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
26 to 41 of 41 Research Studies DisplayedLau BD, Streiff MB, Kraus PS
Missed doses of venous thromboembolism (VTE) prophylaxis at community hospitals: cause for alarm.
This study examined the rate of missed doses of venous thromboembolism (VTE) prophylaxis at community hospitals in the Washington, DC and greater Baltimore metropolitan areas. This retrospective study included four hospitals within the Johns Hopkins Health System. Non-administration of VTE prophylaxis was found 10.9% to 15.0% of the time among the three community hospitals. About 43.6% of patients missed at least one dose in all four hospitals. The investigators weren’t able to categorize patients by specialty, however it has been reported that more doses are missed with medically ill patients than other hospitalized patients.
AHRQ-funded; HS024547.
Citation: Lau BD, Streiff MB, Kraus PS .
Missed doses of venous thromboembolism (VTE) prophylaxis at community hospitals: cause for alarm.
J Gen Intern Med 2018 Jan;33(1):19-20. doi: 10.1007/s11606-017-4203-y..
Keywords: Blood Clots, Prevention, Blood Thinners, Patient Adherence/Compliance, Medication, Hospitals
Wang J, Gong Y
Potential of decision support in preventing pressure ulcers in hospitals.
The development of hospital-acquired pressure ulcers signals low quality of care. To meet the challenges of consistently translating best practices into effective clinical practices and promote effective teamwork communication and interprofessional collaboration, the authors consider the failure of consistent care delivery as loss of information and reveal the opportunities of informatics methods to reinforce information delivery, evidenced by typical cases. They then explain and summarize information-related issues existing at the initial assessment upon hospital admission, routine treatments, and team communication.
AHRQ-funded; HS022895.
Citation: Wang J, Gong Y .
Potential of decision support in preventing pressure ulcers in hospitals.
Stud Health Technol Inform 2017;241:15-20.
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Keywords: Clinical Decision Support (CDS), Shared Decision Making, Hospitals, Patient Safety, Pressure Ulcers, Prevention
Knelson LP, Ramadanovic GK, Chen LF
Self-monitoring by environmental services may not accurately measure thoroughness of hospital room cleaning.
The hospital environment and environmental contamination are increasingly emphasized in the prevention of healthcare associated infection. In this study, the authors compare cleaning compliance data collected by environmental services (EVS) supervisors with parallel cleaning compliance data collected by study personnel. The investigators concluded that their findings validate the recommendations in the CDC tool kit that independent observers should be used to achieve the most objective approach to monitoring.
AHRQ-funded; HS023866.
Citation: Knelson LP, Ramadanovic GK, Chen LF .
Self-monitoring by environmental services may not accurately measure thoroughness of hospital room cleaning.
Infect Control Hosp Epidemiol 2017 Nov;38(11):1371-73. doi: 10.1017/ice.2017.205..
Keywords: Hospitals, Prevention, Patient Safety, Healthcare-Associated Infections (HAIs)
Soban LM, Kim L, Yuan AH
Organisational strategies to implement hospital pressure ulcer prevention programmes: findings from a national survey.
The researchers describe the presence and operationalisation of organisational strategies to support implementation of pressure ulcer prevention programmes across acute care hospitals in a large, integrated health-care system. Organisational strategies that support implementation of a pressure ulcer prevention programme (policy, committee, staff education, wound care specialists, and use of performance data) were reported at high level.
AHRQ-funded; HS000046.
Citation: Soban LM, Kim L, Yuan AH .
Organisational strategies to implement hospital pressure ulcer prevention programmes: findings from a national survey.
J Nurs Manag 2017 Sep;25(6):457-67. doi: 10.1111/jonm.12416.
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Keywords: Pressure Ulcers, Prevention, Hospitals, Patient Safety, Implementation, Organizational Change
Dykes PC, Duckworth M, Cunningham S
Pilot testing Fall TIPS (Tailoring Interventions for Patient Safety): a patient-centered fall prevention toolkit.
Patient falls during an acute hospitalization cause injury, reduced mobility, and increased costs. The laminated paper Fall TIPS Toolkit (Fall TIPS) provides clinical decision support at the bedside by linking each patient's fall risk assessment with evidence-based interventions. The investigators examined strategies to integrate this evidence into clinical practice. They concluded that engaging hospital and clinical leadership is critical in translating evidence-based care into clinical practice. They address and detail barriers to adoption of the protocol to provide guidance for spread to other institutions.
AHRQ-funded; HS025128.
Citation: Dykes PC, Duckworth M, Cunningham S .
Pilot testing Fall TIPS (Tailoring Interventions for Patient Safety): a patient-centered fall prevention toolkit.
Jt Comm J Qual Patient Saf 2017 Aug;43(8):403-13. doi: 10.1016/j.jcjq.2017.05.002..
Keywords: Clinical Decision Support (CDS), Shared Decision Making, Evidence-Based Practice, Falls, Hospitals, Injuries and Wounds, Inpatient Care, Patient Safety, Prevention, Risk, Tools & Toolkits
Deshpande A, Cadnum JL, Fertelli D
Are hospital floors an underappreciated reservoir for transmission of health care-associated pathogens?
In a survey of 5 hospitals, the researchers found that floors in patient rooms were frequently contaminated with pathogens and high-touch objects such as blood pressure cuffs and call buttons were often in contact with the floor. Contact with objects on floors frequently resulted in transfer of pathogens to hands.
AHRQ-funded; HS020004.
Citation: Deshpande A, Cadnum JL, Fertelli D .
Are hospital floors an underappreciated reservoir for transmission of health care-associated pathogens?
Am J Infect Control 2017 Mar;45(3):336-38. doi: 10.1016/j.ajic.2016.11.005.
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Keywords: Hospitals, Healthcare-Associated Infections (HAIs), Clostridium difficile Infections, Methicillin-Resistant Staphylococcus aureus (MRSA), Prevention, Patient Safety
Meddings J, Reichert H, Greene MT
Evaluation of the association between Hospital Survey on Patient Safety Culture (HSOPS) measures and catheter-associated infections: results of two national collaboratives.
This study examined the association between hospital units' results for the Hospital Survey on Patient Safety Culture (HSOPS) and catheter-associated infection rates. It found no association between results of the HSOPS and catheter-associated infection rates when measured at baseline and postintervention in two successful large national collaboratives focused on prevention of central-line-associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI).
AHRQ-funded; 290201000025I; 29032001T; HS019767.
Citation: Meddings J, Reichert H, Greene MT .
Evaluation of the association between Hospital Survey on Patient Safety Culture (HSOPS) measures and catheter-associated infections: results of two national collaboratives.
BMJ Qual Saf 2017 Mar;26(3):226-35. doi: 10.1136/bmjqs-2015-005012.
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Keywords: Catheter-Associated Urinary Tract Infection (CAUTI), Central Line-Associated Bloodstream Infections (CLABSI), Comprehensive Unit-based Safety Program (CUSP), Healthcare-Associated Infections (HAIs), Hospitals, Patient Safety, Prevention
Anderson DJ, Chen LF, Weber DJ
Enhanced terminal room disinfection and acquisition and infection caused by multidrug-resistant organisms and Clostridium difficile (the Benefits of Enhanced Terminal Room Disinfection study): a cluster-randomised, multicentre, crossover study.
The researchers determined the effects of three enhanced strategies for terminal room disinfection (disinfection of a room between occupying patients) on acquisition and infection due to methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, C difficile, and multidrug-resistant Acinetobacter. They found that the incidence of target organisms among exposed patients was significantly lower after adding UV (quaternary ammonium disinfectant and disinfecting ultraviolet [UV-C]) light to standard cleaning strategies.
AHRQ-funded; HS023866.
Citation: Anderson DJ, Chen LF, Weber DJ .
Enhanced terminal room disinfection and acquisition and infection caused by multidrug-resistant organisms and Clostridium difficile (the Benefits of Enhanced Terminal Room Disinfection study): a cluster-randomised, multicentre, crossover study.
Lancet 2017 Feb 25;389(10071):805-14. doi: 10.1016/s0140-6736(16)31588-4.
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Keywords: Clostridium difficile Infections, Healthcare-Associated Infections (HAIs), Hospitals, Methicillin-Resistant Staphylococcus aureus (MRSA), Prevention, Patient Safety
Lau BD, Haut ER, Hobson DB
ICD-9 code-based venous thromboembolism performance targets fail to measure up.
Suboptimal prevention practices have prompted payers to consider hospital-associated Venous thromboembolism (VTE) as a potentially preventable condition for which financial incentives or penalties exist to drive practice improvement. The authors reviewed a subset of hospital-associated VTE that were identified by ICD-9 codes used by a state-run pay-for-performance quality improvement program and discuss their findings.
AHRQ-funded; HS017952.
Citation: Lau BD, Haut ER, Hobson DB .
ICD-9 code-based venous thromboembolism performance targets fail to measure up.
Am J Med Qual 2016 Sep;31(5):448-53. doi: 10.1177/1062860615583547.
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Keywords: Healthcare-Associated Infections (HAIs), Quality Indicators (QIs), Prevention, Hospitals, Quality Improvement, Blood Clots, Payment, Provider Performance
Katsulis Z, Ergai A, Leung WY
Iterative user centered design for development of a patient-centered fall prevention toolkit.
The use of electronic decision support that tailors fall prevention strategy to patient-specific risk factors, known as Fall T.I.P.S (Tailoring Interventions for Patient Safety), has proven to be an effective approach for decreasing hospital falls. A paper version of the Fall T.I.P.S toolkit was developed primarily for hospitals that do not have the resources to implement the electronic solution; however, more work is needed to optimize the effectiveness of the paper version of this tool.
AHRQ-funded; HS023535.
Citation: Katsulis Z, Ergai A, Leung WY .
Iterative user centered design for development of a patient-centered fall prevention toolkit.
Appl Ergon 2016 Sep;56:117-26. doi: 10.1016/j.apergo.2016.03.011.
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Keywords: Falls, Tools & Toolkits, Prevention, Patient Safety, Hospitals
McAlearney AS, Hefner JL
Getting to zero: goal commitment to reduce blood stream infections.
The researchers examined goal-setting as a factor contributing to program outcomes in eight hospitals focused on preventing central line-associated bloodstream infections (CLABSIs). They conducted qualitative case studies to compare higher- and lower-performing hospitals, and explored differences in contextual factors that might contribute to performance variation. Finally, they present a goal commitment framework that characterizes factors associated with successful CLABSI program outcomes.
AHRQ-funded; 290200600022.
Citation: McAlearney AS, Hefner JL .
Getting to zero: goal commitment to reduce blood stream infections.
Med Care Res Rev 2016 Aug;73(4):458-77. doi: 10.1177/1077558715616028.
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Keywords: Central Line-Associated Bloodstream Infections (CLABSI), Healthcare-Associated Infections (HAIs), Hospitals, Outcomes, Patient Safety, Prevention
Croft LD, Liquori M, Ladd J
The effect of contact precautions on frequency of hospital adverse events.
The researchers sought to determine whether use of contact precautions on hospital ward patients is associated with patient adverse events. They concluded that hospital ward patients on contact precautions were less likely to experience noninfectious adverse events during their hospital stay than patients not on contact precautions.
AHRQ-funded; HS018111.
Citation: Croft LD, Liquori M, Ladd J .
The effect of contact precautions on frequency of hospital adverse events.
Infect Control Hosp Epidemiol 2015 Nov;36(11):1268-74. doi: 10.1017/ice.2015.192.
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Keywords: Adverse Events, Patient Safety, Prevention, Hospitals
Michtalik HJ, Carolan HT, Haut ER
Use of provider-level dashboards and pay-for-performance in venous thromboembolism prophylaxis.
The researchers sequentially examined an individualized physician dashboard and pay-for-performance program to improve venous thromboembolism (VTE) prophylaxis rates among hospitalists. They found that direct feedback using dashboards was associated with significantly improved compliance, with further improvement after incorporating an individual physician pay-for-performance program.
AHRQ-funded; HS017952; HS022331.
Citation: Michtalik HJ, Carolan HT, Haut ER .
Use of provider-level dashboards and pay-for-performance in venous thromboembolism prophylaxis.
J Hosp Med 2015 Mar;10(3):172-8. doi: 10.1002/jhm.2303..
Keywords: Provider Performance, Payment, Blood Clots, Prevention, Quality Improvement, Quality of Care, Hospitals, Patient Safety
Harris AD, Pineles L, Belton B
Universal glove and gown use and acquisition of antibiotic-resistant bacteria in the ICU: a randomized trial.
Antibiotic-resistant bacteria are associated with increased patient morbidity and mortality. It is unknown whether wearing gloves and gowns for all patient contact in the intensive care unit (ICU) decreases acquisition of antibiotic-resistant bacteria. The purpose of this study was to assess whether wearing gloves and gowns for all patient contact in the ICU decreases acquisition of methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE) compared with usual care.
AHRQ-funded; HS018111; 290200600015.
Citation: Harris AD, Pineles L, Belton B .
Universal glove and gown use and acquisition of antibiotic-resistant bacteria in the ICU: a randomized trial.
JAMA 2013 Oct 16;310(15):1571-80. doi: 10.1001/jama.2013.277815..
Keywords: Patient Safety, Healthcare-Associated Infections (HAIs), Methicillin-Resistant Staphylococcus aureus (MRSA), Infectious Diseases, Intensive Care Unit (ICU), Hospitals, Prevention, Critical Care
Steinberg JP, Denham ME, Zimring C
https://www.researchgate.net/publication/276382905/download
The role of the hospital environment in the prevention of healthcare-associated infections by contact transmission.
The authors describe the role of the hospital environment in the spread of pathogens by direct and indirect contact. In addition, the prevention of transmission through interventions involving the built environment is discussed. They conclude that enhanced environmental cleaning including touchless technologies and self-cleaning surfaces can reduce environmental contamination and may prevent infections.
AHRQ-funded; 290201000024I.
Citation: Steinberg JP, Denham ME, Zimring C .
The role of the hospital environment in the prevention of healthcare-associated infections by contact transmission.
HERD 2013 Oct;7(1 suppl):46-73..
Keywords: Healthcare-Associated Infections (HAIs), Infectious Diseases, Hospitals, Prevention, Patient Safety
Hempel S, Newberry S, Wang Z
AHRQ Author: Spector WD
Hospital fall prevention: a systematic review of implementation, components, adherence, and effectiveness.
The authors sought to document systematically the implementation, components, comparators, adherence, and effectiveness of published fall prevention approaches in U.S. acute care hospitals. They found that most interventions included multiple components, and the pooled postintervention incidence rate ratio (IRR) was 0.77. They found no systematic association between implementation intensity, intervention complexity, comparator information, or adherence levels and IRR. They concluded that promising approaches exist, but better reporting of outcomes, implementation, adherence, intervention components, and comparison group information is necessary to establish evidence on how hospitals can successfully prevent falls.
AHRQ-authored; AHRQ-funded; 290201000017I.
Citation: Hempel S, Newberry S, Wang Z .
Hospital fall prevention: a systematic review of implementation, components, adherence, and effectiveness.
J Am Geriatr Soc 2013 Apr;61(4):483-94. doi: 10.1111/jgs.12169.
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Keywords: Adverse Events, Falls, Hospitals, Patient Safety, Prevention