Joint Commission journal on quality and patient safety最新文献

{"title":"Mortality and Return Visit Frequency Among Emergency Department Patients Who Leave Without Being Seen at a Regional Health Care System.","authors":"Joshua W Joseph, Alice K Bukhman, Da'Marcus E Baymon, Melisa W Lai-Becker, Dana D Im, Lauren M Nentwich, Paul C Chen, León D Sánchez","doi":"10.1016/j.jcjq.2025.02.008","DOIUrl":"https://doi.org/10.1016/j.jcjq.2025.02.008","url":null,"abstract":"<p><strong>Background: </strong>The rate of emergency department (ED) patients who leave without being seen (LWBS) is a commonly reported quality metric that increased across the United States in concert with COVID-19. However, it is unclear what proportion of patients leave despite an acute medical need. The authors sought to estimate the rates at which patients who leave return, including hospitalization, relative to patients who are evaluated and discharged.</p><p><strong>Methods: </strong>This was a retrospective cohort study examining adult patients presenting between January 1, 2019, and January 1, 2023, across an integrated system including 10 EDs. Demographic variables were compared using independent chi-square tests. Clinical outcomes, including rates of return visits at 72 hours and 30 days (including inpatient admission or ICU admission), and 30-day mortality were compared using multivariate logistic regression.</p><p><strong>Results: </strong>A total of 1,474,395 visits were included, of which 17,523 (1.2%) were LWBS. Patients in the LWBS group were younger (48.1 years [95% confidence interval (CI) 48.1-48.2] vs. 44.8 years [95% CI 44.6-45.1], p < 0.001), more likely to be of Hispanic ethnicity (177,895 [17.7%] vs. 3,884 [22.2%], p < 0.001), and more likely to require a translator (131,510 [13.1%] vs. 3,184 [18.2%], p < 0.001). Independent of other clinical and demographic variables, LWBS was associated with more frequent returns within 72 hours (adjusted odds ratio [AOR] 2.56, 95% CI 2.50-2.62, p < 0.001), 30-day ICU admission (AOR 1.35, 95% CI 1.27-1.66, p < 0.001), and mortality within 30 days (AOR 2.59, 95% CI 1.90-3.53, p <0.001).</p><p><strong>Conclusion: </strong>Patients who left without being seen were more likely to return, to require admission, and to die within 30 days than those discharged. High LWBS rates, most pronounced among disadvantaged groups, should be considered as a source of harm to patients.</p>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":" ","pages":""},"PeriodicalIF":2.3,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143780102","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Patient Engagement in Safety: Are We There Yet?","authors":"Tejal Gandhi MD MPH (is Chief Safety and Transformation Officer, Press Ganey Associates LLC),&nbsp;Urmimala Sarkar MD MPH (is Professor of Medicine, University of California, San Francisco)","doi":"10.1016/j.jcjq.2025.02.006","DOIUrl":"10.1016/j.jcjq.2025.02.006","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 6","pages":"Pages 447-450"},"PeriodicalIF":2.3,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143743135","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Overcoming Professional Silos and Threats to Psychological Safety: A Conceptual Framework for Successful Team-Based Morbidity and Mortality Conferences","authors":"Brian A. Campos MD (is Safe Surgery/Safe Systems Fellow, Ariadne Labs, T.H. Chan School of Public Health, Boston, and General Surgery Resident PGY3, Department of Surgery, Beth Israel Deaconess Medical Center, Boston.),&nbsp;Mary E. Brindle MD, MPH (is Principal Research Scientist, Ariadne Labs, and Professor, Department of Surgery, Cumming School of Medicine, University of Calgary.),&nbsp;Emily Cummins PhD (is Senior Qualitative Specialist, Ariadne Labs.),&nbsp;Alexander Hannenberg MD (is Core Faculty Member, Safe Surgery/Safe Systems Program, Ariadne Labs, and Adjunct Clinical Professor, Department of Anesthesiology, Tufts University School of Medicine.),&nbsp;Danielle Salley MS, BSN, RN (is Manager, Department of Quality and Clinical Projects, Children's Memorial Hermann Hospital, Houston.),&nbsp;Yves Sonnay MSPH (is Assistant Director of Project Management, Safe Surgery/Safe Systems Program, Ariadne Labs.),&nbsp;Aubrey Samost-Williams MD, MS (is Associate Faculty Member, Ariadne Labs, and Assistant Professor, Department of Anesthesia, Critical Care and Pain Medicine, University of Texas Health Science Center, Houston. Please address correspondence to Brian A. Campos)","doi":"10.1016/j.jcjq.2025.02.005","DOIUrl":"10.1016/j.jcjq.2025.02.005","url":null,"abstract":"<div><h3>Background</h3><div>Adverse events in health care are frequently discussed in morbidity and mortality conferences. However, while health care has evolved to be delivered by interprofessional teams, morbidity and mortality conferences have been slow to include all team members. One particularly potent barrier to conducting an interprofessional team–based morbidity and mortality conference is a lack of psychological safety among team members. Clinicians from various professions bring differences in perspectives, culture, perceived hierarchy, and assumptions about other professions. These perspectives may bring value to the interprofessional team–based morbidity and mortality conferences, but they may also degrade psychological safety.</div></div><div><h3>Methods</h3><div>This report explores the link between professional silos and psychological safety among the health care team in the context of an interprofessional team–based morbidity and mortality conference using the perioperative space as an example. The authors draw on the concept of team fault lines—a potential division along a team members' characteristics that can divide a group or team into subgroups. The roots of perioperative professional silos, which define these fault lines, are then traced to the historical context of the health care professions, the individual development of professional identities, and the role of organizations in maintaining these silos. From these observations, a framework for describing these foundations is proposed, which the authors use to evaluate the broader teamwork-in-health-care literature to generate specific recommendations to promote psychological safety in team-based morbidity and mortality conferences.</div></div><div><h3>Conclusion</h3><div>This framework can be used to postulate strategies for improving the ability for teams to learn from morbidity and mortality conferences. However, future work remains in implementing and studying these recommendations.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 6","pages":"Pages 415-422"},"PeriodicalIF":2.3,"publicationDate":"2025-02-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144019454","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Nutrition Optimization in Early Dialysis","authors":"Aditya A. Khanijo MBBS (is Research Fellow, Department of Medicine, Mayo Clinic, Jacksonville),&nbsp;Lorenzo Olivero MD (is Research Fellow, Department of Medicine, Mayo Clinic Jacksonville),&nbsp;Mireille H. Hamdan DCN, RDN, LD/N (is Clinical Nutrition Manager, Department of Nutrition Services, Mayo Clinic Jacksonville),&nbsp;Karen D. Stoner BSN, RN (is Nurse Manager, Critical Care, Mayo Clinic Jacksonville),&nbsp;Angela C. Majerus MHA (is Manager, Outpatient Practices Administration, Mayo Clinic Health System (Austin)),&nbsp;Dimple B. Patel RN (is Nurse Manager, Inpatient Dialysis, Mayo Clinic Jacksonville),&nbsp;Shannon Allen MHA (is Senior Patient Experience Advisor, Department of Quality, Mayo Clinic Jacksonville),&nbsp;Christopher L. Trautman MD (is Nephrologist, Department of Medicine, Mayo Clinic Jacksonville),&nbsp;Lisa M. Heath DNP, RN, NE-BC (is Nursing Quality Specialist, Nursing Administration, Mayo Clinic Jacksonville),&nbsp;Lindsay L. Meeusen MSN, RN, NPD-BC (is Nurse Manager, Nursing Administration, Mayo Clinic Rochester),&nbsp;C.J. Hemeyer APRN (is Nephrology Nurse Practitioner, Department of Medicine, Mayo Clinic Jacksonville),&nbsp;Steph R. Jenkins MSN, RN, CNL (is Nursing Team Leader, Division of Regional Medicine, Mayo Clinic Jacksonville),&nbsp;Pranvera Dautaj APRN (is Nephrology Nurse Practitioner, Department of Medicine, Mayo Clinic Jacksonville),&nbsp;Maria M. Rose MHA (is Associate Director, Department of Food Services, Mayo Clinic Jacksonville),&nbsp;Erlinda M. Flores RN (is Registered Nurse, Inpatient Dialysis, Mayo Clinic Jacksonville),&nbsp;MaQuita D. McGhee DNP, MSN, RN (is Nursing Education Specialist, Nursing Administration, Mayo Clinic Jacksonville),&nbsp;Pablo Moreno Franco MD (is Internist and Chair of Critical Care, Department of Transplantation, Mayo Clinic Jacksonville),&nbsp;Jennifer B. Cowart MD (is Internist and Chair of Quality, Department of Medicine, Mayo Clinic Jacksonville. Please address correspondence to Jennifer B. Cowart)","doi":"10.1016/j.jcjq.2025.02.004","DOIUrl":"10.1016/j.jcjq.2025.02.004","url":null,"abstract":"<div><h3>Background</h3><div>Protein-energy wasting (PEW) syndrome is a common condition among patients suffering from end-stage renal disease (ESRD) receiving intermittent hemodialysis (IHD). Hospital nutrition barriers such as delayed meals and iatrogenic fasting can negatively affect patients’ experiences and contribute to long-standing nutritional deficits in at-risk patients. This project aimed to improve nutrition provision to inpatients with early IHD appointments by 50% (relative increase) without increasing IHD start time delays.</div></div><div><h3>Methods</h3><div>The Six Sigma DMAIC (Define, Measure, Analyze, Improve, and Control) methodology was used to guide the overall framework for process improvement, while specific improvements were implemented using Plan-Do-Study-Act (PDSA) cycles. Baseline data were analyzed for early morning appointments (5:00 <span>a.m.</span>–6:00 <span>a.m.</span>), and fishbone and Pareto charts were used to identify key barriers to nutrition availability. PDSA cycles were implemented to improve nutrition provision. Chi-square tests were conducted to assess significant changes in the percentage of patients reporting improved nutrition provision and reduced delays in dialysis start times.</div></div><div><h3>Results</h3><div>Baseline data showed that 38.6% of early IHD patients with diet orders at one tertiary care center received breakfast prior to their appointment. Stakeholder analysis and Pareto charts revealed that the mismatch between IHD start times and early meal tray delivery was a root cause. The first PDSA cycle adjusted nursing workflows, substituting early meals with bento snack boxes, achieving 54.2% nutrition provision. Following patient feedback, protein shakes were added, increasing provision to 93.8%. IHD start time delays decreased from 24.6% at baseline to an average of 10.2%, with these improvements sustained beyond 30 days postintervention.</div></div><div><h3>Conclusion</h3><div>The use of quality improvement methodology effectively improved nutrition delivery for high-risk patients and was associated with reduced hemodialysis start time delays and enhanced organizational efficiency. This project addressed a specific concern relating to patients receiving dialysis due to baseline rates of undernutrition and barriers to providing nourishment in the hospital. Future studies should focus on further analysis of patients on dialysis and expand to include other hospitalized subpopulations at risk for undernutrition, to optimize and generalize these interventions more broadly.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 6","pages":"Pages 389-397"},"PeriodicalIF":2.3,"publicationDate":"2025-02-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143991179","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Modeling Incremental Benefit of Medication Reconciliation on ICU Outcomes","authors":"Helen A. Harris MS (is Doctoral Candidate in Systems Modeling and Analysis, Department of Mathematics and Applied Mathematics, Virginia Commonwealth University (VCU)),&nbsp;David M. Chan PhD (is Professor, Department of Mathematics and Applied Mathematics, VCU),&nbsp;Laura Ellwein Fix PhD (is Associate Professor, Department of Mathematics and Applied Mathematics, VCU),&nbsp;Melissa Chouinard MD (is Director, Medication Safety, VCU Health, Richmond, Virginia, and Associate Professor, Division of Hospital Medicine, Department of Internal Medicine, VCU),&nbsp;Teresa M. Salgado MPharm, PhD (is Director, Center for Pharmacy Practice Innovation, VCU School of Pharmacy, and Associate Professor, Department of Pharmacotherapy and Outcomes Science, VCU),&nbsp;Le Kang PhD (is Associate Professor, Department of Biostatistics, School of Public Health, VCU),&nbsp;Gonzalo Bearman MD, MPH (is Professor, Department of Internal Medicine, and Chief, Division of Infectious Diseases, VCU. Please address correspondence to Helen Harris)","doi":"10.1016/j.jcjq.2025.02.001","DOIUrl":"10.1016/j.jcjq.2025.02.001","url":null,"abstract":"<div><h3>Background</h3><div>Medication errors such as medication discrepancies can occur in patients who are hospitalized and may result in adverse drug events (ADEs). Pharmacist-led medication reconciliation (MR) is an intervention that can be used to address medication discrepancies. Estimating the impact of MR in a medical setting is challenging to do experimentally. In this study, researchers implemented a mathematical model for estimating impact.</div></div><div><h3>Methods</h3><div>The authors modeled the effects of a series of incremental changes in MR completion on ADEs and conducted a cost-effectiveness analysis using a Markov chain model.</div></div><div><h3>Results</h3><div>In a 28-bed ICU, increasing the MR completion rate resulted in decreases in the total number of yearly ADEs by as many as 106, varying by the baseline ADE rate. The financial implications of increasing MR completion ranged from $27,808 in additional costs to $1,818,440 in savings on a yearly basis, depending on the baseline ADE rate and cost per ADE.</div></div><div><h3>Conclusion</h3><div>For institutions with low ADE rates, as MR completion increases and ADEs decrease, MR (though clinically beneficial) may not be financially worthwhile. However, MR implementation was found to produce significant savings for hospitals with average or high ADE rates.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 6","pages":"Pages 398-404"},"PeriodicalIF":2.3,"publicationDate":"2025-02-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143673934","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Leveraging Approaches and Tools of Implementation Science and Configurational Comparative Methods in Quality Improvement","authors":"Gabrielle Matias MD (Division of Pulmonary and Critical Care Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL),&nbsp;Nandita R. Nadig MD, MSCR, ATSF (Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL),&nbsp;Reiping Huang PhD (Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, Please address correspondence to Reiping Huang)","doi":"10.1016/j.jcjq.2025.02.003","DOIUrl":"10.1016/j.jcjq.2025.02.003","url":null,"abstract":"","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 4","pages":"Pages 239-240"},"PeriodicalIF":2.3,"publicationDate":"2025-02-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143704883","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Patient Safety Event Risk and Language Barriers: A Scoping Review","authors":"Lucy B. Schulson MD, MPH (is Assistant Professor, Section of General Internal Medicine, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine.),&nbsp;Jorge A. Rodriguez MD (is Research and Hospitalist, Division of General Internal Medicine, Brigham and Women's Hospital, Boston, and Assistant Professor, Harvard Medical School.),&nbsp;Ricardo Cruz MD, MPH, MA (is Assistant Professor, Section of General Internal Medicine, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine.),&nbsp;David Flynn MS (is Assistant Professor, Department of Medical Sciences & Education, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine.),&nbsp;Alicia Fernandez MD (is Professor, Department of Medicine, School of Medicine, University of California, San Francisco. Please address correspondence to Lucy B. Schulson)","doi":"10.1016/j.jcjq.2025.02.002","DOIUrl":"10.1016/j.jcjq.2025.02.002","url":null,"abstract":"<div><div>Patients who experience language barriers (LBs) may be at risk for patient safety events (PSEs). We conducted a scoping review of the literature to understand the risk for and type of PSEs in those who experience LBs. We searched PubMed, Web of Science, and Embase in October 2023. The search was organized into the following concepts: language barriers and patient safety. We included English language studies where risk of a PSE was compared in patients who experience to those who do not experience LBs or where types/characteristics of PSEs were compared in patients who are and are not at risk for LBs. We identified 22 studies for inclusion. Studies were primarily based in the United States and inpatient focused. Multiple methods were used to define patients who experience LBs and to identify PSEs. Patients who experienced LBs appeared to be at risk for communication-sensitive safety events, including medication-related adverse events and events related to vaginal deliveries, but at equal or lower risk for other types of events. Studies that did not rely solely on PSEs identified by clinician/staff report were more likely to identify disparities. We found few studies on PSE risk and LBs, a reflection of the dearth of research in this area and data sources with patient language. Studies had mixed results in part due to the multiple methods used to identify patients who experience LBs and PSEs. Interventions to reduce PSEs for patients who experience LBs should focus on events resulting from communication breakdowns.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 6","pages":"Pages 438-446"},"PeriodicalIF":2.3,"publicationDate":"2025-02-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143633936","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The Scholarly Upside to MOC4","authors":"Glenn Seela (is a Medical Student, University of Minnesota Medical School.),&nbsp;David Satin MD (is an Associate Professor, Department of Family Medicine and Community Health, University of Minnesota Medical School, and Affiliate Faculty Center for Bioethics, University of Minnesota.),&nbsp;Cathy Centola (is Division Administrator, Department of Pediatrics, University of Minnesota Medical School.),&nbsp;Sameer Gupta MD, MBA (is an Associate Professor, Department of Pediatrics, University of Minnesota Medical School.),&nbsp;Paul Hodges MPP (is Director of Process Improvement and Clinical Quality, M Health Fairview, University of Minnesota Medical Center.),&nbsp;Jeff Louie MD (is an Associate Professor, Department of Pediatrics, University of Minnesota Medical School.),&nbsp;Tanya E. Melnik MD, MS (is an Associate Professor, Department of Medicine, University of Minnesota Medical School.),&nbsp;David Pelletier MSE, ICBB (is Principal Consultant, Quality Improvement, M Health Fairview.),&nbsp;Christina Russell MD (is an Assistant Professor, Department of Pediatrics, University of Minnesota Medical School.),&nbsp;Andrew Thompson MBA, MBB (Principal Consultant, Performance Improvement, M Health Fairview.),&nbsp;Jordan Marmet MD (is an Associate Professor, Department of Pediatrics, University of Minnesota Medical School. Please address correspondence to Jordan Marmet)","doi":"10.1016/j.jcjq.2024.10.014","DOIUrl":"10.1016/j.jcjq.2024.10.014","url":null,"abstract":"<div><h3>Background</h3><div>Many medical boards require quality improvement (QI) projects for Maintenance of Certification Part IV (MOC4) credits. The American Board of Medical Specialties (ABMS) allows health care organizations that can demonstrate sufficient QI standards to become Portfolio Program Sponsors. This enables internal review and approval of QI projects, crediting all sufficiently contributing physicians. The University of Minnesota's M Health Fairview MOC4 Review Board (MMRB) was approved as an ABMS Portfolio Program Sponsor; the impact was surveyed from inception in 2016 to 2022. The objective was to examine the impact of a Portfolio Sponsor program on scholarship, sustainability, and spread of QI projects.</div></div><div><h3>Methods</h3><div>The authors developed and validated an eight-question survey directed at MOC4 principal investigators (PIs) who were awarded credits through the MMRB from 2016 to 2022. Participants reported on numbers of peer-reviewed publication or presentation, and their perception of increased preparedness for scholarship due to the application process. They also reported on sustainment or spread following their original QI project.</div></div><div><h3>Results</h3><div>Fifty projects were reviewed over a seven-year span. Of these, 44 were approved as demonstrating sufficient QI rigor per ABMS standards. Of 41 PIs, 27 (65.9%) responded to the survey; 15 (55.6%) agreed that the MMRB process helped prepare them for scholarly dissemination, 19 (70.4%) delivered oral or poster presentations, and 10 (37.0%) submitted a total of 14 manuscripts for publication, 10 of which were accepted. A total of 23 QI projects (85.2%) were sustained, and 10 (37.0%) had spread.</div></div><div><h3>Conclusion</h3><div>In addition to generating essential MOC4 credits for participating physicians, an MMRB process can help PIs prepare for scholarship, project sustainment, and spread.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 2","pages":"Pages 101-107"},"PeriodicalIF":2.3,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142864222","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Implementation of the Revised American Academy of Pediatrics Clinical Practice Guidelines for Hyperbilirubinemia Decreases Necessity for Serum Bilirubin and Phototherapy","authors":"Matthew R. Michienzi DO (is Pediatric Resident, Department of Pediatrics, Brooke Army Medical Center, San Antonio, Texas.),&nbsp;Dakota K. Tomasini DO (is Neonatology Fellow, Department of Pediatrics, Brooke Army Medical Center.),&nbsp;Carleigh C. Fisher DO (is Pediatric Resident, Department of Pediatrics, Brooke Army Medical Center.),&nbsp;Adharsh P. Ponnapakkam MD (is Pediatric Resident, Department of Pediatrics, Brooke Army Medical Center. Please address correspondence to Matthew Michienzi)","doi":"10.1016/j.jcjq.2024.10.013","DOIUrl":"10.1016/j.jcjq.2024.10.013","url":null,"abstract":"<div><h3>Background</h3><div>The initial hyperbilirubinemia management recommendations published by the American Academy of Pediatrics (AAP) in 2004 and updated in 2009 led to wide variations in clinical practice among providers, with variable results. In August 2022 AAP published updated clinical practice guidelines for the management of hyperbilirubinemia. The aim of this project was to determine the effect of adaptation of the AAP guidelines on laboratory testing, readmission rates, and phototherapy.</div></div><div><h3>Methods</h3><div>Existing institutional protocol was updated to incorporate the revised AAP guidelines. The primary outcome was percentage of serum bilirubin labs obtained. Balancing measures included monthly readmission rate, need for escalation of care, and percentage of patients requiring additional labs or phototherapy. Statistical process control charts measured changes in quality over time. Chi-square analysis evaluated differences between pre- and postintervention periods.</div></div><div><h3>Results</h3><div>A total of 2,301 infants were evaluated, 1,662 of which were included in the postintervention analysis. A clinically and statistically significant decrease was seen in the percentage of patients with serum bilirubin evaluation, from 21.3% to 8.8% (<em>p</em> &lt; 0.001). There was a decrease in need for phototherapy, from 4.2% to 1.4% (<em>p</em> &lt; 0.001), but duration of treatment was longer when initiated. The authors simultaneously saw no changes in readmission rate or additional laboratory evaluation, with no incidence of bilirubin-induced encephalopathy or escalation of care.</div></div><div><h3>Conclusion</h3><div>Implementation of the revised 2022 AAP guidelines was associated with a decrease in serum bilirubin evaluation and phototherapy initiation. This integrated protocol may represent a sustainable standardized approach to management of hyperbilirubinemia.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 2","pages":"Pages 95-100"},"PeriodicalIF":2.3,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142854204","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Simulation-Debriefing Enhanced Needs Assessment to Address Quality Markers in Health Care: An Innovation for Prospective Hazard Analysis","authors":"Lisa T. Barker MD, MHPE (is Clinical Associate Professor of Emergency Medicine, OSF HealthCare, University of Illinois College of Medicine at Peoria, and Medical Director, Jump Simulation, an OSF HealthCare and University of Illinois College of Medicine at Peoria Collaboration.),&nbsp;William F. Bond MD, MS (is Professor of Clinical Emergency Medicine, University of Illinois College of Medicine at Peoria, and Director of Research, Jump Simulation.),&nbsp;Ann M. Willemsen-Dunlap CRNA, PhD (is Director of Education Development, Jump Simulation.),&nbsp;Kimberly L. Cooley MSN, RN, CCRC (is Research Education Facilitator, OSF HealthCare.),&nbsp;Jeremy S. McGarvey MS (is Senior Statistician, Division of Healthcare Analytics, OSF HealthCare.),&nbsp;Rebecca L. Ruger (is Graduate Student, Department of Psychology, Pennsylvania State University.),&nbsp;Adam Kohlrus MS, CPHQ, CPPS (is Partner and Business Designer, Do Tank, Springfield, Illinois.),&nbsp;Michael J. Kremer PhD, CRNA, CHSE, FAAN (is Professor and Interim Chair, Department of Adult Health and Gerontological Nursing, College of Nursing, and Co-Director, Rush Center for Clinical Skills and Simulation, Rush University.),&nbsp;Michelle Sergel MD (is Co-Director, Rush Center for Clinical Skills and Simulation, Rush University and Assistant Professor of Emergency Medicine, Rush Medical College.),&nbsp;John A. Vozenilek MD (is Vice President and Chief Medical Officer for Innovation, OSF HealthCare. Please address correspondence to Lisa T. Barker)","doi":"10.1016/j.jcjq.2024.10.004","DOIUrl":"10.1016/j.jcjq.2024.10.004","url":null,"abstract":"<div><div>Simulation-Debriefing Enhanced Needs Assessment (SDENA) is a simulation-based approach to prospective hazard analysis that uses simulation and debriefing as a unit-level diagnostic tool. Scenarios address failure modes for health care improvement targets, and debriefing explores unit-specific barriers and resiliencies. Debriefing guides are structured to explore how six drivers of a behavior engineering framework (data, tools/resources, incentives, knowledge/skills, capacity, motivation) influence clinical behaviors. Illinois Hospital Association members who deployed SDENA to address specific hospital-acquired conditions found motivation to be a more significant barrier than anticipated before deployment. SDENA represents a novel approach to improving safety and may refine intervention targets.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 2","pages":"Pages 144-158"},"PeriodicalIF":2.3,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142970973","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}