National Healthcare Quality and Disparities Report
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AHRQ Research Studies Date
Topics
- Adverse Drug Events (ADE) (1)
- Adverse Events (8)
- Behavioral Health (1)
- Blood Clots (3)
- Blood Thinners (1)
- Cardiovascular Conditions (1)
- Caregiving (1)
- Catheter-Associated Urinary Tract Infection (CAUTI) (2)
- Central Line-Associated Bloodstream Infections (CLABSI) (5)
- Children/Adolescents (1)
- Clinical Decision Support (CDS) (3)
- Clostridium difficile Infections (3)
- Communication (1)
- Comparative Effectiveness (1)
- Comprehensive Unit-based Safety Program (CUSP) (1)
- Consumer Assessment of Healthcare Providers and Systems (CAHPS) (1)
- COVID-19 (1)
- Critical Care (1)
- Education: Patient and Caregiver (2)
- Electronic Health Records (EHRs) (2)
- Emergency Department (1)
- Evidence-Based Practice (2)
- Falls (8)
- Healthcare-Associated Infections (HAIs) (19)
- Healthcare Costs (1)
- Health Information Technology (HIT) (2)
- Hospital Discharge (1)
- Hospitalization (6)
- Hospital Readmissions (1)
- (-) Hospitals (41)
- Implementation (2)
- Infectious Diseases (9)
- Injuries and Wounds (2)
- Inpatient Care (7)
- Intensive Care Unit (ICU) (2)
- Medicare (1)
- Medication (2)
- Medication: Safety (1)
- Methicillin-Resistant Staphylococcus aureus (MRSA) (3)
- Mortality (1)
- Neurological Disorders (1)
- Nursing (1)
- Organizational Change (1)
- Outcomes (1)
- Patient-Centered Healthcare (2)
- Patient Adherence/Compliance (1)
- Patient and Family Engagement (2)
- Patient Safety (28)
- Payment (3)
- Policy (1)
- Pressure Ulcers (3)
- (-) Prevention (41)
- Provider (1)
- Provider: Health Personnel (1)
- Provider: Nurse (1)
- Provider Performance (2)
- Public Health (3)
- Public Reporting (1)
- Quality Improvement (4)
- Quality Indicators (QIs) (2)
- Quality Measures (1)
- Quality of Care (4)
- Risk (4)
- Sepsis (1)
- Shared Decision Making (2)
- Surgery (1)
- Teams (2)
- Tools & Toolkits (3)
AHRQ Research Studies
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Research Studies is a compilation of published research articles funded by AHRQ or authored by AHRQ researchers.
Results
1 to 25 of 41 Research Studies DisplayedGoto M, Hasegawa S, Balkenende EC
Effectiveness of ultraviolet-c disinfection on hospital-onset gram-negative rod bloodstream infection: a nationwide stepped-wedge time-series analysis.
This study evaluated the effectiveness of enhanced terminal room cleaning with ultraviolet C (UV-C) disinfection in reducing gram-negative rod (GNR) infections. The authors used information regarding UV-C use and the timing of implementation through a survey of all Veterans Health Administration (VHA) hospitals providing inpatient acute care from January 2010 and December 2018. Among 128 Veterans Health Administration hospitals, 120 provided complete survey responses with 40 reporting implementations of UV-C systems. UV-C use was associated with a 19% lower incident of hospital-onset (HO) GNR bloodstream infection (BSI).
AHRQ-funded; HS027472.
Citation: Goto M, Hasegawa S, Balkenende EC .
Effectiveness of ultraviolet-c disinfection on hospital-onset gram-negative rod bloodstream infection: a nationwide stepped-wedge time-series analysis.
Clin Infect Dis 2023 Jan 13; 76(2):291-98. doi: 10.1093/cid/ciac776..
Keywords: Central Line-Associated Bloodstream Infections (CLABSI), Healthcare-Associated Infections (HAIs), Hospitals, Prevention, Sepsis
McAlearney AS, MacEwan SR, Gregory ME
Identifying management practices for promoting infection prevention: perspectives on strategic communication.
The purpose of this study was to better understand the topics and communication strategies used by hospital administrative and clinical leaders to facilitate healthcare-associated infection prevention. Between 2017 and 2019 the researchers interviewed 188 administrative and clinical leaders in 18 U.S. Hospitals and interviewed them about management practices used to promote the prevention of HAI, with a focus on strategic communications. The study found that information sharing regarding infection prevention focused on two main topics: facilitators of success and barriers to success. The researchers also reported that storytelling using examples of real events was useful. The study concluded that the findings provide useful information about how the strategic communication of HAI information can contribute to improvement and advance hospitals’ infection prevention plans and efforts.
AHRQ-funded; HS024958.
Citation: McAlearney AS, MacEwan SR, Gregory ME .
Identifying management practices for promoting infection prevention: perspectives on strategic communication.
Am J Infect Control 2022 Jun;50(6):593-97. doi: 10.1016/j.ajic.2021.11.025..
Keywords: Catheter-Associated Urinary Tract Infection (CAUTI), Central Line-Associated Bloodstream Infections (CLABSI), Healthcare-Associated Infections (HAIs), Hospitals, Prevention, Communication
Dykes PC, Khasnabish S, Burns Z
Development and validation of a fall prevention efficiency scale.
This study examined nurses’ perception of implementing the Fall TIPS (Tailoring Interventions for Patient Safety) tool, which is an evidence-based fall prevention program which was shown to reduce falls in hospitalized adults by 25%. The authors conducted a 3-phase mixed method study at 3 hospitals in Massachusetts and 3 in New York to assess nurses’ perceptions of burdens imposed on them by using Fall TIPS or other fall prevention programs. A 20-item prototype Fall Prevention Efficiency Scale was developed and administered to 383 clinical nurses. This scale was reduced to 13 items. The scale achieved excellent internal consistency values when examined with the test, validation, and paired (both test and retest) samples.
AHRQ-funded; HS025128.
Citation: Dykes PC, Khasnabish S, Burns Z .
Development and validation of a fall prevention efficiency scale.
J Patient Saf 2022 Mar 1;18(2):94-101. doi: 10.1097/pts.0000000000000811..
Keywords: Falls, Prevention, Patient Safety, Hospitals
Arntson E, Dimick JB, Nuliyalu U
Changes in hospital-acquired conditions and mortality associated with the hospital-acquired condition reduction program.
This study evaluated changes in Hospital-Acquired Conditions (HACs) and 30-day mortality after the announcement of the Centers for Medicare and Medicare Services’ Hospital-Acquired Condition Reduction Program (HACRP) in August 2013. The authors evaluated models to test for changes in HACs and 30-day mortality before and after the Affordable Care Act (ACA), and after the HACRP. Fee-for-service Medicare claims from 2009 to 2015 were used. The HAC rate declined after the ACA was passed and declined further after the HACRP announcement. However, 30-day mortality rates were unchanged.
AHRQ-funded; HS026244.
Citation: Arntson E, Dimick JB, Nuliyalu U .
Changes in hospital-acquired conditions and mortality associated with the hospital-acquired condition reduction program.
Ann Surg 2021 Oct 1;274(4):e301-e07. doi: 10.1097/sla.0000000000003641..
Keywords: Healthcare-Associated Infections (HAIs), Hospitals, Mortality, Medicare, Payment, Prevention, Patient Safety
Leung WY, Adelman J, Bates DW
Validating fall prevention icons to support patient-centered education.
Falls with injury are the most prevalent hospital adverse event. The objective of this project was to refine fall risk and prevention icons for a patient-centric bedside toolkit to promote patient and nurse engagement in accurately assessing fall risks and developing a tailored fall prevention plan. The investigators indicated that all 16 icons were refined and used to form the basis for a bedside fall prevention toolkit.
AHRQ-funded; HS023535.
Citation: Leung WY, Adelman J, Bates DW .
Validating fall prevention icons to support patient-centered education.
J Patient Saf 2021 Aug 1;17(5):e413-e22. doi: 10.1097/pts.0000000000000354..
Keywords: Falls, Prevention, Patient Safety, Patient-Centered Healthcare, Education: Patient and Caregiver, Hospitals, Adverse Events
McGrath SP, Perreard IM, MacKenzie T
Patterns in continuous pulse oximetry data prior to pulseless electrical activity arrest in the general care setting.
This study’s objective was to understand if features derived from continuous pulse oximetry data can provide advanced warning of pulseless electrical activity arrest in general care inpatients. A retrospective analysis of SpO2 and pulse rate data derived from continuous pulse oximetry was performed for patients with electrical pulseless activity (n = 38) and control patients (n = 42). The pulseless electrical activity arrest group tended to have lower mean SpO2 and higher mean pulse rates over time intervals ranging from 1 minute to 1 hour. Several hours to the rescue event changes in variability were observed. Up to 20 minutes before rescue events, pulse rate features were significantly different from feature values for the preceding 30-minute interval. Similar results were found at 10 minutes before the event. These differences might be useful for predicting and preventing rescue events.
AHRQ-funded; HS024403.
Citation: McGrath SP, Perreard IM, MacKenzie T .
Patterns in continuous pulse oximetry data prior to pulseless electrical activity arrest in the general care setting.
J Clin Monit Comput 2021 May;35(3):537-45. doi: 10.1007/s10877-020-00509-8..
Keywords: Patient Safety, Inpatient Care, Hospitals, Prevention, Cardiovascular Conditions
Lee BY, Bartsch SM, Lin MY
How long-term acute care hospitals can play an important role in controlling carbapenem-resistant Enterobacteriaceae in a region: a simulation modeling study.
Researchers investigated how implementing control measures in long-term acute care hospitals (LTACHs) can impact carbapenem-resistant Enterobacteriaceae (CRE) spread regionwide. They used their own Chicago metropolitan region agent-based model to simulate CRE spread and control. They found that a prevention bundle in only LTACHs decreased prevalence and averted new carriers, infections, and deaths over 3 years compared with no CRE control measures. When LTACHs and intensive care units intervened, prevalence decreased further. They concluded that LTACHs may be more important than other acute care settings for controlling CRE, and regional efforts to control drug-resistant organisms should start with LTACHs as a centerpiece.
AHRQ-funded; HS023317.
Citation: Lee BY, Bartsch SM, Lin MY .
How long-term acute care hospitals can play an important role in controlling carbapenem-resistant Enterobacteriaceae in a region: a simulation modeling study.
Am J Epidemiol 2021 Feb 1;190(3):448-58. doi: 10.1093/aje/kwaa247..
Keywords: Healthcare-Associated Infections (HAIs), Infectious Diseases, Prevention, Hospitals, Patient Safety, Implementation
Dykes PC, Burns Z, Adelman J
Evaluation of a patient-centered fall-prevention tool kit to reduce falls and injuries: a nonrandomized controlled trial.
The purpose of this study was to assess whether a fall-prevention tool kit that engages patients and families in the fall-prevention process throughout hospitalization is associated with reduced falls and injurious falls. Findings showed that, in this nonrandomized controlled trial, implementation of a fall-prevention tool kit was associated with a significant reduction in falls and related injuries. A patient-care team partnership appeared to be beneficial for prevention of falls and fall-related injuries.
AHRQ-funded; HS023535.
Citation: Dykes PC, Burns Z, Adelman J .
Evaluation of a patient-centered fall-prevention tool kit to reduce falls and injuries: a nonrandomized controlled trial.
JAMA Netw Open 2020 Nov 2;3(11):e2025889. doi: 10.1001/jamanetworkopen.2020.25889..
Keywords: Falls, Injuries and Wounds, Prevention, Tools & Toolkits, Patient and Family Engagement, Patient-Centered Healthcare, Clinical Decision Support (CDS), Hospitalization, Hospitals
Reeder B, Makic MBF, Morrow C
AHRQ Author: Rodrick D
Design and evaluation of low-fidelity visual display prototypes for multiple hospital-acquired conditions.
Hospital-acquired conditions such as catheter-associated urinary tract infection, stage 3 or 4 hospital-acquired pressure injury, and falls with injury are common, costly, and largely preventable. This study used participatory design methods to design and evaluate low-fidelity prototypes of clinical dashboards to inform high-fidelity prototype designs to visualize integrated risks based on patient profiles.
AHRQ-authored; AHRQ-funded; 233201500025I; 23337003T.
Citation: Reeder B, Makic MBF, Morrow C .
Design and evaluation of low-fidelity visual display prototypes for multiple hospital-acquired conditions.
Comput Inform Nurs 2020 Nov;38(11):562-71. doi: 10.1097/cin.0000000000000668..
Keywords: Healthcare-Associated Infections (HAIs), Adverse Events, Risk, Hospitals, Prevention
Chatterjee P, Williams MD, Coppin JD
Effectiveness of copper-impregnated solid surfaces on lowering microbial bio-burden levels in an acute care hospital.
This study examined whether using novel coper-impregnated solid materials on high-touch surfaces in patient rooms lowered bacterial contamination which may lead to health care-associated infections in acute care hospitals. Sixteen rooms were installed with copper-impregnated surfaces and were compared to standard noncopper laminate surfaces in 16 rooms over a 3-day period. Samples were taken 3 times per day. A lower level of microbial contamination was found in copper-impregnated solid surfaces as compared to standard surfaces.
AHRQ-funded; HS025598.
Citation: Chatterjee P, Williams MD, Coppin JD .
Effectiveness of copper-impregnated solid surfaces on lowering microbial bio-burden levels in an acute care hospital.
Open Forum Infect Dis 2020 Aug;7(8). doi: 10.1093/ofid/ofaa238..
Keywords: Patient Safety, Healthcare-Associated Infections (HAIs), Infectious Diseases, Hospitals, Comparative Effectiveness, Prevention, Evidence-Based Practice
Cho HJ, Feldman LS, Keller S
Choosing Wisely in the COVID-19 era: preventing harm to healthcare workers.
This paper highlights the 5 top recommendations developed for hospitals in the COVID-19 era as part of the Choosing Wisely® campaign. This top 5 list of overuse practices in hospital medicine can lead to harm of both patients and healthcare workers. The recommendations include: 1) Do not obtain nonurgent labs in separate blood draws if they can be batched together; 2) Do not use bronchodilators unless there is active obstructive airway disease; 3) Do not use posteroanterior and lateral chest X-ray (CXR) as initial imaging, use a portable CXR instead; 4) Avoid in-person evaluations in favor of virtual communication unless necessary; and 5) Do not delay goals of care conversations for hospitalized patients who are unlikely to benefit from life-sustaining treatments.
AHRQ-funded; HS025782.
Citation: Cho HJ, Feldman LS, Keller S .
Choosing Wisely in the COVID-19 era: preventing harm to healthcare workers.
J Hosp Med 2020 Jun;15(6):360-62. doi: 10.12788/jhm.3457..
Keywords: COVID-19, Infectious Diseases, Hospitals, Prevention, Public Health, Provider: Health Personnel
Bartsch SM, Wong KF, Stokes-Cawley OJ
Knowing more of the iceberg: how detecting a greater proportion of carbapenem-resistant Enterobacteriaceae carriers influences transmission.
This study examined the impact of detecting a greater proportion of carbapenem-resistant Enterobacteriaceae (CRE) carriers in the hospital inpatient population. The researchers used the Regional Healthcare Ecosystem Analyst-generated agent-based model of adult inpatient healthcare facilities in Orange County, California. They found that only if the detection level is increased to 1 in 5 carriers does it garner large reductions in the number of new CRE carriers. At the present time the detection level is 1 in 9 carriers.
AHRQ-funded; HS023317.
Citation: Bartsch SM, Wong KF, Stokes-Cawley OJ .
Knowing more of the iceberg: how detecting a greater proportion of carbapenem-resistant Enterobacteriaceae carriers influences transmission.
J Infect Dis 2020 May 11;221(11):1782-94. doi: 10.1093/infdis/jiz288..
Keywords: Healthcare-Associated Infections (HAIs), Infectious Diseases, Hospitals, Patient Safety, Prevention
Khan SH, Xu C, Purpura R
Decreasing delirium through music: a randomized pilot trial.
This randomized controlled trial examined the use of music to decrease delirium in intensive care unit (ICU) patients. Patients were either provided personalized music (PM), slow-tempo music (STM), or an audiobook (for attention control). They were provided noise-cancelling headphones and used mp3 plays to listen to their music/audiobook for 1-hour sessions twice daily up to 7 days. Delirium and delirium severity were assessed twice daily using the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Out of 1589 patients screen, 117 (7.4%) were eligible. Of those 52 were randomized between the three groups. Adherence was higher in the groups listening to music and 80% of patients surveyed rated the music as enjoyable. Median rates of delirium/coma-free days by day 7 was 2 for PM, 3 for STM, and 2 for AC. Medium delirium severity rates (from 1-7) was 5.5 for PM, 3.5 for STM, and 4 for AC.
AHRQ-funded; HS024384.
Citation: Khan SH, Xu C, Purpura R .
Decreasing delirium through music: a randomized pilot trial.
Am J Crit Care 2020 Mar 1;29(2):e31-e38. doi: 10.4037/ajcc2020175..
Keywords: Intensive Care Unit (ICU), Inpatient Care, Neurological Disorders, Prevention, Hospitals
Krein SL, Kuhn L, Ratz D
Use of designated nurse PICC teams and CLABSI prevention practices among U.S. hospitals: a survey-based study.
The authors identified the prevalence of and factors associated with having a designated nurse peripherally inserted central catheter (PICC) team among U.S. acute care hospitals. They found that nurse PICC teams inserted PICCs in more than 60% of U.S. hospitals during the study period. Moreover, certain practices to prevent central line-associated bloodstream infection, including maximum sterile barrier precautions, chlorhexidine gluconate for insertion site antisepsis, and facility-wide insertion checklists were regularly used by a higher percentage of hospitals with nurse PICC teams compared with those without. They concluded that nurse PICC teams play an integral role in PICC use at many hospitals and that use of such teams may promote key practices to prevent complications.
AHRQ-funded; HS022835.
Citation: Krein SL, Kuhn L, Ratz D .
Use of designated nurse PICC teams and CLABSI prevention practices among U.S. hospitals: a survey-based study.
J Patient Saf 2019 Dec;15(4):293-95. doi: 10.1097/pts.0000000000000246..
Keywords: Nursing, Teams, Central Line-Associated Bloodstream Infections (CLABSI), Healthcare-Associated Infections (HAIs), Inpatient Care, Hospitals, Patient Safety, Prevention, Provider: Nurse, Provider
Jones KJ, Skinner A, Venema D
Evaluating the use of multiteam systems to manage the complexity of inpatient falls in rural hospitals.
Researchers evaluated the implementation and outcomes of evidence-based fall-risk-reduction processes when those processes are implemented using a multiteam system (MTS) structure. They found that multiteam systems that effectively coordinate fall-risk-reduction processes may improve the capacity of hospitals to manage the complex patient, environmental, and system factors that result in falls.
AHRQ-funded; HS024630; HS021429.
Citation: Jones KJ, Skinner A, Venema D .
Evaluating the use of multiteam systems to manage the complexity of inpatient falls in rural hospitals.
Health Serv Res 2019 Oct;54(5):994-1006. doi: 10.1111/1475-6773.13186..
Keywords: Falls, Hospitals, Inpatient Care, Quality of Care, Quality Improvement, Patient Safety, Prevention, Risk
Pogorzelska-Maziarz M, de Cordova PB, Herzig M, de Cordova PB, Herzig CTA
Perceived impact of state-mandated reporting on infection prevention and control departments.
Currently, most US states have adopted legislation requiring hospitals to submit health care-associated infection (HAI) data. In this study, the authors evaluated the perceived impact of state HAI laws on infection prevention and control (IPC) departments. They concluded that respondents in states with laws reported negative effects on their IPC department, beyond what was required by federal mandates.
AHRQ-funded; HS024339.
Citation: Pogorzelska-Maziarz M, de Cordova PB, Herzig M, de Cordova PB, Herzig CTA .
Perceived impact of state-mandated reporting on infection prevention and control departments.
Am J Infect Control 2019 Feb;47(2):118-22. doi: 10.1016/j.ajic.2018.08.012..
Keywords: Public Reporting, Policy, Public Health, Healthcare-Associated Infections (HAIs), Infectious Diseases, Prevention, Hospitals
Padula WV, Pronovost PJ, Makic MBF
Value of hospital resources for effective pressure injury prevention: a cost-effectiveness analysis.
The objective of this study was to analyze the cost-utility of repeated risk-assessments for pressure-injury prevention in all hospital patients or in high-risk groups. Hospitalized adults were classified by Braden Scale scores into five risk levels: very high risk, high risk, moderate risk, at-risk, and minimal risk. The costs of pressure-injury treatment and prevention, and quality-adjusted life years (QALYs) related to pressure injuries were weighted by transition probabilities to calculate the incremental cost-effectiveness ratio. The results of the study indicate that simulating prevention for all patients yielded greater QALYs at higher cost from societal and healthcare sector perspectives. Prevention for all patients was cost-effective in more than 99% of probabilistic simulations. The authors conclude that hospitals should invest in nursing compliance with international prevention guidelines.
AHRQ-funded; HS023710.
Citation: Padula WV, Pronovost PJ, Makic MBF .
Value of hospital resources for effective pressure injury prevention: a cost-effectiveness analysis.
BMJ Qual Saf 2019 Feb;28(2):132-41. doi: 10.1136/bmjqs-2017-007505..
Keywords: Healthcare Costs, Hospitals, Pressure Ulcers, Prevention
Goodman KE, Simner PJ, Klein EY
How frequently are hospitalized patients colonized with carbapenem-resistant
This study evaluated whether hospitalized patients who tested positive for carbapenem-resistant Enteriobacteriaceae (CRE) were on contact precautions so that staff and other patients would not risk transmission. Since CRE colonization at admission was infrequent, there is some risk of transmission.
AHRQ-funded; HS025089.
Citation: Goodman KE, Simner PJ, Klein EY .
How frequently are hospitalized patients colonized with carbapenem-resistant
Infect Control Hosp Epidemiol 2018 Dec;39(12):1491-93. doi: 10.1017/ice.2018.236..
Keywords: Hospitalization, Hospitals, Infectious Diseases, Prevention, Risk
Prey JE, Polubriaginof F, Grossman LV
Engaging hospital patients in the medication reconciliation process using tablet computers.
Researchers conducted a pilot study to determine whether patients’ use of an electronic home medication review tool on a table computer could improve medication safety before or after hospitalization. Patients were randomized to the tool and out of 76 patients approached, 65 participated. About three-quarters (74%) made changes to their home medication list. Out of that total, 74% of the changes identified had a significant or greater potential severity, and 49% had a greater than 50-50 chance of harm. This medication reconciliation tool showed great potential to improve medication safety during and after hospitalization.
AHRQ-funded; HS021816.
Citation: Prey JE, Polubriaginof F, Grossman LV .
Engaging hospital patients in the medication reconciliation process using tablet computers.
J Am Med Inform Assoc 2018 Nov;25(11):1460-69. doi: 10.1093/jamia/ocy115..
Keywords: Adverse Drug Events (ADE), Adverse Events, Electronic Health Records (EHRs), Health Information Technology (HIT), Hospitalization, Hospitals, Medication, Medication: Safety, Patient and Family Engagement, Patient Safety, Prevention
Anderson DJ, Moehring RW, Weber DJ
Effectiveness of targeted enhanced terminal room disinfection on hospital-wide acquisition and infection with multidrug-resistant organisms and Clostridium difficile: a secondary analysis of a multicentre cluster randomised controlled trial with crossover
In this study, the investigators aimed to assess the effectiveness of four disinfection strategies on hospital-wide incidence of multidrug-resistant organisms and Clostridium difficile in the Benefits of Enhanced Terminal Room (BETR) Disinfection study. The investigators found that enhanced terminal room disinfection with ultraviolet (UV) in a targeted subset of high-risk rooms led to a decrease in hospital-wide incidence of C difficile and vancomycin-resistant enterococci.
AHRQ-funded; HS023866.
Citation: Anderson DJ, Moehring RW, Weber DJ .
Effectiveness of targeted enhanced terminal room disinfection on hospital-wide acquisition and infection with multidrug-resistant organisms and Clostridium difficile: a secondary analysis of a multicentre cluster randomised controlled trial with crossover
Lancet Infect Dis 2018 Aug;18(8):845-53. doi: 10.1016/s1473-3099(18)30278-0..
Keywords: Clostridium difficile Infections, Healthcare-Associated Infections (HAIs), Hospitals, Infectious Diseases, Inpatient Care, Patient Safety, Prevention
Baker AW, Haridy S, Salem J
Performance of statistical process control methods for regional surgical site infection surveillance: a 10-year multicentre pilot study.
The authors performed a pilot study within a large network of community hospitals to evaluate performance of statistical process control (SPC) methods for detecting surgical site infections (SSI) outbreaks. Their findings illustrated the potential usefulness and feasibility of real-time SPC surveillance of SSI to rapidly identify outbreaks and improve patient safety. Further study is needed to optimize SPC chart selection and calculation, statistical outbreak detection rules and the process for reacting to signals of potential outbreaks.
AHRQ-funded; HS023821.
Citation: Baker AW, Haridy S, Salem J .
Performance of statistical process control methods for regional surgical site infection surveillance: a 10-year multicentre pilot study.
BMJ Qual Saf 2018 Aug;27(8):600-10. doi: 10.1136/bmjqs-2017-006474..
Keywords: Healthcare-Associated Infections (HAIs), Patient Safety, Surgery, Hospitals, Public Health, Prevention, Adverse Events
Graham KL, Auerbac AD, Schnipper JL
Preventability of early versus late hospital readmissions in a national cohort of general medicine patients.
The purpose of this study was to determine whether readmissions within 7 days of discharge differed from those between 8 and 30 days after discharge with respect to preventability. The investigators found that early readmissions were more likely to be preventable and amenable to hospital-based interventions. Late readmissions were less likely to be preventable and were more amenable to ambulatory and home-based interventions.
AHRQ-funded; HS022241.
Citation: Graham KL, Auerbac AD, Schnipper JL .
Preventability of early versus late hospital readmissions in a national cohort of general medicine patients.
Ann Intern Med 2018 Jun 5;168(11):766-74. doi: 10.7326/m17-1724..
Keywords: Hospital Discharge, Hospital Readmissions, Hospitals, Hospitalization, Prevention
Reiter-Palmon R, Kennel V, Allen J
Good catch! Using interdisciplinary teams and team reflexivity to improve patient safety.
This article considers the role of reflexivity in team innovation implementation and its association with inpatient fall rates. The study it describes examined 16 small rural hospitals in which interdisciplinary teams intended to decrease fall risk were implemented, supported, and evaluated. Team reflexivity was assessed at the start and at the end of the 2-year intervention, and innovation implementation assessed at the end of the intervention. The hospitals reported objective fall event data and patient days throughout the project. Both the theoretical and practical applications of the results are discussed.
AHRQ-funded; HS021429; HS024630.
Citation: Reiter-Palmon R, Kennel V, Allen J .
Good catch! Using interdisciplinary teams and team reflexivity to improve patient safety.
Group & Organization Management 2018 Jun;43(3):414-39. doi: 10.1177/1059601118768163..
Keywords: Teams, Patient Safety, Falls, Prevention, Hospitals, Adverse Events
Parast L, Bardach NS, Burkhart Q
Development of new quality measures for hospital-based care of suicidal youth.
This study researched the value of 4 new quality measures developed to assess hospital-based care for suicidal youth. The four quality measures focused on counseling caregivers about restricting access to lethal means of self-harm, and the benefits and risks of antidepressant medications. They were divided into measures for the emergency department (ED) and inpatient measures. Survey field tests were conducted with caregivers of youth who were admitted to the ED or inpatient care for suicidality at 1 of 2 children’s hospitals between July 2013 and June 2014. Most caregivers did receive counseling about restricting their child’s access to lethal means of self-harm and also reported higher rates of counseling of benefits on antidepressants both in the ED and in the inpatient setting than the risks.
AHRQ-funded; HS020506.
Citation: Parast L, Bardach NS, Burkhart Q .
Development of new quality measures for hospital-based care of suicidal youth.
Acad Pediatr 2018 Apr;18(3):248-55. doi: 10.1016/j.acap.2017.09.017..
Keywords: Caregiving, Children/Adolescents, Consumer Assessment of Healthcare Providers and Systems (CAHPS), Education: Patient and Caregiver, Emergency Department, Hospitalization, Hospitals, Inpatient Care, Behavioral Health, Prevention, Quality of Care, Quality Measures
Bhise V, Sittig DF, Vaghani V
An electronic trigger based on care escalation to identify preventable adverse events in hospitalised patients.
Researchers refined the methods of the Institute of Healthcare Improvement's Global Trigger Tool application and leveraged electronic health record data to improve detection of preventable adverse events, including diagnostic errors. In the studied sample, preventable adverse events were identified, including adverse drug events, patient falls, procedure-related complications, and hospital-associated infections. The authors concluded that such e-triggers can help overcome limitations of currently available methods to detect preventable harm in hospitalized patients.
AHRQ-funded; HS022087; HS023602.
Citation: Bhise V, Sittig DF, Vaghani V .
An electronic trigger based on care escalation to identify preventable adverse events in hospitalised patients.
BMJ Qual Saf 2018 Mar;27(3):241-46. doi: 10.1136/bmjqs-2017-006975..
Keywords: Adverse Events, Electronic Health Records (EHRs), Health Information Technology (HIT), Hospitalization, Hospitals, Patient Safety, Prevention, Quality of Care, Quality Improvement, Quality Indicators (QIs)