QUALITATIVE RESEARCH METHODS Primary Care Research - William L Miller and Benjamin F Crabtree A Multimethod Typology and Qualitative Roadmap PART TWO: DISCOVERY: DATA COLLECTION STRATEGIES Sampling in Qualitative Inquiry - Anton J Kuzel Participant Observation - Stephen P Bogdewic Key Informant Interviews - Valerie J Gilchrist PART THREE: INTERPRETATION: STRATEGIES OF ANALYSIS A Template Approach to Text Analysis - Benjamin F Crabtree and William L Miller Developing and Using Codebooks Grounded Hermeneutic Research - Richard B Addison Computer Management Strategies for Text Data - Alfred O Reid Jr PART FOUR: SPECIAL CASES OF ANALYSIS Approaches to Audio and Video Tape Analysis - Moira Stewart Interpreting the Interactions Between Patients and Physicians Historical Method - Miguel Bedolla A Brief Introduction Philosophic Approaches - Howard Brody PART FIVE: PUTTING IT ALL TOGETHER: COMPLETED STUDIES A Qualitative Study of Family Practice Physician Health Promotion Activities - Dennis G Willms, Nancy A Johnson and Norman A White Doctor-Caregiver Relationships - David Morgan An Exploration Using Focus Groups PART SIX: SUMMARY Qualitative Research - Ian McWhinney et al Perspectives on the Future
Positive deviance studies combining qualitative and quantitative designs-a mixed-methods approach-can discover strategies to produce exemplary performance. We present the SAMI study, a national positive deviance study to discover hospital strategies associated with lower 30-day hospital risk-standardized mortality rates (RSMRs). There is marked variation across hospitals in 30-day hospital RSMRs for patients with acute myocardial infarction and little information about what accounts for differences in performance. We first conducted a qualitative study of hospitals in the United States (n = 11; 158 key staff) that ranked in the top 5% of RSMRs for each of the 2 most recent years of data (2005-2006 and 2006-2007) from the Centers for Medicare & Medicaid Services at the time of sample selection and in the bottom 5% for contrast, with diversity among hospitals in key characteristics. Using hypotheses generated in this qualitative stage, we constructed a quantitative survey that was administered in a cross-sectional study of acute care hospitals in the United States operating from July 1, 2005, through June 30, 2008, that publicly reported Centers for Medicare & Medicaid Services data for RSMRs during this time. We included hospitals with at least 75 acute myocardial infarction discharges during the 3-year period. Of the 600 hospitals we attempted to contact, 10 had closed, leaving a final sample of 590, of which 537 responded (91%). This type of study, using a positive deviance approach and mixed-methods design, can generate and test hypotheses about factors most strongly associated with exemplary performance based on practices currently in use.
Early treatment with intravenous (IV) recombinant tissue plasminogen activator/alteplase (tPA) is associated with improved outcomes for patients with an acute ischemic stroke. Thus, rapid triage and treatment of stroke patients are essential, with a goal of door-to-needle time of no more than 60 minutes. We sought to identify best practices associated with faster treatment among hospitals participating in Get With the Guidelines--Stroke. Qualitative telephone interviews were conducted to elicit strategies being used by these centers to assess, treat, and monitor stroke patients treated with IV tPA. We sequentially carried out these interviews until we no longer identified novel factors. Interviews were conducted with 13 personnel at 7 top-performing U.S. hospitals. With the use of a hermeneutic-phenomenological framework, 5 distinct domains associated with rapid IV tPA delivery were identified. These included (a) communication and teamwork, (b) process, (c) organizational culture, (d) performance monitoring and feedback, and (e) overcoming barriers.
Although interdisciplinary hospital quality improvement (QI) teams are both prevalent and associated with success of (QI) efforts, little is known about the behaviors of successful interdisciplinary QI teams.
We examined the specific behaviors of interdisciplinary QI teams in hospitals that successfully redesigned care for patients with ST-elevation myocardial infarction (STEMI) and reduced door-to-balloon times.
Qualitative study.
Researchers interviewed 122 administrators, providers, and staff in 11 hospitals with substantial improvements in door-to-balloon times.
Using data from the in-depth qualitative interviews, the authors identified themes that described the behaviors of interdisciplinary QI teams in successful hospitals.
Teams focused on 5 behaviors: (1) motivating involved hospital staff toward a shared goal, (2) creating opportunities for learning and problem-solving, (3) addressing the impact of changes to care processes on staff, (4) protecting the integrity of the new care processes, and (5) representing each involved clinical discipline effectively.
The behaviors observed may enhance a QI team's ability to motivate the various disciplines involved, understand the care process they must change, be responsive to front-line concerns while maintaining control over the improvement process, and share information across all levels of the hospital hierarchy. Teams in successful hospitals did not avoid interdisciplinary conflict, but rather allowed each discipline to contribute to the team from its own perspective. Successful QI teams addressed the concerns of each involved discipline, modified protocols guided by clinical outcomes, and became conduits of information on changes to care processes to both executive managers and front-line staff.
Some of the most intractable challenges in prehospital medicine include response time optimization, inefficiencies at the emergency medical services (EMS)-emergency department (ED) interface, and the ability to correlate field interventions with patient outcomes. Information technology (IT) can address these and other concerns by ensuring that system and patient information is received when and where it is needed, is fully integrated with prior and subsequent patient information, and is securely archived. Some EMS agencies have begun adopting information technologies, such as wireless transmission of 12-lead electrocardiograms, but few agencies have developed a comprehensive plan for management of their prehospital information and integration with other electronic medical records. This perspective article highlights the challenges and limitations of integrating IT elements without a strategic plan, and proposes an open, interoperable, and scalable prehospital information technology (PHIT) architecture. The two core components of this PHIT architecture are 1) routers with broadband network connectivity to share data between ambulance devices and EMS system information services and 2) an electronic patient care report to organize and archive all electronic prehospital data. To successfully implement this comprehensive PHIT architecture, data and technology requirements must be based on best available evidence, and the system must adhere to health data standards as well as privacy and security regulations. Recent federal legislation prioritizing health information technology may position federal agencies to help design and fund PHIT architectures.
We investigated these questions: Does formal team training improve team behaviors in the trauma resuscitation bay? If yes, then does improved teamwork lead to more efficiency in the trauma bay and/or improved clinical outcomes?
This intervention study used a pretraining/posttraining design. The intervention was TeamSTEPPS augmented by simulation. The evaluation instrument, which was the Trauma Team Performance Observation Tool (TPOT), was used by trained evaluators to assess teams' performance during trauma resuscitations. From November 2008 to February 2009, a convenience sample (n = 33) of trauma resuscitations was evaluated. From February to April 2009, team training was conducted. From May to July 2009, another sample (n = 40) of resuscitations were evaluated. Clinical data were gathered from our trauma registry. The clinical parameters included time from arrival to computed tomography (CT) scanner, arrival to intubation, arrival to operating room, arrival to Focused Assessment Sonography in Trauma (FAST) examination, time in emergency department (ED), hospital length of stay (LOS), intensive care unit LOS, complications, and mortality. Comparing pretraining and posttraining resuscitations, we calculated means, standard deviations, and p values for teamwork ratings and clinical parameters, and we determined significance using the independent samples t-test.
Level I Trauma Center.
The trauma team included surgery residents, faculty, and nurses.
Our trauma team showed significant improvement in all teamwork domain ratings and overall ratings from pretraining to posttraining-leadership (2.87-3.46, p = 0.003), situation monitoring (3.30-3.91, p = 0.009), mutual support (3.40-3.96, p = 0.004), communication (2.90-3.46, p = 0.001), and overall (3.12-3.70, p < 0.001). The times from arrival to the CT scanner (26.4-22.1 minutes, p = 0.005), endotracheal intubation (10.1-6.6 minutes, p = 0.49) and the operating room (130.1-94.5 minutes, p = 0.021) were decreased significantly after the training.
Structured trauma resuscitation team training augmented by simulation improves team performance, resulting in improved efficiency of patient care in the trauma bay. We propose that formal teamwork training augmented by simulation be included in surgery residency training as well as Advanced Trauma Life Support (ATLS).
The participants of the Electronic Collaboration working group of the 2010 Academic Emergency Medicine consensus conference developed recommendations and research questions for improving regional quality of care through the use of electronic collaboration. A writing group devised a working draft prior to the meeting and presented this to the breakout session at the consensus conference for input and approval. The recommendations include: 1) patient health information should be available electronically across the entire health care delivery system from the 9-1-1 call to the emergency department (ED) visit through hospitalization and outpatient care, 2) relevant patient health information should be shared electronically across the entire health care delivery system, 3) Web-based collaborative technologies should be employed to facilitate patient transfer and timely access to specialists, 4) personal health record adoption should be considered as a way to improve patient health, and 5) any comprehensive reform of regionalization in emergency care must include telemedicine. The workgroup emphasized the need for funding increases so that research in this new and exciting area can expand.
ACADEMIC EMERGENCY MEDICINE 2010; 17:1312–1321 © 2010 by the Society for Academic Emergency Medicine
Cardiopulmonary resuscitation (CPR) is a series of lifesaving actions that improve the chance of survival following cardiac arrest.1 Although the optimal approach to CPR may vary, depending on the rescuer, the victim, and the available resources, the fundamental challenge remains: how to achieve early and effective CPR. Given this challenge, recognition of arrest and prompt action by the rescuer continue to be priorities for the 2010 AHA Guidelines for CPR and ECC. This chapter provides an overview of cardiac arrest epidemiology, the principles behind each link in the Chain of Survival, an overview of the core components of CPR (see Table 1), and the approaches of the 2010 AHA Guidelines for CPR and ECC to improving the quality of CPR. The goal of this chapter is to integrate resuscitation science with real-world practice in order to improve the outcomes of CPR.
View this table:
Table 1.
Summary of Key BLS Components for Adults, Children and Infants
Despite important advances in prevention, cardiac arrest remains a substantial public health problem and a leading cause of death in many parts of the world.2 Cardiac arrest occurs both in and out of the hospital. In the US and Canada, approximately 350 000 people/year (approximately half of them in-hospital) suffer a cardiac arrest and receive attempted resuscitation.3,–,7 This estimate does not include the substantial number of victims who suffer an arrest without attempted resuscitation. While attempted resuscitation is not always appropriate, there are many lives and life-years lost because appropriate resuscitation is not attempted.
The estimated incidence of EMS-treated out-of-hospital cardiac arrest in the US and Canada is about 50 to 55/100 000 persons/year and approximately 25% of these present with pulseless ventricular arrhythmias.3,8 The estimated incidence of in-hospital cardiac arrest is 3 to 6/1000 admissions4,– …
Hospitals vary by twofold in their hospital-specific 30-day risk-stratified mortality rates (RSMRs) for Medicare beneficiaries with acute myocardial infarction (AMI). However, we lack a comprehensive investigation of hospital characteristics associated with 30-day RSMRs and the degree to which the variation in 30-day RSMRs is accounted for by these characteristics, including the socioeconomic status (SES) profile of hospital patient populations. We conducted a cross-sectional national study of hospitals with ≥15 AMI discharges from July 1, 2005 to June 20, 2008. We estimated a multivariable weighted regression using Medicare claims data for hospital-specific 30-day RSMRs, American Hospital Association Survey of Hospitals for hospital characteristics, and the United States Census data reported by Neilsen Claritas, Inc., for zip-code level estimates of SES status. Analysis included 2,908 hospitals with 513,202 AMI discharges. Mean hospital 30-day RSMR was 16.5% (SD 1.7 percentage points). Our multivariable model explained 17.1% of the variation in hospital-specific 30-day RSMRs. Teaching status, number of hospital beds, AMI volume, cardiac facilities available, urban/rural location, geographic region, ownership type, and SES profile of patients were significantly (p < 0.05) associated with 30-day RSMRs. In conclusion, substantial variation in hospital outcomes for patients with AMI remains unexplained by measurements of hospital characteristics including SES patient profile.
Aims The NCDR ACTION Registry-GWTG collects detailed in-hospital clinical, process-of-care and outcomes data for patients admitted with acute myocardial infarction (AMI) in the USA. The registry is a national AMI surveillance system that contributes to the scientific enquiry process of AMI care through the facilitation of local and national quality improvement efforts.
Interventions No treatments are mandated, participating centres receive routine quality-of-care and outcomes performance feedback reports and access to quality of care tools, such as dosing algorithms and standing orders.
Population AMI patients are retrospectively identified. No informed consent is required, as data are anonymised. From January 2007 to date, 147 165 records have been submitted from 383 participating US hospitals. Patients with a primary diagnosis of ST-segment elevation myocardial infarction or non-ST-segment elevation myocardial infarction are eligible for enrolment in the registry. These patients must have ischemic symptoms and electrocardiogram changes, and/or positive cardiac markers within 24 hours of initial presentation.
Baseline data Approximately 350 fields encompassing patient demographics, medical history and risk factors, hospital presentation, initial cardiac status, medications and associated doses, reperfusion strategy, procedures, laboratory values, and outcomes. Data are manually entered by study personnel; there are non-financial incentives at the hospital level. Completeness within the registry is noteworthy with most fields at less than 5% missing.
Endpoints Main outcome measures include American College of Cardiology/American Heart Association myocardial infarction performance indicators, as well as in-hospital patient outcomes. Data are available for research by application to: http://www.ncdr.com.
Contenido: Parte I.Cuestiones conceptuales en la investigación cualitativa: Naturaleza de la investigación cualitativa; Temas estratégicos en la investigación cualitativa; Diversidad en la investigación cualitativa: orientaciones teóricas; Aplicaciones cualitativas particulares. Parte II. Diseños cualitativos y recolección de datos: Estudios de diseños cualitativos; Estrategias de trabajo de campo y métodos de observación; Entrevistas cualitativas. Parte III. Análisis, interpretación e informe: Análisis cualitativo e interpretación; Incrementar la calidad y la credibilidad del análisis cualitativo.
In 2009, the Centers for Medicare & Medicaid Services is publicly reporting hospital-level risk-standardized 30-day mortality and readmission rates after acute myocardial infarction (AMI) and heart failure (HF). We provide patterns of hospital performance, based on these measures.
We calculated the 30-day mortality and readmission rates for all Medicare fee-for-service beneficiaries ages 65 years or older with a primary diagnosis of AMI or HF, discharged between July 2005 and June 2008. We compared weighted risk-standardized mortality and readmission rates across Hospital Referral Regions and hospital structural characteristics. The median 30-day mortality rate was 16.6% for AMI (range, 10.9% to 24.9%; 25th to 75th percentile, 15.8% to 17.4%; 10th to 90th percentile, 14.7% to 18.4%) and 11.1% for HF (range, 6.6% to 19.8%; 25th to 75th percentile, 10.3% to 12.0%; 10th to 90th percentile, 9.4% to 13.1%). The median 30-day readmission rate was 19.9% for AMI (range, 15.3% to 29.4%; 25th to 75th percentile, 19.5% to 20.4%; 10th to 90th percentile, 18.8% to 21.1%) and 24.4% for HF (range, 15.9% to 34.4%; 25th to 75th percentile, 23.4% to 25.6%; 10th to 90th percentile, 22.3% to 27.0%). We observed geographic differences in performance across the country. Although there were some differences in average performance by hospital characteristics, there were high and low hospital performers among all types of hospitals.
In a recent 3-year period, 30-day risk-standardized mortality rates for AMI and HF varied among hospitals and across the country. The readmission rates were particularly high.
Libro de metodología cualitativo para investigación en las ciencias sociales. La utilización de la computadora, el uso de datos y la recolección de los mismos. Se describen detalladamente numerosos métodos de datos y análisis.
Despite 3 decades of scientific progress, rates of survival from out-of-hospital cardiac arrest remain low. The Cardiac Arrest Registry to Enhance Survival (CARES) was created to provide communities with a means to identify cases of out-of-hospital cardiac arrest, measure how well emergency medical services (EMS) perform key elements of emergency cardiac care, and determine outcomes through hospital discharge. CARES collects data from 3 sources-911 dispatch, EMS, and receiving hospitals-and links them to form a single record. Once data entry is completed, individual identifiers are stripped from the record. The anonymity of CARES records allows participating agencies and institutions to compile cases without informed consent. CARES generates standard reports that can be used to characterize the local epidemiology of cardiac arrest and help managers determine how well EMS is delivering out-of-hospital cardiac arrest care. After pilot implementation in Atlanta, GA, and subsequent expansion to 7 surrounding counties, CARES was implemented in 22 US cities with a combined population of 14 million people. Additional cities are interested in joining the registry. CARES currently contains more than 13,000 cases and is growing rapidly.
To provide an overview of reasons why qualitative methods have been used and can be used in health services and health policy research, to describe a range of specific methods, and to give examples of their application.
Classic and contemporary descriptions of the underpinnings and applications of qualitative research methods and studies that have used such methods to examine important health services and health policy issues.
Qualitative research methods are valuable in providing rich descriptions of complex phenomena; tracking unique or unexpected events; illuminating the experience and interpretation of events by actors with widely differing stakes and roles; giving voice to those whose views are rarely heard; conducting initial explorations to develop theories and to generate and even test hypotheses; and moving toward explanations. Qualitative and quantitative methods can be complementary, used in sequence or in tandem. The best qualitative research is systematic and rigorous, and it seeks to reduce bias and error and to identify evidence that disconfirms initial or emergent hypotheses.
Qualitative methods have much to contribute to health services and health policy research, especially as such research deals with rapid change and develops a more fully integrated theory base and research agenda. However, the field must build on the best traditions and techniques of qualitative methods and must recognize that special training and experience are essential to the application of these methods.
Qualitative research methods could help us to improve our understanding of medicine. Rather than thinking of qualitative and quantitative strategies as incompatible, they should be seen as complementary. Although procedures for textual interpretation differ from those of statistical analysis, because of the different type of data used and questions to be answered, the underlying principles are much the same. In this article I propose relevance, validity, and reflexivity as overall standards for qualitative inquiry. I will discuss the specific challenges in relation to reflexivity, transferability, and shared assumptions of interpretation, which are met by medical researchers who do this type of research, and I will propose guidelines for qualitative inquiry.
A growing line of research indicates a positive relationship between a healthcare organization's culture and various performance measures. In these studies, a key cultural characteristic is the emphasis placed on teamwork. None of the studies, however, have examined teamwork culture relative to patient satisfaction, which is now 1 of the most widely used performance measures for healthcare organizations.
This study investigated the relationship between teamwork culture of hospitals and patient reports of their satisfaction with the care they received.
The study setting was the Veterans Health Administration (VHA), Department of Veterans Affairs. The study sample consisted of 125 VHA hospitals for which independent and valid sources of data for culture and patient satisfaction were obtained. Each hospital's culture was assessed relative to 4 dimensions: teamwork, entrepreneurial, bureaucratic, and rational. Patient satisfaction data were available for both inpatient and outpatient settings.
Results from multivariate regression analyses indicated a significant and positive relation between teamwork culture and patient satisfaction for inpatient care, and a significant and negative relation between bureaucratic culture and patient satisfaction for inpatient care. Additional analyses revealed an almost 1 standard deviation difference in patient satisfaction scores between hospitals in the top third and bottom third of the distribution for the teamwork culture measure.
Study results suggest that hospitals and possibly other healthcare organizations should strive to develop a culture emphasizing teamwork and deemphasizing those aspects of bureaucracy that are not essential to assuring efficiency and quality care.
Background:
At The Johns Hopkins Hospital (JHH), a culture of safety refers to the presence of characteristics such as the belief that harm is untenable and the use of a systems approach to analyzing safety issues.
Patient safety as a leadership and organizational priority:
The leadership of JHH provides strategic planning guidance for safety and improvement initiatives, involves the patient safety committee in capital investment allocation decisions and in designing and planning new hospital facilities, and ensures that safety and quality head the agenda of board-of-trustees meetings. Although JHH takes a systems approach, structures such as monitoring staff behavior trends are used to hold people accountable for job performance.
Challenges and lessons learned:
JHH encountered three major hurdles in implementing and sustaining a culture of safety. First, JHH's decentralized organizational structure contributes to a silo effect that limits the spread of ideas, practices, and culture. JHH intends to create an internal collaborative of departmental safety initiatives to foster opportunities for units to share ideas and results. Second, in response to the challenge of encouraging teams to think and act in an interdisciplinary fashion, communication and teamwork training are being used to enhance the effectiveness of interdisciplinary teams. Further development of valid and meaningful safety-related measurement and data collection methodologies is JHH's largest remaining challenge.
A model using administrative claims data that is suitable for profiling hospital performance for acute myocardial infarction would be useful in quality assessment and improvement efforts. We sought to develop a hierarchical regression model using Medicare claims data that produces hospital risk-standardized 30-day mortality rates and to validate the hospital estimates against those derived from a medical record model.
For hospital estimates derived from claims data, we developed a derivation model using 140,120 cases discharged from 4664 hospitals in 1998. For the comparison of models from claims data and medical record data, we used the Cooperative Cardiovascular Project database. To determine the stability of the model over time, we used annual Medicare cohorts discharged in 1995, 1997, and 1999-2001. The final model included 27 variables and had an area under the receiver operating characteristic curve of 0.71. In a comparison of the risk-standardized hospital mortality rates from the claims model with those of the medical record model, the correlation coefficient was 0.90 (SE=0.003). The slope of the weighted regression line was 0.95 (SE=0.007), and the intercept was 0.008 (SE=0.001), both indicating strong agreement of the hospital estimates between the 2 data sources. The median difference between the claims-based hospital risk-standardized mortality rates and the chart-based rates was <0.001 (25th and 75th percentiles, -0.003 and 0.003). The performance of the model was stable over time.
This administrative claims-based model for profiling hospitals performs consistently over several years and produces estimates of risk-standardized mortality that are good surrogates for estimates from a medical record model.
Prior studies have reported conflicting findings concerning the association of socioeconomic status (SES), treatment, and outcomes in patients hospitalized with heart failure (HF).
We conducted a retrospective analysis of medical record data from a national sample of Medicare beneficiaries hospitalized with HF between March 1998 and April 1999 (n = 25,086) to assess the association of patient SES, treatment, and outcomes. Patients' SES was designated as lower, lower-middle, higher-middle, and higher using residential ZIP code characteristics. Patients were evaluated for left ventricular systolic function assessment, prescription of angiotensin-converting enzyme inhibitors at discharge, readmission within 1 year of discharge, and mortality within 30 days and 1 year of admission. Hierarchical logistic regression models were used to assess the association of SES, quality of care, and outcomes adjusting for patient, physician, and hospital characteristics.
Lower SES patients (relative risk [RR] 0.92, 95% CI 0.87-0.96) were modestly less likely to have had a left ventricular systolic function assessment, but had a similar adjusted likelihood of being prescribed angiotensin-converting enzyme inhibitors (RR 1.03, 95% CI 0.93-1.11) compared with higher SES patients after multivariable adjustment. Socioeconomic status was not associated with 30-day mortality after multivariable adjustment, but lower SES patients had a higher risk of 1-year mortality (RR 1.10, 95% CI 1.02-1.19) and readmission within 1 year of discharge (RR 1.08, 95% CI 1.03-1.12) compared with higher SES patients.
Socioeconomic status in patients hospitalized with HF was not strongly associated with quality of care or 30-day mortality. However, the increased risk of 1-year mortality and readmission among patients of lower SES suggest SES may influence outcomes after hospitalization for HF.
Early administration of reperfusion therapy improves survival among patients with ST-elevation myocardial infarction. For primary percutaneous intervention, a goal of 90 minutes or less for door-to-balloon time is incorporated into many measures of quality performance, but delay remains common, with little improvement in this measure over recent years. This review examines the strategies for reducing door-to-balloon time and for selecting the appropriate reperfusion therapy, especially when a delay is unavoidable.
American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
- A H Travers
- T D Rea
- B J Bobrow
- D P Edelson
- R A Berg
- M R Sayre
Travers AH, Rea TD, Bobrow BJ, Edelson DP, Berg RA, Sayre MR, et al. Part 4: CPR overview:
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency
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What distinguishes top-performing hospitals in acute myocardial infarction mortality rates?
- Curry