Multiple component patient safety intervention in English hospitals: controlled evaluation of second phase
Multiple component patient safety intervention in English hospitals: controlled evaluation of second phase
复制标题
DOI：
10.1136/bmj.d199
复制
发表时间：
2011-02-03
影响因子：
105.7
通讯作者：
Lilford, Richard
中科院分区：
文献类型：
--
作者：
Benning, Amirta;Dixon-Woods, Mary;Lilford, Richard
目的独立评估健康基金会的更安全的病人倡议（SPI 2）的第二阶段的影响，对一系列的病人安全measurement.Design A控制前后设计。5个子研究：员工态度调查;审查高风险病例记录（呼吸）内科病房的病人;审查外科病人的病例记录;通过衡量医院洗手材料的使用情况间接评价手卫生;成果计量（不良事件、进入内科病房的高风险患者的死亡率、患者满意度、重症监护中的死亡率，医院获得性感染的发生率）。设置NHS医院在英格兰。参与者9家医院参加SPI 2和9个匹配的对照医院。干预-SPI 2干预是类似的SPI 1，有点修改的目标，稍长的干预期，和较小的预算每个hospital.Results的分数（组织气候）之一，显示出显着的（P=0.009）差异的变化率随着时间的推移，有利于控制医院，虽然差异只有0.07分的5点量表。明确的情况下，高风险的医疗病人的笔记审查的结果表明，随着时间的推移，在控制和SPI 2医院（和没有恶化）的某些做法有所改善，但控制和SPI 2医院之间没有显着差异。对照和SPI 2研究中心的生命体征监测得到改善。这种时间效应对于监测入院后6小时（调整后比值比2.1，99%置信区间1.0至4.3; P=0.010）和12小时（2.4，1.1至5.0; P=0.002）的呼吸频率具有显著性。SPI对任何生命体征指标均无显著影响。使用推荐的肺炎严重程度评分系统，对照组从1.9%（1/52）改善至21.4%（12/56），SPI 2组从2.0%（1/50）改善至41.7%（25/60）。这种时间变化具有显著性（7.3，1.4至37.7; P=0.002），但差异无显著性（2.1，0.4至11.1; P=0.236）。无论是随着时间的推移，还是在对照组和SPI 2组医院之间，处方错误的模式都没有明显或显著的变化。两个项目的病史采集（运动耐量和职业）显示出显着的改善，随着时间的推移，在控制和SPI 2医院，但没有额外的SPI 2的影响。整体审查显示，无论是随着时间的推移，还是在控制和SPI 2医院之间，错误率都没有显着变化。围手术期护理的明确病例记录审查显示，SPI 2针对的四个围手术期标准中的两个标准的依从率在基线时已经很好，抗生素预防超过94%，深静脉血栓预防超过98%。两组的术中温度监测均随时间推移而改善，但不显著（1.8，0.4 - 7.6; P=0.279），且SPI 2无其他影响。肥皂和酒精洗手液的消费量在对照组和SPI 2医院中的急剧上升相似（分别为P=0.760和P=0.889），艰难梭菌和耐甲氧西林金黄色葡萄球菌感染率的相应下降也相似（分别为P=0.652和P=0.693）。对照医院病例记录审查中纳入的医疗患者的死亡率从17.3%（42/ 243）增加到21.4%（24/112），而SPI 2医院的死亡率从10.3%（24/233）下降到6.1%（7/114）（P=0.043）。只有不到8%的死亡被归类为可以避免的;比例的变化无法解释对照医院和SPI 2医院之间总体死亡率的差异。重症监护组的死亡率变化率无显著差异。患者的满意度提高，在控制和SPI 2医院的各个方面，但再次有两组hospital.Conclusions护理的许多方面已经很好，或改善整个NHS在英格兰之间没有显着的变化，这表明相当大的改善质量全面。这些改进可能是由于与患者安全相关的同期政策活动，包括具有与SPI相似特征的政策活动，以及对某些临床过程的专业共识的出现。这种现象可能削弱了SPI的增量效应，使其难以检测。或者，SPI的全部影响可能只有在较长期内才能观察到。如果未使用同期对照，本研究的结论可能不同。
Objective To independently evaluate the impact of the second phase of the Health Foundation's Safer Patients Initiative (SPI2) on a range of patient safety measures.Design A controlled before and after design. Five substudies: survey of staff attitudes; review of case notes from high risk (respiratory) patients in medical wards; review of case notes from surgical patients; indirect evaluation of hand hygiene by measuring hospital use of handwashing materials; measurement of outcomes (adverse events, mortality among high risk patients admitted to medical wards, patients' satisfaction, mortality in intensive care, rates of hospital acquired infection).Setting NHS hospitals in England.Participants Nine hospitals participating in SPI2 and nine matched control hospitals. Intervention The SPI2 intervention was similar to the SPI1, with somewhat modified goals, a slightly longer intervention period, and a smaller budget per hospital.Results One of the scores (organisational climate) showed a significant (P=0.009) difference in rate of change over time, which favoured the control hospitals, though the difference was only 0.07 points on a five point scale. Results of the explicit case note reviews of high risk medical patients showed that certain practices improved over time in both control and SPI2 hospitals (and none deteriorated), but there were no significant differences between control and SPI2 hospitals. Monitoring of vital signs improved across control and SPI2 sites. This temporal effect was significant for monitoring the respiratory rate at both the six hour (adjusted odds ratio 2.1, 99% confidence interval 1.0 to 4.3; P=0.010) and 12 hour (2.4, 1.1 to 5.0; P=0.002) periods after admission. There was no significant effect of SPI for any of the measures of vital signs. Use of a recommended system for scoring the severity of pneumonia improved from 1.9% (1/52) to 21.4% (12/56) of control and from 2.0% (1/50) to 41.7% (25/60) of SPI2 patients. This temporal change was significant (7.3, 1.4 to 37.7; P=0.002), but the difference in difference was not significant (2.1, 0.4 to 11.1; P=0.236). There were no notable or significant changes in the pattern of prescribing errors, either over time or between control and SPI2 hospitals. Two items of medical history taking (exercise tolerance and occupation) showed significant improvement over time, across both control and SPI2 hospitals, but no additional SPI2 effect. The holistic review showed no significant changes in error rates either over time or between control and SPI2 hospitals. The explicit case note review of perioperative care showed that adherence rates for two of the four perioperative standards targeted by SPI2 were already good at baseline, exceeding 94% for antibiotic prophylaxis and 98% for deep vein thrombosis prophylaxis. Intraoperative monitoring of temperature improved over time in both groups, but this was not significant (1.8, 0.4 to 7.6; P=0.279), and there were no additional effects of SPI2. A dramatic rise in consumption of soap and alcohol hand rub was similar in control and SPI2 hospitals (P=0.760 and P=0.889, respectively), as was the corresponding decrease in rates of Clostridium difficile and meticillin resistant Staphylococcus aureus infection (P=0.652 and P=0.693, respectively). Mortality rates of medical patients included in the case note reviews in control hospitals increased from 17.3% (42/ 243) to 21.4% (24/112), while in SPI2 hospitals they fell from 10.3% (24/233) to 6.1% (7/114) (P=0.043). Fewer than 8% of deaths were classed as avoidable; changes in proportions could not explain the divergence of overall death rates between control and SPI2 hospitals. There was no significant difference in the rate of change in mortality in intensive care. Patients' satisfaction improved in both control and SPI2 hospitals on all dimensions, but again there were no significant changes between the two groups of hospitals.Conclusions Many aspects of care are already good or improving across the NHS in England, suggesting considerable improvements in quality across the board. These improvements are probably due to contemporaneous policy activities relating to patient safety, including those with features similar to the SPI, and the emergence of professional consensus on some clinical processes. This phenomenon might have attenuated the incremental effect of the SPI, making it difficult to detect. Alternatively, the full impact of the SPI might be observable only in the longer term. The conclusion of this study could have been different if concurrent controls had not been used.