National Healthcare Quality and Disparities Report
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Search All Research Studies
Topics
- Adverse Drug Events (ADE) (1)
- Adverse Events (3)
- Blood Clots (2)
- Blood Thinners (1)
- Caregiving (1)
- (-) Care Management (16)
- Case Study (1)
- Catheter-Associated Urinary Tract Infection (CAUTI) (1)
- Central Line-Associated Bloodstream Infections (CLABSI) (1)
- Children/Adolescents (4)
- Colonoscopy (1)
- Communication (1)
- Diabetes (2)
- Diagnostic Safety and Quality (1)
- Disparities (1)
- Education: Continuing Medical Education (1)
- Emergency Department (1)
- Emergency Medical Services (EMS) (1)
- Evidence-Based Practice (2)
- Guidelines (1)
- Healthcare-Associated Infections (HAIs) (2)
- Healthcare Delivery (1)
- Health Information Technology (HIT) (2)
- Hospitalization (1)
- Infectious Diseases (1)
- Injuries and Wounds (2)
- Inpatient Care (3)
- Intensive Care Unit (ICU) (2)
- Labor and Delivery (2)
- Long-Term Care (1)
- Maternal Care (1)
- Newborns/Infants (2)
- Nursing (2)
- Outcomes (1)
- Patient-Centered Healthcare (1)
- (-) Patient Safety (16)
- Patient Self-Management (1)
- Pregnancy (2)
- Pressure Ulcers (1)
- Prevention (2)
- Provider (1)
- Provider: Nurse (1)
- Quality Improvement (1)
- Quality of Care (3)
- Respiratory Conditions (2)
- Risk (2)
- TeamSTEPPS (1)
- Tools & Toolkits (1)
- Training (1)
- Urinary Tract Infection (UTI) (2)
- Women (1)
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 16 of 16 Research Studies DisplayedKreutzer L, Yang AD, Sansone C
Barriers to providing VTE chemoprophylaxis to hospitalized patients: a nursing-focused qualitative evaluation.
This study analyzed barriers for administration of VTE chemoprophylaxis to hospitalized patients from nurses. Researchers conducted 14 focus group interviews with nurses from five inpatient units to assess their perceptions of barriers to administration of VTE chemoprophylaxis. Barriers included nurses’ misconceptions that patients did not require chemoprophylaxis, their uncertainty when counseling patients on the importance of chemoprophylaxis, and a lack of comparative data regarding specific refusal rates.
AHRQ-funded; HS024516.
Citation: Kreutzer L, Yang AD, Sansone C .
Barriers to providing VTE chemoprophylaxis to hospitalized patients: a nursing-focused qualitative evaluation.
J Hosp Med 2019 Nov 1;14(10):668-72. doi: 10.12788/jhm.3290..
Keywords: Blood Clots, Patient Safety, Prevention, Inpatient Care, Care Management, Nursing
Griffey RT, Schneider RM, Peterson C
Diabetic ketoacidosis management in the emergency department: implementation of a protocol to reduce variability and improve safety.
The authors studied the impact of a standardizing emergency department diabetic ketoacidosis management in two phases: rollout of a diabetic ketoacidosis pathway in their computerized order entry system followed by audit and feedback. They evaluated adherence, clinical process, operational, and safety measures following these interventions. They found that adherence to the pathway was initially slow, improving significantly after audit and feedback. They observed mixed improvements in clinical processes, no changes in operational metrics, and reductions in variability for several measures.
AHRQ-funded; HS025052.
Citation: Griffey RT, Schneider RM, Peterson C .
Diabetic ketoacidosis management in the emergency department: implementation of a protocol to reduce variability and improve safety.
J Healthc Qual 2019 Nov/Dec;41(6):e61-e69. doi: 10.1097/jhq.0000000000000211..
Keywords: Emergency Department, Diabetes, Patient Safety, Care Management
Keller SC, Cosgrove SE, Arbaje AI
Roles and role ambiguity in patient- and caregiver-performed outpatient parenteral antimicrobial therapy.
This study examined roles and role ambiguity in patient- and caregiver-performed outpatient parenteral antimicrobial therapy (OPAT). A qualitative study of patients and caregivers was conducted using 40 semistructured telephone interviews and 20 contextual inquiries for patients and caregivers. The participants had been discharged from two academic medical centers and put on OPAT. Four main roles were identified: communicator, advocate, learner-trainer, and lay health care worker. There was ambiguity shown among health care workers as well as patients and caregivers. Clearer delineation of roles as to who performs which tasks was indicated in the study.
AHRQ-funded; HS025782.
Citation: Keller SC, Cosgrove SE, Arbaje AI .
Roles and role ambiguity in patient- and caregiver-performed outpatient parenteral antimicrobial therapy.
Jt Comm J Qual Patient Saf 2019 Nov;45(11):763-71. doi: 10.1016/j.jcjq.2019.07.003..
Keywords: Patient-Centered Healthcare, Quality Improvement, Healthcare Delivery, Patient Self-Management, Care Management, Caregiving, Quality of Care, Patient Safety
Simpson KR, Lyndon A, Spetz J
Adherence to the AWHONN staffing guidelines as perceived by labor nurses.
Labor and delivery nurses were surveyed to determine if their units adhere to Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) staffing guidelines. Labor nurses in selected hospitals in California, Michigan and New Jersey were invited via email to participate in the study. Their nurse leaders facilitated the invitations. A total of 615 labor nurses from 67 hospitals participated. Most nurses did report that staffing guidelines were adhered to. The hospitals with smaller annual birth volumes (500-999 range) were significantly more like to be perceived as compliant than hospitals with 2,500 or more annual births.
AHRQ-funded; HS025715.
Citation: Simpson KR, Lyndon A, Spetz J .
Adherence to the AWHONN staffing guidelines as perceived by labor nurses.
Nurs Womens Health 2019 Jun;23(3):217-23. doi: 10.1016/j.nwh.2019.03.003..
Keywords: Care Management, Guidelines, Labor and Delivery, Maternal Care, Patient Safety, Pregnancy, Provider, Provider: Nurse, Women
Santosa KB, Keller M, Olsen MA
Negative-pressure wound therapy in infants and children: a population-based study.
Although the safety and benefits of negative-pressure wound therapy (NPWT) have been clearly demonstrated in the adult population, studies evaluating the safety and describing the use of NPWT in the pediatric population have been limited. In this study, the investigators performed a literature review and analyzed the Truven Health Analytics MarketScan Commercial Claims Databases from 2006 to 2014 to identify infants and children treated with NPWT.
AHRQ-funded; HS019455.
Citation: Santosa KB, Keller M, Olsen MA .
Negative-pressure wound therapy in infants and children: a population-based study.
J Surg Res 2019 Mar;235:560-68. doi: 10.1016/j.jss.2018.10.043..
Keywords: Children/Adolescents, Newborns/Infants, Pressure Ulcers, Injuries and Wounds, Care Management, Patient Safety
Lee JH, Nuthall G, Ikeyama T
Tracheal intubation practice and safety across international PICUs: a report from national emergency airway registry for children.
Researchers hypothesized that there would be differences in the process of care and adverse outcomes for tracheal intubation across pediatric ICUs (PICUs) in six different geographical regions: Germany, Japan, Singapore, India, New Zealand, and North America. Adverse tracheal intubation-associated events and desaturation occurrences in PICUS in these regions were evaluated, and the international PICUs compared with those in North America. The proportion of tracheal intubations for endotracheal tube change was greater in international PICUs, and the median age for international tracheal intubations was younger when compared with North America PICUs. Occurrences of adverse tracheal intubation-associated events were slightly lower for international than for North American PICUs, except for Germany and Japan, which were slightly higher.
AHRQ-funded; HS021583; HS022464; HS024511.
Citation: Lee JH, Nuthall G, Ikeyama T .
Tracheal intubation practice and safety across international PICUs: a report from national emergency airway registry for children.
Pediatr Crit Care Med 2019 Jan;20(1):1-8. doi: 10.1097/pcc.0000000000001782..
Keywords: Adverse Events, Care Management, Children/Adolescents, Intensive Care Unit (ICU), Respiratory Conditions, Outcomes, Patient Safety
Bradley SM, Schweon SJ, Mody L
Identifying safe practices for use of the urinary leg bag drainage system in the postacute and long-term care setting: an integrative review.
In the postacute and long-term care setting, the practice of changing the indwelling urinary catheter large sterile drainage bag to a small-size leg drainage bag is intended to maintain a person's mobility, dignity, and comfort. There is scant evidence that assesses the impact of intermittent use of a leg bag on frequency of urinary tract infection since this breaks the closed urinary drainage system. The investigators identified the existence of low-level evidence that leg bags pose no evident, disproportionate risk of infection compared with maintaining a closed system.
AHRQ-funded; 290201000025I.
Citation: Bradley SM, Schweon SJ, Mody L .
Identifying safe practices for use of the urinary leg bag drainage system in the postacute and long-term care setting: an integrative review.
Am J Infect Control 2018 Sep;46(9):973-79. doi: 10.1016/j.ajic.2018.03.029..
Keywords: Care Management, Evidence-Based Practice, Healthcare-Associated Infections (HAIs), Long-Term Care, Patient Safety, Urinary Tract Infection (UTI)
McArdle J, Sorensen A, Fowler CI
Strategies to improve management of shoulder dystocia under the AHRQ Safety Program for Perinatal Care.
The purpose of this study using TeamSTEPPS was to assess the implementation of safety strategies to improve management of births complicated by shoulder dystocia in labor and delivery units. Results suggested that successful management of shoulder dystocia requires a rapid, standardized, and coordinated response. The Safety Program for Perinatal Care strategies to increase safety of shoulder dystocia management are scalable, replicable, and adaptable to unit needs and circumstances.
AHRQ-funded; 2902010000241.
Citation: McArdle J, Sorensen A, Fowler CI .
Strategies to improve management of shoulder dystocia under the AHRQ Safety Program for Perinatal Care.
J Obstet Gynecol Neonatal Nurs 2018 Mar;47(2):191-201. doi: 10.1016/j.jogn.2017.11.014.
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Keywords: Labor and Delivery, Newborns/Infants, Pregnancy, Adverse Events, TeamSTEPPS, Injuries and Wounds, Care Management, Education: Continuing Medical Education, Training, Tools & Toolkits, Patient Safety, Nursing, Communication, Quality of Care
Patel PK, Gupta A, Vaughn VM
Review of strategies to reduce central line-associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) in adult ICUs.
This systematic review was conducted back in October 2015 within PubMed and Cochrane databases on interventions to reduce central line-associated bloodstream infections (CLABSI) and catheter-associated urinary tract infections (CAUTI). The interventions were categorized by stages applicable to both CAUTI and CLABSI prevention. Stage 0: avoid catheter if possible; Stage 1: ensure aseptic placement; Stage 2: maintain awareness and proper care of catheters in place, and Stage 3: promptly remove unnecessary catheters. They also looked for effective components that the 5 stages were most successful with. The review is designed for hospitalists to use to formulate quality improvement interventions for infection reduction.
AHRQ-funded; HS018334.
Citation: Patel PK, Gupta A, Vaughn VM .
Review of strategies to reduce central line-associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) in adult ICUs.
J Hosp Med 2018 Feb;13(2):105-16. doi: 10.12788/jhm.2856..
Keywords: Care Management, Catheter-Associated Urinary Tract Infection (CAUTI), Central Line-Associated Bloodstream Infections (CLABSI), Evidence-Based Practice, Healthcare-Associated Infections (HAIs), Infectious Diseases, Intensive Care Unit (ICU), Patient Safety, Urinary Tract Infection (UTI)
Bowen ME, Rumana U, Kilgore EA
A user-centered glucose-insulin data display for the inpatient setting.
Researchers sought to develop a set of user-centered displays of capillary glucose data and insulin dose to improve inpatient management of insulin-dependent diabetes. Their proposed conceptual data display prototype is designed to simplify the presentation and visualization of key information needed for treatment decisions. The goal is also to enhance clinician's ability to identify opportunities to optimize insulin dosing and decrease end users' cognitive load and error rates.
AHRQ-funded; HS022895.
Citation: Bowen ME, Rumana U, Kilgore EA .
A user-centered glucose-insulin data display for the inpatient setting.
Stud Health Technol Inform 2017;245:684-88.
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Keywords: Care Management, Diabetes, Health Information Technology (HIT), Inpatient Care, Patient Safety
Jindai K, Sterkel AK, Reed KD
Limb embolism in a 52-year-old woman.
In response to a photo quiz, the authors make the following diagnosis: arterial thrombus caused by Histoplasma capsulatum deriving from native valve endocarditis caused by the same organism. Various aspects of the case are discussed.
AHRQ-funded; HS022465; HS023779.
Citation: Jindai K, Sterkel AK, Reed KD .
Limb embolism in a 52-year-old woman.
Clin Infect Dis 2016 May 15;62(10):1320-1. doi: 10.1093/cid/ciw081.
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Keywords: Blood Clots, Care Management, Case Study, Diagnostic Safety and Quality, Patient Safety
Metersky ML, Eldridge N, Wang Y
AHRQ Author: Eldridge N
Predictors of warfarin-associated adverse events in hospitalized patients: Opportunities to prevent patient harm.
The researchers assessed the relationship between daily versus less frequent international normalized ratio ( INR) monitoring and overanticoagulation and warfarin-related adverse events. They bconcluded that daily INR measurement and recognition of a rapidly rising INR might decrease the frequency of warfarin-associated adverse events in hospitalized patients.
AHRQ-authored; AHRQ-funded; 290201200003C.
Citation: Metersky ML, Eldridge N, Wang Y .
Predictors of warfarin-associated adverse events in hospitalized patients: Opportunities to prevent patient harm.
J Hosp Med 2016 Apr;11(4):276-82. doi: 10.1002/jhm.2528.
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Keywords: Blood Thinners, Care Management, Adverse Drug Events (ADE), Patient Safety, Hospitalization, Prevention
Wernli KJ, Brenner AT, Rutter CM
Risks associated with anesthesia services during colonoscopy.
The researchers aimed to quantify the difference in complications from colonoscopy with vs without anesthesia services. They concluded that the overall risk of complications after colonoscopy increases when individuals receive anesthesia services. The widespread adoption of anesthesia services with colonoscopy should be considered within the context of all potential risks.
AHRQ-funded; HS013853; HS019482.
Citation: Wernli KJ, Brenner AT, Rutter CM .
Risks associated with anesthesia services during colonoscopy.
Gastroenterology 2016 Apr;150(4):888-94. doi: 10.1053/j.gastro.2015.12.018.
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Keywords: Adverse Events, Care Management, Colonoscopy, Disparities, Patient Safety, Risk
Nykiel-Bailey SM, McAllister JD, Schrock CR
Difficult airway consultation service for children: steps to implement and preliminary results.
The article demonstrates how to implement a consultative service focusing on difficult airway (DAW) identification, management and education. The initial 3-month experience confirmed that a majority of pediatric DAW events are associated with congenital or acquired abnormalities. Through appropriate consultation and leadership, the Difficult Airway Service was able to physically and electronically identify pediatric patients with a DAW and provide management.
AHRQ-funded; HS022265.
Citation: Nykiel-Bailey SM, McAllister JD, Schrock CR .
Difficult airway consultation service for children: steps to implement and preliminary results.
Paediatr Anaesth 2015 Apr;25(4):363-71. doi: 10.1111/pan.12625..
Keywords: Care Management, Children/Adolescents, Respiratory Conditions, Patient Safety, Risk
Banerjee T, Enayati M, Keller JM
Monitoring patients in hospital beds using unobtrusive depth sensors.
The researchers presented an approach for patient activity recognition in hospital rooms using depth data collected using a Kinect sensor. They described a technique to reduce false alerts such as pillows falling off the bed or equipment movement. They tested their algorithm on 96 hours obtained in two hospital rooms from the University of Missouri Hospital.
AHRQ-funded; HS018477.
Citation: Banerjee T, Enayati M, Keller JM .
Monitoring patients in hospital beds using unobtrusive depth sensors.
Conf Proc IEEE Eng Med Biol Soc 2014;2014:5904-7. doi: 10.1109/embc.2014.6944972.
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Keywords: Care Management, Inpatient Care, Health Information Technology (HIT), Patient Safety
Cottrell EK, O'Brien K, Curry M
Understanding safety in prehospital emergency medical services for children.
This paper adds to the qualitative understanding of the nature of and contributors to safety events in the prehospital emergency care of children. The findings of this study suggest that factors at the systems, team, child/family, and individual provider level system contribute to errors in prehospital emergency care. These factors may be modifiable through interventions and systems improvements.
AHRQ-funded; HS019456.
Citation: Cottrell EK, O'Brien K, Curry M .
Understanding safety in prehospital emergency medical services for children.
Prehosp Emerg Care 2014 Jul-Sep;18(3):350-8. doi: 10.3109/10903127.2013.869640.
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Keywords: Care Management, Children/Adolescents, Emergency Medical Services (EMS), Quality of Care, Patient Safety