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Aims and objectives: Pressure ulcers (PUs) are a serious health problem. They can be considered as an indicator of the quality of health care and are associated with considerable cost increases for the health care system. The prevention of PUs is a major concern in hospital care. The aim of the study was to reveal the current PU prevention‐related processes and structures with a specific focus on the Accident and Emergency (A&E) Department. Method: In late 2018/early 2019, all German hospitals were invited to participate in a nationwide cross‐sectional survey. One standardized questionnaire was assigned to a representative of each hospital. The representative was asked to state what PU‐related structures and processes are implemented in their hospital, in general and specific to the A&E department. Besides mostly descriptive analysis, PU‐related processes were analysed on PU incidence in a multivariate linear regression model. Results: Two hundred seventy‐six hospitals participated in the survey. 63.4% (n = 175) of the participating hospitals had at least one PU manager. Skin inspection was the most frequently performed procedure. Although not recommended, 1.3% (2.1%) of the facilities still use sheepskins quite often (very often). In the regression model on PU incidence, only the process 'mobilization in bed' was statistically significantly associated. Although the risk of developing a PU in the emergency department is high, more than half of the facilities had no PU guidelines. Conclusion: Even if recommended procedures (skin inspection, 30° positioning) have been used frequently, regular training could help to bring new scientific findings such as the use of local skin protection dressings into clinical practice. Prevention guidelines should be established in all areas of care even for A&E as well as when patients are transferred inside or out of the hospital, where the risk of PU development was considered low. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives: Strong health systems are said to be paramount to achieving effective and equitable health care. The World Health Organization has been advocating for using system-wide approaches such as 'systems thinking' to guide intervention design and evaluation. In this paper we report the system-wide effects of a complex health system intervention in Zambia known as Better Health Outcome through Mentorship and Assessment (BHOMA) that aimed to improve service quality. Methods: We conducted a qualitative study in three target districts. We used a systems thinking conceptual framework to guide the analysis focusing on intended and unintended consequences of the intervention. NVivo version 10 was used for data analysis. Results: The addressed community responded positively to the BHOMA intervention. The indications were that in the short term there was increased demand for services but the health worker capacity was not severely affected. This means that the prediction that service demand would increase with implementation of BHOMA was correct and the workload also increased, but the help of clinic lay supporters meant that some of the work of clinicians was transferred to these lay workers. However, from a systems perspective, unintended consequences also occurred during the implementation of the BHOMA. Conclusions: We applied an innovative approach to evaluate a complex intervention in low-income settings, exploring empirically how systems thinking can be applied in the context of health system strengthening. Although the intervention had some positive outcomes by employing system-wide approaches, we also noted unintended consequences. [ABSTRACT FROM AUTHOR]

Rationale This paper reports an initiative which promoted evidence-based practice in pressure risk assessment and management among home nursing clients in Melbourne, Australia. Aim and objectives The aim of this study was to evaluate the introduction and uptake of the Australian Wound Management Association Guidelines for the Prediction and Prevention of Pressure Ulcers. Method In 2007 a pilot study was conducted. Nurse perspectives (n=21) were obtained via survey and a client profile (n=218) was generated. Audit of the uptake and continued use of the pressure risk screening tool, during the pilot study and later once implemented as standard practice organizational wide, was conducted. Results Nurses at the pilot site successfully implemented the practice guidelines, pressure risk screening was adopted and supporting resources were well received. Most clients were at low risk of pressure ulcer development. The pilot site maintained and extended their pilot study success, ensuring more than 90% of clients were screened for pressure risk over the 18 months which followed. All other sites performed less well initially, however subsequently improved, meeting the pilot sites success after 18 months. Two years later, the organization continues to screen more than 90% of all clients for pressure risk. Conclusion Implementation of clinical practice guidelines was successful in the pilot project and pressure risk screening became a well-adopted practice. Success continued following organizational wide implementation. Pilot study findings suggest it may be prudent to monitor the pressure ulcer risk status of low risk clients so as to prevent increasing risk and pressure ulcer development among this group. [ABSTRACT FROM AUTHOR]

Rationale Little scrutiny has been applied to how 'cost per fall' values have been calculated and applied. This paper presents discourse discussing how the cost of fall statistic could potentially be misleading when applied to inpatient health or residential care settings and provides estimates of the cost of falls and cost of falls per person. Method Burden of disease was estimated using a decision tree approach. Data informing the decision tree were drawn from a retrospective audit of 545 falls in a residential care facility, a visual observation study of 46 residents from the same facility and a cohort study of 186 residents from nine different facilities in Australia. Acute care and transportation costs were extracted from the retrospective audit using incident reports and care note review. The distribution of falls per person and associations between falls, fractures and change in resident mobility were extracted from the cohort study. The association between resident mobility and the amount of time required to perform toileting, transfer and dressing activities was extracted from the visual observational study. Results The minimum 'cost per fall' was estimated to be $AUD 841 and the maximum was $AUD 1024. The 'cost of falls per person' estimate was $AUD 1887 (2008 base year). Conclusions This cost per fall estimate was substantially lower than three previous internationally derived estimates possibly as a consequence of how fall data were collected and modelled in these studies. Cost of falls per person may be a preferable statistic for future use. [ABSTRACT FROM AUTHOR]

Often, when conducting programme evaluations or studying the effects of policy changes, researchers may only have access to aggregated time series data, presented as observations spanning both the pre- and post-intervention periods. The most basic analytic model using these data requires only a single group and models the intervention effect using repeated measurements of the dependent variable. This model controls for regression to the mean and is likely to detect a treatment effect if it is sufficiently large. However, many potential sources of bias still remain. Adding one or more control groups to this model could strengthen causal inference if the groups are comparable on pre-intervention covariates and level and trend of the dependent variable. If this condition is not met, the validity of the study findings could be called into question. In this paper we describe a propensity score-based weighted regression model, which overcomes these limitations by weighting the control groups to represent the average outcome that the treatment group would have exhibited in the absence of the intervention. We illustrate this technique studying cigarette sales in California before and after the passage of Proposition 99 in California in 1989. While our results were similar to those of the Synthetic Control method, the weighting approach has the advantage of being technically less complicated, rooted in regression techniques familiar to most researchers, easy to implement using any basic statistical software, may accommodate any number of treatment units, and allows for greater flexibility in the choice of treatment effect estimators. [ABSTRACT FROM AUTHOR]

Rationale, Aims and Objectives: Nasogastric feeding is becoming commonly used to support patients with medically compromised eating disorders. Previous research has demonstrated the safety of this approach, however there is limited evidence as to how adult patients and staff perceive this feeding method. This study aimed to describe the acceptability of a nasogastric refeeding protocol with adult patients with medically unstable eating disorders and the staff involved in their treatment. Method: This was a qualitative exploratory study using semi‐structured interviews conducted in acute medical wards of a tertiary hospital where nasogastric nutrition is the sole source of nutrition for the first 7 days of the eating disorder admission. Data were analysed using the Framework method. Results: Eight patients (100% female, median: 22 years old, n = 6 diagnosed with anorexia nervosa) and 12 staff members (medical n = 5, nursing n = 5, dietitians n = 2; median: 8.5 years clinical experience) were interviewed. Patients reported that nasogastric feeding was tolerable, however concerns were raised regarding communication and the desire for concurrent oral feeding. Acceptability from staff was influenced by perceived competence, confidence, tensions around patient‐centred care, and working with stigma and ambivalence. Conclusions: Consideration needs to be given as to whether a 'nil by mouth' status during nasogastric feeding further impacts recommencing an oral diet to progress treatment. Improvements are required within the current service, including improved communication, additional educational resources for patients, and allowing patients to partake in decision‐making as able. [ABSTRACT FROM AUTHOR]

Background: At the start of the COVID‐19 pandemic, guidance was needed more than ever to direct frontline healthcare and national containment strategies. Rigorous guidance based on robust research was compromised by the emergence of the pandemic and the urgency of need for guidance. Rather than aiming to "get guidance right", guidance developers needed to "get guidance right now". Aim: To examine how guidance developers have responded to the need for credible guidance at the start of the COVID‐19 pandemic. Methods: An exploratory mixed‐methods study was conducted among guidance developers. A web‐based survey and follow‐up interviews were used to examine the most pertinent challenges in developing COVID‐19 guidance, strategies used to address these, and perspectives on the implications of the COVID‐19 pandemic on future guidance development. Results: The survey was completed by 46 guidance developers. Survey findings showed that conventional methods of guidance development were largely unsuited for COVID‐19 guidance, with 80% (n = 37) of respondents resorting to other methods. From the survey and five follow‐up interviews, two themes were identified to bolster the credibility of guidance in a setting of extreme uncertainty: (1) strengthening end‐user involvement and (2) conjoining evidence review and recommendation formulation. 70% (n = 32) of survey respondents foresaw possible changes in future guidance production, most notably shortening development time, by reconsidering how to balance between rigour and speed for different types of questions. Conclusion: "Getting guidance right" and "getting guidance right now" are not opposites, rather uncertainties are always part of guidance development and require guidance developers to balance scientific robustness with usability, acceptability, adequacy and contingency. This crisis points to the need to acknowledge uncertainties of scientific evidence more explicitly and points to mechanisms to live with such uncertainty, thus extending guidance development methods and processes more widely. [ABSTRACT FROM AUTHOR]

Rationale: Low mood may affect developing relationships with a new baby, partner and family. Early identification of mood disturbance is crucial to improve outcomes for women perinatally. Instruments such as the Edinburgh Postnatal Depression Scale (EPDS) are used routinely, with evidence that some women do not feel comfortable with how they are asked about their mental health. Objective: To develop a mood checklist as a user‐friendly, effective measure of well‐being in post‐partum women, for use by health professionals. Methods: Cognitive interviews with women who had recently given birth assessed response format and face validity of a prototype measure. A cross‐sectional survey followed. A random split‐half instrument development protocol was used. Exploratory factor analysis determined factor structure with the first sample,. The second sample confirmed factor structure and evaluationof key psychometric variables and known‐groups discriminant validity (KGDV), requiring a supplementary between‐subjects design with stratification based on case negative/case positive classification using EPDSscreening cut‐off criteria. Results: Cognitive interview data confirmed the face validity of the measure. Exploratory factor analysis indicated an 18 item two‐factor model with two (negatively) correlated factors. Factor 1 loaded with items reflecting positive mood and factor 2 negative items. Confirmatory factor analysis showed a good fit to the two‐factor model across the full spectrum of fit indices. Statistically significant differences between groups were observed in relation to as EPDS caseness classification. Cronbach alpha coefficients for the positive and negative subscales revealed acceptable internal consistency of 0.79 and 0.72, respectively. Conclusion: The outcome checklist may be appropriate for use in clinical practice. It demonstrated effective psychometric properties and clear cross‐validation with existing commonly used measures. [ABSTRACT FROM AUTHOR]

Rationale: Patients with complex care needs who frequently use health services often face challenges in managing their health and with integrated care, leading to frequent decision making. These complex care needs require a good understanding of health issues and their impact on daily life. As the decisional needs of this particular clientele have yet to be described in scientific literature, they warrant further study. Objectives: To assess the decision‐making needs of patients with complex care needs (PCCN) who frequently use health care services. Methods: We performed a multicenter cross‐sectional qualitative descriptive study in four institutions of the health and social services network of Quebec (Canada). We enrolled a convenience sample of PCCNs who frequently use health care services, health care providers, case managers, and decision‐makers. We conducted interviews and focus groups and investigated decisional needs according to the Ottawa decision support framework: roles played and desired in the decision‐making process, facilitators, and barriers. We conducted qualitative data collection and qualitative deductive/inductive thematic analysis within and across participating groups. Results: In total, 16 patients, 38 clinicians, six case managers, and 14 decision‐makers participated in the study. The decisional needs of this clientele are numerous, varied and different from those of the general population. We identified 26 decisional needs grouped under five themes. The most frequent decisions related to visiting the emergency department, moving to a nursing home, and adhering to a plan or treatment. In addition, we identified new themes such as patients' fear and mistrust of health professionals, differences of opinion between health professionals and health professionals' preconceived opinions of patients. Conclusion: We observed a wide range of types of decisions that patients face and differences in decision‐making needs across participating groups. Our results should inform future research on the development of a patient decision aid tool. [ABSTRACT FROM AUTHOR]

Rationale, Aims, and Objectives: The prevalence of burnout among medical doctors and its negative effect on empathy can influence therapeutic success. The aim of this study was to compare the levels of empathy and burnout between residents and specialists as well as to study the correlation between empathy and burnout. Methods: This is an exploratory study of a convenience sample of 104 doctors who work in health institutions in Greater Lisbon area in Portugal, covering central hospitals, district hospitals, and health centres. Each doctor filled in a questionnaire, which included the Maslach Burnout Inventory (MBI) and the Jefferson Scale of Empathy (JSE). Results: Participants were divided in two subgroups: 51% residents (n = 53) and 49% specialists (n = 51). A difference (p =.048) in JSE scores between residents (mean 116.4, SD 12.8) and specialists (mean 120.78, SD 12.84) has been identified. Furthermore, in all three MBI subscales (emotional exhaustion, depersonalization, and lack of personal accomplishment), the group of residents showed significantly higher mean scores. In general, empathy scores showed an inverse relationship between depersonalization (r = –0.390, p <.0001) and lack of personal accomplishment (r = –0.447, p <.0001). Finally, we found that an increase in MBI level is associated with a decrease in empathy levels. Conclusion: Our findings suggest that there is a significant difference in burnout subscales scores between residents and specialists and that these have a negative correlation with empathy level. These exploratory results draw attention to the importance of preventing burnout in hospital and health care centres professionals, in particular in residents, through the implementation of individual and organizational structured measures. [ABSTRACT FROM AUTHOR]

Background: In emergency departments, for some patients, death is preceded by a decision of withholding or withdrawing life‐sustaining treatments. This concerns mainly patients over 80, with many comorbidities. The decision‐making process of these decisions in emergency departments has not been extensively studied, especially for noncommunicating patients. Aim: The purpose of this study is to describe the decision‐making process of withholding and withdrawing life‐sustaining treatments in emergency departments for noncommunicating patients and the outcome of said patients. Design We conducted a prospective multicenter study in three emergency departments of university hospitals from September 2015 to January 2017. Results: We included 109 patients in the study. Fifty‐eight (53.2%) patients were coming from nursing homes and 52 (47.7%) patients had dementia. Decisions of withholding life‐sustaining treatment concerned 93 patients (85.3%) and were more frequent when a surrogate decision maker was present 61 (65.6%) versus seven (43.8%) patients. The most relevant factors that lead to these decisions were previous functional limitation (71.6%) and age (69.7%). Decision was taken by two physicians for 80 patients (73.4%). The nursing staff and general practitioner were, respectively, involved in 31 (28.4%) and two (1.8%) patients. A majority of the patients had no advance directives (89.9%), and the relatives were implicated in the decision‐making process for 96 patients (88.1%). Death in emergency departments occurred for 47 patients (43.1%), and after 21 days, 84 patients (77.1 %) died. Conclusion: There is little anticipation in end‐of‐life decisions. Discussion with patients concerning their end‐of‐life wishes and the writing of advance directives, especially for patients with chronic diseases, must be encouraged early. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Disparities in haemodialysis outcomes among centres have been well-documented. Besides, attempts to assess haemodialysis results have been based on non-comprehensive methodologies. This study aimed to develop a comprehensive methodology for assessing haemodialysis centres, based on the value of health care. The value of health care is defined as the patient benefit from a specific medical intervention per monetary unit invested (Value = Patient Benefit/Cost). This study assessed the value of health care and ranked different haemodialysis centres. Method A nephrology quality management group identified the criteria for the assessment. An expert group composed of stakeholders (patients, clinicians and managers) agreed on the weighting of each variable, considering values and preferences. Multi-criteria methodology was used to analyse the data. Four criteria and their weights were identified: evidence-based clinical performance measures = 43 points; yearly mortality = 27 points; patient satisfaction = 13 points; and health-related quality of life = 17 points (100-point scale). Evidence-based clinical performance measures included five sub-criteria, with respective weights, including: dialysis adequacy; haemoglobin concentration; mineral and bone disorders; type of vascular access; and hospitalization rate. The patient benefit was determined from co-morbidity-adjusted results and corresponding weights. The cost of each centre was calculated as the average amount expended per patient per year. Results The study was conducted in five centres (1-5). After adjusting for co-morbidity, value of health care was calculated, and the centres were ranked. A multi-way sensitivity analysis that considered different weights (10-60% changes) and costs (changes of 10% in direct and 30% in allocated costs) showed that the methodology was robust. The rankings: 4-5-3-2-1 and 4-3-5-2-1 were observed in 62.21% and 21.55%, respectively, of simulations, when weights were varied by 60%. Conclusions Value assessments may integrate divergent stakeholder perceptions, create a context for improvement and aid in policy-making decisions. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Variation in the workup of rectal bleeding may result in guideline-discordant care and delayed diagnosis of colorectal cancer. Accordingly, we undertook this study to characterize primary care clinicians' initial rectal bleeding evaluation. Methods We studied 438 patients at 10 adult primary care practices affiliated with three Boston, Massachusetts, academic medical centres and a multispecialty group practice, performing medical record reviews of subjects with visit codes for rectal bleeding, haemorrhoids or bloody stool. Nurse reviewers abstracted patients' sociodemographic characteristics, rectal bleeding-related symptoms and components of the rectal bleeding workup. Bivariate and multivariable logistic regression models examined factors associated with guideline-discordant workups. Results Clinicians documented a family history of colorectal cancer or polyps at the index visit in 27% of cases and failed to document an abdominal or rectal examination in 21% and 29%. Failure to order imaging or a diagnostic procedure occurred in 32% of cases and was the only component of the workup associated with guideline-discordant care, which occurred in 27% of cases. Compared with patients at hospital-based teaching sites, patients at urban clinics or community health centres had 2.9 (95% confidence interval 1.3-6.3) times the odds of having had an incomplete workup. Network affiliation was also associated with guideline concordance. Conclusion Workup of rectal bleeding was inconsistent, incomplete and discordant with guidelines in one-quarter of cases. Research and improvements strategies are needed to understand and manage practice and provider variation. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives To assess the adequacy of diagnostic effort in the emergency departments of Spanish hospitals with respect to episodes of exacerbation of chronic obstructive pulmonary disease ( COPD). Methods A descriptive cross-sectional study, conducted between 2007 and 2010 in 15 hospitals in Andalusia, Catalonia, Madrid and the Basque Country. The study population included cases of COPD exacerbation attended at the emergency departments of the participating hospitals. Diagnostic efforts were considered sufficient and appropriate when the emergency room conducted a clinical evaluation including electrocardiogram, chest X-ray, arterial blood gas analysis and spirometry. Results 2852 episodes of COPD exacerbation attended in hospital emergency departments were assessed. 91.4% of the patients were male, with a mean age of 72.8 ( SD 9.5) years, and 45.6% had had a previous emergency admission. The diagnostic effort was considered adequate in 60.1% of the episodes (95% CI: 58.3-61.9). The inter-hospital range of variation25-75 was 1.67 and the coefficient of variation was 28.3%. In multivariate analysis, adjusting for hospital, date of admission and previous hospitalization, among the male patients, the OR for adequate diagnostic effort was 1.38 (95% CI: 1.04-1.84) Conclusion With respect to diagnostic effort, inequities were observed in our assessment of episodes of COPD exacerbation attended in the emergency departments of Spanish public hospitals. In a high percentage of cases (40%), proper assessment was not conducted. Moreover, inter-individual and inter-hospital differences were observed. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Many peripheral intravenous catheter ( PIVC) infusion phlebitis scales and definitions are used internationally, although no existing scale has demonstrated comprehensive reliability and validity. We examined inter-rater agreement between registered nurses on signs, symptoms and scales commonly used in phlebitis assessment. Methods Seven PIVC-associated phlebitis signs/symptoms (pain, tenderness, swelling, erythema, palpable venous cord, purulent discharge and warmth) were observed daily by two raters (a research nurse and registered nurse). These data were modelled into phlebitis scores using 10 different tools. Proportions of agreement (e.g. positive, negative), observed and expected agreements, Cohen's kappa, the maximum achievable kappa, prevalence- and bias-adjusted kappa were calculated. Results Two hundred ten patients were recruited across three hospitals, with 247 sets of paired observations undertaken. The second rater was blinded to the first's findings. The Catney and Rittenberg scales were the most sensitive (phlebitis in >20% of observations), whereas the Curran, Lanbeck and Rickard scales were the most restrictive (≤2% phlebitis). Only tenderness and the Catney (one of pain, tenderness, erythema or palpable cord) and Rittenberg scales (one of erythema, swelling, tenderness or pain) had acceptable (more than two-thirds, 66.7%) levels of inter-rater agreement. Conclusions Inter-rater agreement for phlebitis assessment signs/symptoms and scales is low. This likely contributes to the high degree of variability in phlebitis rates in literature. We recommend further research into assessment of infrequent signs/symptoms and the Catney or Rittenberg scales. New approaches to evaluating vein irritation that are valid, reliable and based on their ability to predict complications need exploration. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives In the United States, paediatric patients receive only 41% of indicated preventive services. Past improvement efforts have not bundled preventive services to measure the reliability with which infants' physical, developmental and emotional needs are all addressed. We aimed to create a comprehensive bundle measure that reflects reliable delivery of preventive services during primary care visits, as well as overall preventive service status of a population of patients served by three primary care centres. Method Data were collected from electronic health records for cohorts of infants < 14 months old with at least one visit to one of three primary care centres. Immunizations, lead screening, developmental screening and screening for biopsychosocial risk factors (gestational age, parental depression, food insecurity) were chosen by local expert consensus for inclusion in the preventive services bundle measure. Monthly measures of preventive service status at 14 months of age were constructed. A visit-level bundle measure of preventive service delivery was also created. To obtain a baseline for improvement work, bundle completion rates were calculated for infants born in May 2011. Visit-level performance was measured for visits from July to August 2012. Results Among 278 patients born in May 2011, 22% of patients received the entire bundle of preventive services by 14 months of age. On a visit level, patients received all indicated services at 58% of visits. Conclusion A novel bundle measure can be used to characterize delivery of preventive services and drive improvement at both an individual visit level and a population level. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives The Hospital Federation of Vaud ( Switzerland) used a Breakthrough Collaborative with the aim of reducing adverse drug events ( ADEs) by 20% in 10 participating hospitals. Methods A set of interventions (covering patient identification, high-alert medication and medication preparation in the ward) was deployed over 18 months starting in October 2010. All hospitals monitored discrepancies between drugs prescribed and those prepared for administration, as well as the occurrence of ADEs using the ADE Trigger Tool for 18 months (cohort 1). A subset of five hospitals continued this monitoring for 12 additional months (cohort 2). Results In cohort 1, pill box discrepancies were present in 5.9% of doses ( n = 9772) in 2011 and in 5.8% ( n = 2251) in the first 3 months of 2012 (no statistical significance). There were no significant differences in the rate of ADEs/1000 doses across time (1.2 in 2010, 1.0 in 2011 and 1.0 in 2012). In cohort 2, pill box discrepancies were reduced from 6.5% ( n = 4846 doses) in 2011 to 4.4% ( n = 7355) in 2012 ( P < 0.001) to 3.0% for the first 3 months of 2013 ( n = 2251; P = 0.004). The rate of ADEs/1000 doses decreased (1.8 in 2010, 1.1 in 2011 and 0.6 in 2012/13 ( P = 0.008 for 2010-2011, and P < 0.001 for 2011-2012/2013). Conclusions Reductions in drug discrepancies and ADEs occurred in the cohort with the longer monitoring duration. Factors contributing to success may include the strategic status of the project, executive support, perseverance in post-intervention measurement, and institution-wide rather than partial deployment. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Clinical pathways ( CPs) can improve quality of care on intensive care units ( ICUs), but are infrequently utilized and of varying quality. Knowledge regarding factors that facilitate versus hinder successful implementation of CPs is insufficient and a better understanding of the activities and individuals involved is needed. The aim of this study was to explore the implementation process of CPs within the context of ICUs. Methods An exploratory design with a sequential mixed method was used. A CP survey, including all Swedish ICUs, was used to collect quantitative data from ICUs using CPs ( n = 15) and interviews with key informants ( n = 10) were used to collect qualitative data from the same ICUs. Descriptive statistics and qualitative content analysis were used, and the quantitative and qualitative findings were integrated. Results The CP implementation was conceptualized according to two interplaying themes: a process to realize the usefulness of CPs and create new habits; and a necessity of enthusiasm, support and time. Multiple factors affected the process and those factors were organized in six main categories and 14 subcategories. Conclusions Bottom-up initiatives, interprofessional project groups and small ICUs seem to enhance successful implementation of CPs while inadequate electronic health record systems, insufficient support and time constrains can be barriers. Support regarding the whole implementation process from centralized units at the local hospitals, as well as cooperation between ICUs and national guidance, has the potential to raise the quality of CPs and benefit the progress of CP implementation. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives This study aimed to evaluate the relative effectiveness of electronic and postal reminders for increasing adherence to the quality assurance programme for the international normalized ratio ( INR) point-of-care testing ( POCT) device in primary care. Methods All 213 family practices that use the Elective Laboratory of the Capital Region, Denmark, and regularly conduct INR POCT were randomly allocated into two similarly sized groups. During the 4-month intervention, these practices were sent either computer reminders ( Com Rem) or computer-generated postal reminders ( Postal) if they did not perform a split test to check the quality of their INR POCT for each calendar month. The adherence of the practices was tracked during the subsequent 8 months subdivided into two 4-month periods both without intervention. Outcomes were measures of split test procedure adherence. Results Both interventions were associated with an increase in adherence to the split test procedure - a factor 6.00 [95% confidence interval (CI) 4.46-7.72] and 8.22 [95% CI 5.87-11.52] for ComRem and Postal, respectively - but there is no evidence that one of the interventions was more effective than the other. In the Com Rem group, the expected number of split tests (out of four) was 2.54 (95% CI 2.33-2.76) versus 2.44 (95% CI 2.24-2.65) in the Postal group, P = 0.14. There was a slight decrease in adherence over the two follow-ups, but neither intervention was better than the other in achieving a lasting improvement in adherence. Conclusion Computer reminders are as efficient as postal reminders in increasing adherence to a quality assurance programme for the INR POCT device in primary care. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Continuous quality improvement programmes often target several aspects of care, some of which may be more effective meaning that resources could be focussed on these. The objective was to identify the effective and ineffective aspects of a successful continuous quality improvement programme for individuals with type 2 diabetes in primary care. Methods Data were from a series of cross-sectional studies ( GEDAPS) in primary care, Catalonia, Spain, in 55 centres (2239 participants) in 1993, and 92 centres (5819 participants) in 2002. A structural equation modelling approach was used. Results The intervention was associated with improved microvascular outcomes through microalbuminuria and funduscopy screening, which had a direct effect on microvascular outcomes, and through attending 2-4 nurse visits and having ≥1 blood pressure measurement, which acted through reducing systolic blood pressure. The intervention was associated with improved macrovascular outcomes through blood pressure measurement and attending 2-4 nurse visits (through systolic blood pressure) and having ≥3 education topics, ≥1 HbA1c measurement and adequate medication (through HbA1c). Cholesterol measurement, weight measurement and foot examination did not contribute towards the effectiveness of the intervention. Conclusions The pathways through which a continuous quality improvement programme appeared to act to reduce microvascular and macrovascular complications were driven by reductions in systolic blood pressure and HbA1c, which were attained through changes in nurse and education visits, measurement and medication. This suggests that these factors are potential areas on which future quality improvement programmes should focus. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives To determine whether US home health agencies that intensively engaged with the 2010 Home Health Quality Improvement National Campaign were more likely to reduce acute care hospitalization ( ACH) rates than less engaged agencies. Method We included all Medicare-certified agencies that accessed Campaign resources in the first month of the Campaign and also responded to an online survey of resource utilization at month two. We used the survey data and item response theory to estimate a latent construct we called engagement with the campaign. ACH rates were calculated from the Centers for Medicare & Medicaid Services Outcome and Assessment Information Set for pre- and post-intervention periods ( March- November 2009 and 2010, respectively). Results Staff from 1077 agencies accessed resources in the first month of the Campaign. Of these, 382 provided information about resource use and had 10 or more monthly discharges throughout the measurement periods. Dividing these agencies into quartiles based on engagement score, we found an association between engagement and reduction in ACH rates, P = 0.049 (χ2 for trend). Exploratory path analysis revealed the effect of engagement score on reduction in ACH rate to be partially mediated through reduction in average length of service rates. Conclusion We found evidence that early intensity of engagement with the Campaign, as measured through use of activities and resources, was positively associated with improvement. To continue the investigation of this relationship, future work in this and other campaigns should focus on further development of engagement measures. [ABSTRACT FROM AUTHOR]

Rationale, aims, and objectives Large-scale, multi-network clinical trials are seen as a means for efficient and effective utilization of resources with greater responsiveness to new discoveries. Formal structures instituted within the National Institutes of Health ( NIH) HIV/ AIDS Clinical Trials facilitate collaboration and coordination across networks and emphasize an integrated approach to HIV/ AIDS vaccine, prevention and therapeutics clinical trials. This study examines the joint usage of clinical research sites as means of gaining efficiency, extending capacity, and adding scientific value to the networks. Methods A semi-structured questionnaire covering eight clinical management domains was administered to 74 (62% of sites) clinical site coordinators at single- and multi-network sites to identify challenges and efficiencies related to clinical trials management activities and coordination with multi-network units. Results Overall, respondents at multi-network sites did not report more challenges than single-network sites, but did report unique challenges to overcome including in the areas of study prioritization, community engagement, staff education and training, and policies and procedures. The majority of multi-network sites reported that such affiliations do allow for the consolidation and cost-sharing of research functions. Suggestions for increasing the efficiency or performance of multi-network sites included streamlining standards and requirements, consolidating protocol activation methods, using a single cross-network coordinating centre, and creating common budget and payment mechanisms. Conclusions The results of this assessment provide important information to consider in the design and management of multi-network configurations for the NIH HIV/ AIDS Clinical Trials Networks, as well as others contemplating and promoting the concept of multi-network settings. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Fibromyalgia ( FM) is challenging to diagnose, especially in primary care settings. The Fibromyalgia Diagnostic Screen was developed to facilitate the diagnosis of FM in clinical practice. The objectives of this study were to assess the performance of the Fibromyalgia Diagnostic Screen in primary care and specialty clinics, using the 1990 American College of Rheumatology ( ACR) diagnostic criteria as the gold standard, and comparing the Fibromyalgia Diagnostic Screen with the London Fibromyalgia Epidemiology Study Screening Questionnaire ( LFESSQ) and the modified 2010 ACR Fibromyalgia Diagnostic Criteria ( ACR-FDC). Methods This multicenter, cross-sectional study included 150 adult chronic pain patients who underwent a physician-administered structured history and physical exam and completed the Fibromyalgia Diagnostic Screen, the LFESSQ and the modified ACR-FDC. The analyses determined the predictive ability of the Fibromyalgia Diagnostic Screen for FM. Results Item-level analyses provided support for the response categories and predictive ability of most of the Fibromyalgia Diagnostic Screen items. Additionally, the evaluation of the Fibromyalgia Diagnostic Screen scoring models demonstrated the greatest accuracy in predicting an FM diagnosis with a combination of patient items and clinician items that included an abbreviated tender point exam (sensitivity 0.68, specificity, 0.82). Sensitivity of the modified ACR-FDC and the LFESSQ was 0.87 and 0.86, respectively, with specificity 0.62 and 0.49, respectively. Conclusions The Fibromyalgia Diagnostic Screen is a useful new clinical tool to aid in the evaluation of FM in clinical practice. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives To identify the prevalence of clinical pathways ( CPs) in Swedish intensive care units ( ICUs) and to explore the quality, content and evidence base of the documents. Methods A descriptive and explorative survey of all Swedish ICUs ( N84) and a review of submitted examples of CPs (n12) were conducted. Results CPs were in use at 20% of the Swedish ICUs. There was a significant geographic variation but no relationship between the use of CPs and category of hospital, type of ICU, size of ICU or type of health record applied. In total, 56 CPs were reported within a range of scopes and extensions. The content of the ICUs' CPs, as well as the degree to which they were interprofessional, evidence based, and renewed varied. Conclusions Progress has been made in relation to CPs in recent years, but there is potential for further improvements. None of the ICUs had CPs that contained all key characteristics of a high-quality, interprofessional and evidence-based CP identified in the literature. Greater knowledge sharing and cooperation within the field would be beneficial, and further research is needed. [ABSTRACT FROM AUTHOR]

Background Various authorities recommend the participation of patients in promoting patient safety, but little is known about health care professionals' (HCPs') attitudes towards patients' involvement in safety-related behaviours. Objective To investigate how HCPs evaluate patients' behaviours and HCP responses to patient involvement in the behaviour, relative to different aspects of the patient, the involved HCP and the potential error. Design Cross-sectional fractional factorial survey with seven factors embedded in two error scenarios (missed hand hygiene, medication error). Each survey included two randomized vignettes that described the potential error, a patient's reaction to that error and the HCP response to the patient. Setting Twelve hospitals in Switzerland. Participants A total of 1141 HCPs (response rate 45%). Measurements Approval of patients' behaviour, HCP response to the patient, anticipated effects on the patient-HCP relationship, HCPs' support for being asked the question, affective response to the vignettes. Outcomes were measured on 7-point scales. Results Approval of patients' safety-related interventions was generally high and largely affected by patients' behaviour and correct identification of error. Anticipated effects on the patient-HCP relationship were much less positive, little correlated with approval of patients' behaviour and were mainly determined by the HCP response to intervening patients. HCPs expressed more favourable attitudes towards patients intervening about a medication error than about hand sanitation. Conclusions This study provides the first insights into predictors of HCPs' attitudes towards patient engagement in safety. Future research is however required to assess the generalizability of the findings into practice before training can be designed to address critical issues. [ABSTRACT FROM AUTHOR]

Background In recent years, factors that affect patients' willingness and ability to participate in safety-relevant behaviours have been investigated. However, how trained healthcare professionals or medical students would feel participating in safety-relevant behaviours as a patient in hospital remains largely unexplored. Objectives To investigate medical students' willingness to participate in behaviours related to the quality and safety of their health care. Design A cross-sectional exploratory study using a survey that addressed willingness to participate in different behaviours recommended by current patient safety initiatives. Three types of interactional behaviours (asking factual or challenging questions, notifying doctors or nurses of errors/problems) and three non-interactional behaviours (choosing a hospital based on the safety record, bringing medicines and a list of allergies into hospital, and reporting an error to a national reporting system) were assessed. Participants One hundred and seventy-nine medical students from an inner city London teaching hospital participated in the study. Findings Students' willingness to participate was affected ( P < 0.05) by the action required by the patient and (for interactional behaviours) whether the patient was engaging in the specific action with a doctor or nurse. Students were least willing to ask 'challenging' questions to doctors and nurses and to report errors to a national reporting system. Doctors' and nurses' encouragement appeared to increase self-reported willingness to participate in behaviours where baseline willingness was low. Conclusion Similar to research on lay patient populations; medical students do not view involvement in safety-related behaviours equally. Interventions should be tailored at encouraging students to participate in behaviours they are less inclined to take on an active role in. Future research is required to examine students' motivations for participation in this important but heavily under-researched area. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Understanding sources of knowledge used in everyday practice is very helpful in improving the quality of health care services. There is a consensus in the literature that nurses mostly relied in their practice on experiential knowledge gained through their interactions with other members of health care professionals and patients. The general aim of this study is to explore the sources of knowledge Jordanian registered nurses use during their practice. Method A descriptive correlational design was used to collect data from 539 Jordanian registered nurses from 10 hospitals using a self-administered questionnaire. Results The mean year of experience of the sample was 7.08 years. Of the 615 questionnaires distributed, 555 were returned. This yields a response rate of 87.6%. Results revealed that the top five ranked sources used by Jordanian registered nurses include: the information that nurses learned during nursing education, personal experience in nursing over time, what was learned through providing care to patients, information gained through discussion between physicians and nurses about patients, and information from policy and procedure manuals. Conclusion Jordanian registered nurses recognize the value of research and that research utilization (RU) is an important issue and must not be ignored. The study has many implications for practice, education and research. Health care managers and decision makers need to play a more visible and instrumental role in encouraging RU to improve patients' quality of life. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Systematic reviews, meta-analyses and clinical guidelines (reviews) are intended to inform clinical practice, and in this sense can be thought of as scientific truthmakers. High-quality controlled trials should align to this truth, and method quality markers should predict truth status. We sought to determine in what way controlled trial quality relates to scientific truth, and to determine predictive utility of trial quality and bibliographic markers. Method A sample of reviews in rehabilitation medicine was examined. Two scientific truth dimensions were established based on review outcomes. Quality and bibliographic markers were extracted from associated trials for use in a regression analysis of their predictive utility for trial truth status. Probability analysis was undertaken to examine judgments of future trial truth status. Results Of the 93 trials included in contemporaneous reviews, overall, n = 45 (48%) were true. Randomization was found more in true trials than false trials in one truth dimension ( P = 0.03). Intention-to-treat analysis was close to significant in one truth dimension ( P = 0.058), being more commonly used in false trials. There were no other significant differences in quality or bibliographic variables between true and false trials. Regression analysis revealed no significant predictors of trial truth status. Probability analysis reported that the reasonable chance of future trials being true was between 2 and 5%, based on a uniform prior. Conclusions The findings are at odds with what is considered gold-standard research methods, but in line with previous reports. Further work should focus on scientific dynamics within healthcare research and evidence-based practice constructs. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives To evaluate asthma management and control in primary care clinics so as to design improvements based on guideline-directed outcomes. Methods In this study, all medical records of asthma-diagnosed patients (children as well as adults, entire lifespan, asthma-related visits or not) were retrospectively reviewed as a basis for assessing the level of guideline adherence and asthma control. Six primary health care clinics were visited in the Dr Kenneth Kaunda Municipal District, Potchefstroom, South Africa during May to July 2008, 2009 and 2010. Results A total of 323 asthma patient records were reviewed over the three time slots, resulting in 125, 87, and 111 patients respectively. A suboptimal clinical asthma control picture, with a mere 16% (n = 20) of females and 2% (n = 3) of males with Peak Expiratory Flow (PEF) percentages above 60%, were observed in the initial assessment. Improvement in control was observed during the following time slot, but with an end result in 2010 of no PEF percentages above 60% for males and only 9% (n = 7) for females. Conclusion Over all three of the data collection periods adherence to effectively applied management of asthma guidelines proved to be below the minimum recommended clinical evaluation work-up as set out by the Expert Panel Report 3 (EPR3) of the National Asthma Education and Prevention Program (NAEPP). Applying a greater focus on essential outcomes through different disease management documents resulted in an improved quality of managed care, but still requires dedicated and continuous education and motivation. (NWU-0052-08-A5) [ABSTRACT FROM AUTHOR]

Purpose This exploratory study sought to explore the patient experience of the surgical journey from decision to operate, to hospitalization, discharge and subsequent recovery. Design Patients attended one of two focus group discussions. Patient sample Seven patients that had undergone surgery for spinal stenosis or disc prolapsed participated, aged between 48-75 years (mean age 59); five were male. Methods Patients' attitudes towards the information and care they received from the point of the decision to operate through to post-operative recovery were explored. Particular attention was paid to patients' information needs, support provided, general understanding of the processes and ways in which care could have been improved. Results Patients identified nine main 'needs' they felt played an integral part in enhancing the patient experience including the need for reduced waiting times, for better information and preparation, to be proactive, to speak up and ask questions, to feel safe and to be treated with dignity and respect; and the need for ongoing support, human contact, and; continuity of care. Conclusion These findings suggest that there are several measures that could be taken to improve the patient's surgical experience. In particular, providing appropriate information to patients in a timely manner and ensuring that support and advice is easily accessible for those patients that need it are key areas for improvement. [ABSTRACT FROM AUTHOR]

Objective Self-efficacy - the confidence to carry out certain behaviour in order to achieve a specific goal - has increasingly been recognized as an essential prerequisite of effective self-management of chronic diseases. Therefore, valid and reliable measures are needed to evaluate self-efficacy in both research and clinical practice. This study explored the psychometric properties of the German version of the Self-Efficacy for Managing Chronic Disease 6-Item Scale (SES6G). Methods We performed standardized translation and cultural adaptation of the SES6G into German. The SES6G was externally validated with the German General Self-Efficacy Scale (SWE). Cronbach's alpha, descriptive statistics and principal component analysis were used to assess psychometric properties of the SES6G. We assessed the effect of the number of co-occurring chronic diseases on SES6G scores using linear regression modelling by controlling for age, gender and education level. Results We analysed data of 244 primary care patients in Germany. The SES6G showed good convergent construct validity to the SWE (spearman rank correlation 0.578, P < 0.001) and high internal consistency (Cronbach's alpha 0.930). Principal component analysis underlined the one-dimensional structure of the instrument. Adjusted for age and gender, increasing numbers of co-occurring chronic diseases were associated with lower SES6G scores (standardized β-value −0.27, P < 0.001). Education level showed no significant effect. Conclusions The SES6G is a reliable and valid instrument to assess patients' self-efficacy for managing chronic diseases. It may enhance further research in German-speaking countries and appears to be a valuable measure for clinical practice. [ABSTRACT FROM AUTHOR]

Rational, aims and objective The aim of the present study was to compare the ease of use and the capability of four approaches [Medication Appropriateness Index (MAI), the Beers' criteria 2003, the Improved Prescribing in the Elderly Tool (IPET) and Health Plan Employer Data and Information Set (HEDIS)] in assessing changes in medication appropriateness in elderly patients over a period of hospitalization. Methods A retrospective observational study in two hospitals in Northern Ireland using the four measures was undertaken, involving a cohort of 192 patients (aged > 65 years). Medication appropriateness assessments were made at three stages during the patients' hospital 'journey', that is, at admission, during their inpatient stay and at discharge. The identifying rates of inappropriate prescribing in elderly patients in hospital used validated screening tools: MAI, the Beers' criteria 2003, the IPET and HEDIS. Results The MAI was the most comprehensive approach but was also the most time consuming to apply. Data derived using the MAI indicated clearly that there was improved medication appropriateness over the three hospital stay stages ( P < 0.001). Although this trend was also significant for the Beers' criteria 2003 ( P < 0.05) and the IPET ( P < 0.05) approaches, the HEDIS was unable to differentiate changes in appropriateness over time. There was a good correlation between data derived using the MAI and the Beers' criteria 2003 and the IPET approaches; this correlation was not evident for the HEDIS. Conclusions The MAI is the most convincing tool in evaluating medication appropriateness, but is very time consuming to apply. Beers' criteria 2003 and the IPET perform to an acceptable standard within the clinical setting and are more practical in their application. The HEDIS, although simplest to apply, does not have the sensitivity to measure change in appropriateness over time. [ABSTRACT FROM AUTHOR]

Rationale Understanding scientific collaboration networks can assist research centres to develop strategies to maximize productivity, and help diagnose the causes of low system productivity. The purpose of this study was to use social network analysis to better understand how research collaboration within a productive department impacts scholarly productivity individually and departmentally. Methods Over a 13-year period, departmental faculty completed an annual survey describing their research collaborations and scholarly productivity. Data were analyzed using social network analysis. Quadratic assignment procedure regression assessed the predictive value that an individual's measures of centrality within the network and effective size of their own network (egonet) had each year in predicting each scholarly outcome. Simulation Investigation for Empirical Network Analysis software assessed the co-evolution of the collaborative network and scholarship. Results While no consistent patterns for individual's presentations were seen, individual's publications were associated with betweenness and eigenvector centrality, and effective egonet size. Grant submissions were associated with degree and eigenvector centrality, as well as effective egonet size. Departmentally, network dynamics depended upon the scholarship of those around you, but none of the forms of scholarship depended upon network characteristics. Of the three forms of scholarship, network dynamics depended primarily on publications in others. Conclusion Although individual scholarship was dependent upon individual centrality and effective egonet size, research collaboration within the department depended upon reciprocity, transitivity and scholarly productivity of its constituent investigators. Scholarly dynamics, at a departmental level, did not depend upon network characteristics. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Early adopters of electronic health records (EHRs) are transitioning from older to newer EHRs to satisfy meaningful use requirements. Facilitators and barriers to satisfaction after transitioning are important to understand as provider satisfaction is linked with improvement in health care. Method We conducted a cross-sectional survey of providers who transitioned from an older to a newer EHR at six academic, urban ambulatory medical practices. A novel survey was developed to assess: (1) satisfaction with the EHR implementation; (2) patterns of information technology use; (3) work perceptions; (4) methods for completing clinical tasks; and (5) demographic characteristics. We analysed the results using bivariate and multivariate analyses. Results The response rate was 64% ( n = 197). A small majority were satisfied with the new EHR (64%, n = 120). Providers who reported satisfaction with overall quality of work life, their workload and the transition were more likely to be satisfied with the new EHR ( P < 0.01). Providers who reported using the Internet at least daily were also more likely to be satisfied with the new EHR ( P < 0.05). In a multivariate model, satisfaction with the transition was a strong predictor of satisfaction with the new EHR ( P < 0.01). Barriers to satisfaction include dissatisfaction with: maintaining problem and medication lists, tracking health maintenance information, referring to clinical practice guidelines and ordering laboratory and radiology tests ( P < 0.01). Conclusion This study provides groundwork for understanding the facilitators and barriers to provider satisfaction after the transition between EHRs and provides insight into areas requiring attention by entities undergoing similar transitions. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Cardiovascular disease (CVD) often arises from modifiable lifestyle factors. Health care professionals may lack the skills and resources to sustain behaviour change, lay 'health trainers' (LHT) offer a potential alternative. We sought to assess the cost-effectiveness of using a LHT to improve heart-health lifestyles in deprived communities. Methods Participants in this randomized trial were aged ≥18 years with at least one risk factor for CVD (hypertension, raised cholesterol, diabetes, BMI>30 or current smoker). Both groups received health promotion literature. LHT were also able to provide intervention participants with information, advice and support aimed at changing beliefs and behaviour. Costs and quality-adjusted life year (QALY) changes were estimated over 6 months. The cost-utility [incremental cost-effectiveness ratio (ICER)] of LHT was calculated and assessed in relation to the cost-effectiveness threshold of £20 000-30 000 per QALY. The probability of LHT being cost-effective was also calculated. Results Seventy-two participants were randomized to a LHT, with 38 controls. The mean cost of the LHT intervention was £151. On average, other health and social service costs fell by £21 for controls and £75 for intervention participants giving a LHT mean overall incremental cost of £98. The mean QALY gains were 0.022 and 0.028, respectively. The ICER for LHT was £14 480, yet there was a 61% chance of making the wrong decision at a £20 000/QALY threshold. Conclusion LHT provision was estimated to be cost-effective for people at risk of CVD. However, a large level of uncertainty was associated with that decision. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Patients can play an important role in reducing health care harm. Finding strategies to encourage patients to take on an active role in issues related to the quality and safety of their care is therefore essential. The aim of this study was to examine patients' and health care professionals' attitudes towards a video aimed at promoting patient involvement in safety-related behaviours. Method A within-subjects design was used where participants were required to complete a questionnaire pre and post screening of a patient safety video. Participants are 201 patients aged 19-103 years (mean 52) and 95 health care professionals aged 23-48 years (mean 32). Main outcome measures include (i) patients' willingness to participate and perceived importance in participating in safety-related behaviours; and (ii) health care professionals' willingness to support patient involvement. Results After watching the video patients elicited more positive attitudes towards asking doctors and nurses if they had washed their hands and notifying them about issues to do with personal hygiene. No significant effects were observed in relation to patients notifying staff if they have not received their medication or if they were in pain or feeling unwell. In relation to health care professionals, doctors and nurses were more willing to support patient involvement in asking about hand hygiene after they had watched the video. Conclusion Video may be effective at changing patients' and health care professionals' attitudes towards patient involvement in some, but not all safety-related behaviours. Our findings suggest video may be most effective at encouraging involvement in behaviours patients are less inclined to participate in and health care professionals are less willing to support. [ABSTRACT FROM AUTHOR]

Aim To compare overall unit-level pressure ulcer (PU) prevalence, hospital-acquired pressure ulcer (HAPU) prevalence and prevention strategies, as well as nurse staffing and workload in two hospitals in Sweden with data from the USA. Methods Medical and surgical units in a university hospital and a general hospital in Sweden were compared with 207 hospitals in the USA participating in the Collaborative Alliance for Nursing Outcomes (CALNOC) benchmarking registry. All adult inpatients in university hospital ( n = 630), general hospital ( n = 253) and CALNOC hospitals ( n = 3506) were included in the study. Outcome indicators were pressure ulcer prevalence for all types (PU) and HAPU prevalence, specifically. Process indicators were risk assessment and PU prevention strategies. Structure indicators were nurse staffing (hours of care, and skill mix) and workload (admissions, discharges and transfers). Results The prevalence of PU (categories 1-4) was 17.6% (university hospital) and 9.5% (general hospital) compared with 6.3-6.7% in the CALNOC sample. The prevalence of full thickness HAPU (categories 3 and 4) was 2.7% (university hospital) and 2.0% (general hospital) compared with 0-0.5% in the CALNOC sample. Risk and skin assessment varied between 6% and 60% in the Swedish hospitals compared with 100% in the CALNOC sample. Total hours per patient day were 8.4 in both Swedish hospitals and 9.5 to 9.8 in the CALNOC hospitals Conclusions The findings suggest a link between processes of care and outcomes that is exciting to observe internationally and suggest the opportunity to expedite performance improvement through global benchmarking. Using HAPU as a complement to point prevalence of PU in Sweden has revealed this indicator as a more valid measure for patient care quality. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Previous service development work in the area of integrated medicines management (IMM) has demonstrated clear quality improvements in a targeted group of patients within a hospital in Northern Ireland. In order to determine whether this programme could be transferable to routine practice and thereby assess its generalizability, research has been carried out to quantify the health care benefits of incorporating the concept of IMM as routine clinical practice. Method The IMM programme of care was delivered to all eligible patients (subject to inclusion criteria) across two hospital sites in Northern Ireland during normal pharmacy opening hours. All patients were followed up for a period of 12 months from their time of hospital admission. All patient data were collected using the custom-designed Electronic Pharmacist Intervention Clinical System at each stage of their hospital journey, that is, admission, inpatient stay and discharge. Results Patients who received the IMM service benefited from a reduced length of hospital stay on their reference admission (1.42 days; P = 0.020) as well as a reduced length of stay during the first rehospitalization (5.86 days; P = 0.013). There was also a trend of a reduced number of readmissions and a longer time to readmission during the 12-month follow-up period. Potential significant opportunity cost savings were demonstrated as well as a significant improvement in medication appropriateness (discharge vs. reference admission). Conclusions The IMM programme of care has proven to be transferable to routine hospital care within two hospitals in Northern Ireland. It is anticipated that this current research will further inform the development of IMM as routine clinical practice across Northern Ireland and beyond. [ABSTRACT FROM AUTHOR]

Objective Knee range of motion (ROM) at discharge from acute care is used as a clinical indicator following total knee replacement (TKR) surgery. This study aimed to assess the clinical relevance of this indicator by determining whether discharge knee ROM predicts longer-term knee ROM and patient-reported knee pain and function. Methods A total of 176 TKR recipients were prospectively followed after discharge from acute care. Outcomes assessed included knee ROM and Oxford knee score post rehabilitation and 1 year post surgery. Discharge ROM and other patient factors were identified a priori as potential predictors in multiple linear regression modelling. Results A total of 133 (76%) and 141 (80%) patients were available for follow-up post rehabilitation [mean postoperative week 8.1 (SD 2.7)] and at 1 year [mean postoperative month 12.1 (SD 1.4)], respectively. Greater discharge knee flexion was a significant ( P < 0.001) predictor of greater post-rehabilitation flexion but not 1-year knee flexion ( P < 0.083). Better discharge knee extension was a significant predictor of better post-rehabilitation ( P = 0.001) and 1-year knee extension ( P = 0.013). Preoperative Oxford score and post-rehabilitation knee flexion independently predicted post-rehabilitation Oxford score, and gender predicted 1-year Oxford score. Discharge ROM did not significantly predict Oxford score in either model. Conclusion The finding that early knee range predicts longer-term range provides clinical evidence favouring the relevance of discharge knee ROM as a clinical indicator. Although longer-term patient-reported knee pain and function were not directly associated with discharge knee ROM, they were associated with ROM when measured concurrently in the sub-acute phase. No causal effect has been demonstrated, but the findings suggest it may be important for physiotherapists to maximize range in the early and sub-acute periods. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives This study was to examine changes in doctor pharmaceutical utilization behaviour in response to Taiwan's newly implemented National Health Insurance individual hospital global budget (GB) programme and the changes in health care costs and prescription trends for hypertensive (HT) patients. Method We analysed hospital outpatient prescription utilization with a pre-post individual hospital GB group and comparison group (the hospitals who did not join the programme) to evaluate the impact of GB strategies on hypertensive expenditure. Descriptive analyses were performed based on the average daily medication expenditure for each prescription, and average number of items per prescription. Results This study reviewed 16 770 057 outpatient records and prescription records of 213 568 hypertensive patients. The average total medication expense (+17.6%), HT medication expense (+8.8%), daily medication expense (+16.3%), and daily HT medication expense (+6.3%) significantly increased after the action. After the individual hospital GB action, hospital doctors participating in action switched their patients' prescription drugs to other less expensive drugs such as rennin-angiotensin-aldosterone system inhibitors (−1.1%). The increase in volume of medications prescribed for control group were significantly larger for both alfa- and beta-adrenergic blocking agents (1.5%), and calcium channel blocking agents (3.9%). Conclusion The individual hospital GB programme slowed down the trend of prescription drug cost increasing rate and reduced the prescription drug volume in hospitals. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Arguably, a shared perspective between managers and their clinical staff on an improvement initiative would allow for most effective implementation and increase programme success. However, it has been reported that research has failed to differentiate between managers and line employees on quality management implementation and examine their differences in perceptions of quality and safety initiatives. The aim of this study was to compare clinical frontline staff and senior managers' perceptions on the importance of an organization-wide quality and safety collaborative: the Safer Patients Initiative (SPI). Method A quantitative study obtained 635 surveys at 20 trusts participating in SPI. Participants included the teams and frontline staff involved within the programme at each organization. Independent T-tests were carried out between frontline staff and senior managers' perceptions of SPI programme elements, success factors and impact & sustainability. Results Statistically significant differences were found between the perceptions of frontline staff and senior managers on a wide number of issues, including the frontline perceiving a significantly larger improvement on the timeliness of care delivery ( t = 2.943, P = 0.004), while managers perceived larger improvement on the culture within the organization for safe, effective and reliable care ( t = −2.454, P = 0.014). Conclusion This study has identified statistically significant disparities in perceptions of an organization-wide improvement initiative between frontline staff and senior managers. This holds valuable implications for the importance of getting both frontline and management perspectives when designing such interventions, in monitoring their performance, and in evaluating their impact. [ABSTRACT FROM AUTHOR]