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Evidence suggests that the patient-centered medical home (PCMH) model of primary care improves management of chronic disease, but there is limited research contrasting this model's effect when financed by a single payer versus multiple payers, and among patients with different types of health insurance. This study evaluates the impact of a statewide medical home demonstration, the Maryland Multi-Payer PCMH Program (MMPP), on adherence to antihypertensive medication therapy relative to non-PCMH primary care and to the PCMH model when financed by a single payer. The authors used a difference-in-differences analytic design to analyze changes in medication possession ratio for antihypertensive medications among Medicaid-insured and privately insured non-elderly adult patients attributed to primary care practices in the MMPP ("multi-payer PCMHs"), medical homes in Maryland that participated in a regional PCMH program funded by a single private payer ("single-payer PCMHs"), and non-PCMH practices in Maryland. Comparison sites were matched to multi-payer PCMHs using propensity scores based on practice characteristics, location, and aggregated provider characteristics. Multi-payer PCMHs performed better on antihypertensive medication adherence for both Medicaid-insured and privately insured patients relative to single-payer PCMHs. Statistically significant effects were not observed consistently until the second year of the demonstration. There were negligible differences in outcome trends between multi-payer medical homes and matched non-PCMH practices. Findings indicate that health care delivery innovations may yield superior population health outcomes under multi-payer financing compared to when such initiatives are financed by a single payer.

SARS-CoV-2 circulating variants coupled with waning immunity pose a significant threat to the long-term care (LTC) population. Our objective was to measure salivary IgG antibodies in residents and staff of an LTC facility to (1) evaluate IgG response in saliva post-natural infection and vaccination and (2) assess its feasibility to describe the seroprevalence over time.We performed salivary IgG sampling of all residents and staff who agreed to test in a 150-bed skilled nursing facility during three seroprevalence surveys between October 2020 and February 2021. The facility had SARS-CoV-2 outbreaks in May 2020 and November 2020, when 45 of 138 and 37 of 125 residents were infected, respectively; they offered two Federal vaccine clinics in January 2021. We evaluated quantitative IgG in saliva to the Nucleocapsid (N), Spike (S), and Receptor-binding domain (RBD) Antigens of SARS-CoV-2 over time post-infection and post-vaccination.One hundred twenty-four residents and 28 staff underwent saliva serologic testing on one or more survey visits. Over three surveys, the SARS-CoV-2 seroprevalence at the facility was 49%, 64%, and 81%, respectively. IgG to S, RBD, and N Antigens all increased post infection. Post vaccination, the infection naïve group did not have a detectable N IgG level, and N IgG levels for the previously infected did not increase post vaccination (p 0.001). Fully vaccinated subjects with prior COVID-19 infection had significantly higher RBD and S IgG responses compared with those who were infection-naïve prior to vaccination (p 0.001 for both).Positive SARS-COV-2 IgG in saliva was concordant with prior infection (Anti N, S, RBD) and vaccination (Anti S, RBD) and remained above positivity threshold for up to 9 months from infection. Salivary sampling is a non-invasive method of tracking immunity and differentiating between prior infection and vaccination to inform the need for boosters in LTC residents and staff.

To evaluate changes in Clostridioides difficile incidence rates for Maryland hospitals that participated in the Statewide Prevention and Reduction of C. difficile (SPARC) collaborative. Pre-post, difference-in-difference analysis of non-randomised intervention using four quarters of preintervention and six quarters of postintervention National Healthcare Safety Network data for SPARC hospitals (April 2017 to March 2020) and 10 quarters for control hospitals (October 2017 to March 2020). Mixed-effects negative binomial models were used to assess changes over time. Process evaluation using hospital intervention implementation plans, assessments and interviews with staff at eight SPARC hospitals. Maryland, USA. All Maryland acute care hospitals; 12 intervention and 36 control hospitals. Participation in SPARC, a public health–academic collaborative made available to Maryland hospitals, with staggered enrolment between June 2018 and August 2019. Hospitals with higher C. difficile rates were recruited via email and phone. SPARC included assessments, feedback reports and ongoing technical assistance. Primary outcomes were C. difficile incidence rate measured as the quarterly number of C. difficile infections per 10 000 patient-days (outcome measure) and SPARC intervention hospitals’ experiences participating in the collaborative (process measures). SPARC invited 13 hospitals to participate in the intervention, with 92% (n=12) participating. The 36 hospitals that did not participate served as control hospitals. SPARC hospitals were associated with 45% greater C. difficile reduction as compared with control hospitals (incidence rate ratio=0.55, 95% CI 0.35 to 0.88, p=0.012). Key SPARC activities, including access to trusted external experts, technical assistance, multidisciplinary collaboration, an accountability structure, peer-to-peer learning opportunities and educational resources, were associated with hospitals reporting positive experiences with SPARC. SPARC intervention hospitals experienced 45% greater reduction in C. difficile rates than control hospitals. A public health–academic collaborative might help reduce C. difficile and other hospital-acquired infections in individual hospitals and at state or regional levels.

Background Our objective was to determine if the addition of ultraviolet-C (UV-C) light to daily and discharge patient room cleaning reduces healthcare-associated infection rates of vancomycin-resistant enterococci (VRE) and Clostridioides difficile in immunocompromised adults. Methods We performed a cluster randomized crossover control trial in 4 cancer and 1 solid organ transplant in-patient units at the Johns Hopkins Hospital, Baltimore, Maryland. For study year 1, each unit was randomized to intervention of UV-C light plus standard environmental cleaning or control of standard environmental cleaning, followed by a 5-week washout period. In study year 2, units switched assignments. The outcomes were healthcare-associated rates of VRE or C. difficile. Statistical inference used a two-stage approach recommended for cluster-randomized trials with Results In total, 302 new VRE infections were observed during 45787 at risk patient-days. The incidence in control and intervention groups was 6.68 and 6.52 per 1000 patient-days respectively; the unadjusted incidence rate ratio (IRR) was 0.98 (95% confidence interval [CI], .78 − 1.22; P = .54). There were 84 new C. difficile infections observed during 26118 at risk patient-days. The incidence in control and intervention periods was 2.64 and 3.78 per 1000 patient-days respectively; the unadjusted IRR was 1.43 (95% CI, .93 − 2.21; P = .98). Conclusions When used daily and at post discharge in addition to standard environmental cleaning, UV-C disinfection did not reduce VRE or C. difficile infection rates in cancer and solid organ transplant units.

Objective: To examine (1) patient perceptions regarding their engagement and the engagement of their families in perioperative pain management, (2) demographic and clinical characteristics associated with perceived patient and family engagement, and (3) the association between perceived patient and family engagement and patient outcomes.Design: A prospective, observational study. Setting: The Personalized Pain Program (PPP) at the Johns Hopkins Hospital in Baltimore, Maryland.Participants: Patients having more than one visit to the PPP.Interventions: n/a.Main outcome measures: Since the inception of the PPP, patients were surveyed prior to each clinic visit to assess their pain severity and interference using the Brief Pain Inventory. Starting August 22, 2018, two additional questions were added to the survey to assess patient perceptions of their engagement and the engagement of their families in perioperative pain management. In addition, electronic medical records were reviewed to collect data on daily opioid consumption during the first and last PPP visits presurgery and post-surgery. Results: The final analysis included 511 survey responses from 155 patients. Perceived engagement of the patient in perioperative pain management improved over time (p < .001) and was significantly associated with reduction in prescription opioid consumption after surgery (coef = 12.7, SE = 5.8, p = .031).Conclusions: Surgical patients and their family members should be actively engaged in perioperative pain management to improve prescription opioid use and the quality and safety of perioperative care.

Objectives Trauma (i.e., musculoskeletal injury from a blunt or penetrating force) can change the trajectory of a person’s life. Patients often experience chronic pain, reduced quality of life, long-term opioid therapy, and psychiatric comorbidities after trauma surgery. This case report presents clinical outcomes of four patients who received postsurgical pain care in a transitional pain service (TPS) that provides long-term coordinated multimodal pain care, opioid tapering plans, and psychiatric care. Methods The Personalized Pain Program (PPP) measures prescription opioid use and patient-reported outcomes: pain severity and pain interference (Brief Pain Inventory), pain catastrophizing (Pain Catastrophizing Scale), insomnia severity (Insomnia Severity Index), physical and mental health functioning (SF-12 pre-COVID-19; SF-36 during COVID-19 pandemic) at initial and subsequent clinic visits. Results All four patients reduced their postsurgical opioid use with concurrent reductions in pain and improved functioning while receiving postoperative care in the PPP (average length of treatment: 2.8 years). Psychiatric co-treatment addressed the onset or exacerbation of mental health comorbidities following trauma. Conclusions Long-term multidisciplinary pain care may improve post-trauma recovery and reduce risks of long-term opioid therapy and disability. Prospective studies are needed to evaluate the effectiveness of TPSs for patients undergoing trauma surgery.

In a cross-sectional evaluation of healthcare worker reuse of their own 3M N95 respirators, 83% (76/92) passed the seal check and the fit-test after a median of 40 repeated donnings. User seal-check failure correlated with fit-test failure, and it may help HCWs recognize when to appropriately discard a reused N95.

Introduction Using a human factors engineering approach, the Johns Hopkins Personalized Pain Program adopted telemedicine for perioperative pain management in response to the COVID-19 pandemic. This study examines the impact of telemedicine adoption on the quality and outcomes of perioperative pain management. Methods A mixed-methods study with a convergent parallel design was conducted. From June 2017 to December 2021, 902 patients participated in the Personalized Pain Program. Quantitative data on daily opioid consumption, pain severity and interference, physical and mental health status, and patient satisfaction and engagement were continuously collected with all patients using chart review and patient surveys. Beginning 23 March 2020, the Personalized Pain Program transitioned to telemedicine. A pre–post quasi-experimental design was used to examine the impact of telemedicine. In addition, qualitative interviews were conducted with 3 clinicians and 17 patients to explore their experience with telemedicine visits. Results The monthly number of new patients seen in the Personalized Pain Program did not significantly change before and after telemedicine adoption. Compared to patients having in-person visits before the pandemic, patients having telemedicine visits during the pandemic achieved comparable improvements in daily opioid consumption, pain severity and interference, and physical health status. While telemedicine helped overcome many challenges faced by the patients, the limitations of telemedicine were also discussed. Conclusion The COVID-19 pandemic stimulated the use of telemedicine. To facilitate telemedicine adoption beyond the pandemic, future research is needed to examine best practices for telemedicine adoption and provide additional evidence on the effectiveness of telemedicine.

Background:Healthcare workers (HCWs) not adhering to physical distancing recommendations is a risk factor for acquisition of severe acute respiratory coronavirus virus 2 (SARS-CoV-2). The study objective was to assess the impact of interventions to improve HCW physical distancing on actual distance between HCWs in a real-life setting.Methods:HCWs voluntarily wore proximity beacons to measure the number and intensity of physical distancing interactions between each other in a pediatric intensive care unit. We compared interactions before and after implementing a bundle of interventions including changes to the layout of workstations, cognitive aids, and individual feedback from wearable proximity beacons.Results:Overall, we recorded 10,788 interactions within 6 feet (∼2 m) and lasting >5 seconds. The number of HCWs wearing beacons fluctuated daily and increased over the study period. On average, 13 beacons were worn daily (32% of possible staff; range, 2–32 per day). We recorded 3,218 interactions before the interventions and 7,570 interactions after the interventions began. Using regression analysis accounting for the maximum number of potential interactions if all staff had worn beacons on a given day, there was a 1% decline in the number of interactions per possible interactions in the postintervention period (incident rate ratio, 0.99; 95% confidence interval, 0.98–1.00; P = .02) with fewer interactions occurring at nursing stations, in workrooms and during morning rounds.Conclusions:Using quantitative data from wearable proximity beacons, we found an overall small decline in interactions within 6 feet between HCWs in a busy intensive care unit after a multifaceted bundle of interventions was implemented to improve physical distancing.

The optimal timing of blood culture (BCx) sets collection has not been evaluated with continuous BCx detection systems. The yield of BCx was similar between short intervals (median, 3 minutes) and longer intervals (median, 16 or 43 minutes) among 5,856 BCx, except for improved polymicrobial bacteremia detection with long-interval BCx.

Background More than 28 000 people were infected with Ebola virus during the 2014–2015 West African outbreak, resulting in more than 11 000 deaths. Better methods are needed to reduce the risk of self-contamination while doffing personal protective equipment (PPE) to prevent pathogen transmission. Methods A set of interventions based on previously identified failure modes was designed to mitigate the risk of self- contamination during PPE doffing. These interventions were tested in a randomized controlled trial of 48 participants with no prior experience doffing enhanced PPE. Contamination was simulated using a fluorescent tracer slurry and fluorescent polystyrene latex spheres (PLSs). Self-contamination of scrubs and skin was measured using ultraviolet light visualization and swabbing followed by microscopy, respectively. Doffing sessions were videotaped and reviewed to score standardized teamwork behaviors. Results Participants in the intervention group contaminated significantly fewer body sites than those in the control group (median [interquartile range], 6 [3–8] vs 11 [6–13], P = .002). The median contamination score was lower for the intervention group than the control group when measured by ultraviolet light visualization (23.15 vs 64.45, P = .004) and PLS swabbing (72.4 vs 144.8, P = .001). The mean teamwork score was greater in the intervention group (42.2 vs 27.5, P < .001). Conclusions An intervention package addressing the PPE doffing task, tools, environment, and teamwork skills significantly reduced the amount of self-contamination by study participants. These elements can be incorporated into PPE guidance and training to reduce the risk of pathogen transmission., An intervention package that addressed components of the task, tools, environment, and teamwork skills during personal protective equipment (PPE) doffing significantly reduced the amount of self-contamination by study participants. These elements can be incorporated into PPE guidance and training to prevent pathogen transmission.

Opioid use disorder (OUD) is a national crisis. Health care must achieve greater success than it has to date in helping opioid users achieve recovery. Integration of comprehensive primary care with treatment for OUD has the potential to increase care access among the substance-using population, improve outcomes, and reduce costs. However, little is known about the effectiveness of such care models. The Comprehensive Care Practice (CCP), a primary care practice located in Maryland, implemented a care model that blends buprenorphine treatment for OUD with attention to primary care needs. This study evaluates the model by comparing patients with OUD treated in CCP and other Maryland facilities in a large state Medicaid program. Compared to the non-CCP patient group (n = 867), the CCP group (n = 131) had a higher 6-month buprenorphine treatment retention rate (79% vs. 61%, adjusted average marginal effect (AME) = 0.17

Using a pre–post design, this study examined the impact of a multifaceted program to simultaneously improve 3 health care–associated infections and patient safety culture throughout the cardiac surgery service line in 11 hospitals. Interventions included the Comprehensive Unit-based Safety Program to improve safety culture and evidence-based bundles to prevent central line–associated bloodstream infection (CLABSI), surgical site infection (SSI), and ventilator-associated pneumonia (VAP). CLABSIs and SSIs showed a downward trend over 2 years, then the rates returned to levels similar to baseline in the third year. VAP rate changes were difficult to interpret because of the VAP definition change. Patient safety culture domain “hospital management support” showed significant improvement, but feedback and communication about errors and staffing declined. Simultaneous implementation of multiple interventions across units is challenging. The findings highlight the importance of sustainment efforts and suggest future work should anticipate both positive and negative change in safety culture dimensions.

In a cross-sectional evaluation of healthcare worker reuse of their own 3M N95 respirators, 83% (76/92) passed the seal check and the fit-test after a median of 40 repeated donnings. The user seal-check had 31% sensitivity to detect N95 respirator failure but 100% specificity.

Interventions to optimize blood culture (BCx) practices in adult inpatients are limited. We conducted a before-after study evaluating the impact of a diagnostic stewardship program that aimed to optimize BCx use in a medical intensive care unit (MICU) and five medicine units at a large academic center. The program included implementation of an evidence-based algorithm detailing indications for BCx use and education and feedback to providers about BCx rates and indication inappropriateness. Neutropenic patients were excluded. BCx rates from contemporary control units were obtained for comparison. The primary outcome was the change in BCxs ordered with the intervention. Secondary outcomes included proportion of inappropriate BCx, solitary BCx, and positive BCx. Balancing metrics included compliance with the Centers for Medicare and Medicaid Services (CMS) SEP-1 BCx component, 30-day readmission, and all-cause in-hospital and 30-day mortality. After the intervention, BCx rates decreased from 27.7 to 22.8 BCx/100 patient-days (PDs) in the MICU (P = 0.001) and from 10.9 to 7.7 BCx/100 PD for the 5 medicine units combined (P

Objectives The patient-centered medical home (PCMH) may provide a key model for ambulatory patient safety. Our objective was to explore which PCMH and patient safety implementation and social network factors may be necessary or sufficient for higher patient safety culture. Methods This was a cross-case analysis study in 25 diverse U.S. PCMHs. Data sources included interviews of a clinician and an administrator in each PCMH, surveys of clinicians and staff, and existing data on the PCMHs' characteristics. We used coincidence analysis, a novel method based on set theory and Boolean logic, to evaluate relationships between factors and the implementation outcome of patient safety culture. Results The coincidence analysis identified 5 equally parsimonious solutions (4 factors), accounting for all practices with higher safety culture. Three solutions contained the same core minimally sufficient condition: the implementation factor leadership priority for patient safety and the social network factor reciprocity in advice-seeking network ties (advice-seeking relationships). This minimally sufficient condition had the highest coverage (5/7 practices scoring higher on the outcome) and best performance across solutions; all included leadership priority for patient safety. Other key factors included self-efficacy and job satisfaction and quality improvement climate. The most common factor whose absence was associated with the outcome was a well-functioning process for behavioral health. Conclusions Our findings suggest that PCMH safety culture is higher when clinicians and staff perceive that leadership prioritizes patient safety and when high reciprocity among staff exists. Interventions to improve patient safety should consider measuring and addressing these key factors.

BACKGROUND: Hypertension control and diabetes control are important for reducing cardiovascular disease burden. A growing body of research suggests an association between neighborhood environment and hypertension or diabetes control among patients engaged in clinical care. OBJECTIVE: To investigate whether neighborhood conditions (i.e., healthy food availability, socioeconomic status (SES), and crime) were associated with hypertension and diabetes control. DESIGN: Cross-sectional analyses using electronic medical record (EMR) data, U.S. Census data, and secondary data characterizing neighborhood food environments. Multivariate logistic regression analyses adjusted for potential confounders. Analyses were conducted in 2017. PARTICIPANTS: Five thousand nine hundred seventy adults receiving primary care at three Baltimore City clinics in 2010–2011. MAIN MEASURES: Census tract–level neighborhood healthy food availability, neighborhood SES, and neighborhood crime. Hypertension control defined as systolic blood pressure

The ideal sampling method and benefit of qualitative versus quantitative culture for carbapenem-resistant Enterobacteriaceae (CRE) recovery in hospitalized patient rooms and bathrooms is unknown. Although the use of nylon-flocked swabs improved overall gram-negative organism recovery compared with cellulose sponges, they were similar for CRE recovery. Quantitative culture was inferior and unrevealing beyond the qualitative results.

BACKGROUND A health system's commitment to delivering culturally competent care is essential in creating a culture of respect for patients, clinicians, and administrative staff. As the diversity of the health care workforce grows, gaining an understanding of the perspectives among different health care personnel and the value that they place on organizational cultural competence is a first step in developing more effective team environments. PURPOSE The aim of the study was to determine whether an association exists between perceptions of organizational cultural competence and teamwork climate among employees in a health system. METHODOLOGY/APPROACH One thousand eighty employees in a primary care network consisting of 49 ambulatory practices were surveyed on their perceptions of senior management's efforts in organizational cultural competence and teamwork climate in their own work setting using 5-point Likert scales. Linear regression models were used to evaluate the association between organizational cultural competence and teamwork climate. RESULTS The overall organizational response rate for the survey was 84%. Higher perception of organizational cultural competence was associated with better teamwork climate (coef. = 0.4, p

Supplemental Digital Content is available in the text., Objective: To evaluate impact of the Maryland Multipayor Patient-centered Medical Home Program (MMPP) on: (1) quality, utilization, and costs of care; (2) beneficiaries’ experiences and satisfaction with care; and (3) perceptions of providers. Design: 4-year quasiexperimental design with a difference-in-differences analytic approach to compare changes in outcomes between MMPP practices and propensity score-matched comparisons; pre-post design for patient-reported outcomes among MMPP beneficiaries. Subjects: Beneficiaries (Medicaid-insured and privately insured) and providers in 52 MMPP practices and 104 matched comparisons in Maryland. Intervention: Participating practices received unconditional financial support and coaching to facilitate functioning as medical homes, membership in a learning collaborative to promote education and dissemination of best practices, and performance-based payments. Measures: Sixteen quality, 20 utilization, and 13 cost measures from administrative data; patient-reported outcomes on care delivery, trust in provider, access to care, and chronic illness management; and provider perceptions of team operation, team culture, satisfaction with care provided, and patient-centered medical home transformation. Results: The MMPP had mixed impact on site-level quality and utilization measures. Participation was significantly associated with lower inpatient and outpatient payments in the first year among privately insured beneficiaries, and for the entire duration among Medicaid beneficiaries. There was indication that MMPP practices shifted responsibility for certain administrative tasks from clinicians to medical assistants or care managers. The program had limited effect on measures of patient satisfaction (although response rates were low) and on provider perceptions. Conclusions: The MMPP demonstrated mixed results of its impact and indicated differential program effects for privately insured and Medicaid beneficiaries.

We evaluated use of a program to improve blood pressure measurement at 6 primary care clinics over a 6-month period. The program consisted of automated devices, clinical training, and support for systems change. Unannounced audits and electronic medical records provided evaluation data. Clinics used devices in 81.0% of encounters and used them as intended in 71.6% of encounters, but implementation fidelity varied. Intervention site systolic and diastolic blood pressure with terminal digit "0" decreased from 32.1% and 33.7% to 11.1% and 11.3%, respectively. Improvement occurred uniformly, regardless of sites' adherence to the measurement protocol. Providers rechecked blood pressure measurements less often post-intervention (from 23.5% to 8.1% of visits overall). Providers at sites with high protocol adherence were less likely to recheck measurements than those at low adherence sites. Comparison sites exhibited no change in terminal digit preference or repeat measurements. This study demonstrates that clinics can apply a pragmatic intervention to improve blood pressure measurement. Additional refinement may improve implementation fidelity.

Objective The addition of rapid response teams (RRTs) has emerged as a treatment option for medically deteriorating psychiatric inpatients. The goal of this study was to identify risk factors for use of RRTs at the time of initial psychiatric evaluation and develop measures to predict use of this emergent medical intervention. We have not located any studies that have previously addressed this issue. Methods We studied the use of RRTs and code teams (CTs) on inpatient general and specialty psychiatric services in a large urban academic psychiatric hospital. RRT or CT calls were made for 60 patients on these units between January, 2010 and December, 2012. Our retrospective chart review study compared the cases of these 60 patients with 120 matched controls. Using χ and the Fisher exact tests, we identified variables that differed significantly between the case and control groups. Next, we used a forward stepwise regression model to create prediction tools to risk stratify patients at the time of initial assessment. Results Bivariate analyses identified 14 independent statistically significant patient variables. We created 2 risk prediction tools: (1) an "exhaustive" tool (which used 12 of the total 38 factors we considered) based on a stepwise regression model that yielded an area under the receiver operating curve (AUC) of 0.91, and (2) a simplified tool referred to by the acronym "SCHEME" with 6 factors and an AUC of 0.76. Conclusions We propose the acronym SCHEME to refer to a tool that can be used to quickly and easily assess medical risk in prospective psychiatric inpatients at the time of admission, which can help reduce the use of RRTs and CTs.

In this systematic evaluation of fluorescent gel markers (FGM) applied to high-touch surfaces with a metered applicator (MA) made for the purpose versus a generic cotton swab (CS), removal rates were 60.5% (476 of 787) for the MA and 64.3% (506 of 787) for the CS. MA-FGM removal interpretation was more consistent, 83% versus 50% not removed, possibly due to less varied application and more adhesive gel.

BACKGROUND: While playing a critical role in preventing healthcare-associated infections, patient room cleaning is often unsatisfactorily performed. To improve patient room cleaning, a human factors and systems engineering (HFSE) approach is needed to understand the complex cleaning process and associated work system factors. PURPOSE: We conducted an observational study to assess the performance of environmental care (EVC) associates during daily patient room cleaning and identify work system factors influencing their performance. METHODS: This study was conducted in eight adult medicine inpatient units at a large urban academic medical center. An HFSE researcher shadowed 10 day-shift EVC associates performing daily patient room cleanings and used a semi-structured observation form to collect quantitative data (e.g., duration of room cleaning, orders for surface cleaning) and qualitative data (e.g., challenges to patient room cleaning). Descriptive statistics (e.g., median, interquartile range) were reported for cleaning performance, and bivariate and regression analyses were conducted to identify factors influencing cleaning performance. We also performed link analyses of the workflow of EVC associates and qualitative analyses of observer notes to identify challenges to daily patient room cleaning. RESULTS: We observed 89 patient room cleanings. Median duration of cleaning a room was 14 minutes, and median percentage of surfaces cleaned in a room was 63%. High-touch surfaces that were frequently missed during daily cleaning included the bedrails, telephone, patient and visitor chairs, and cabinet. Work system factors that could influence cleaning performance included the type of unit, the presence of the patient and family members in the room, cleaning patterns and orders of EVC associates, and interruptions EVC associates encountered while cleaning. CONCLUSIONS: Daily patient room cleaning was influenced by a number of work system factors. To improve daily patient room cleaning, multifaceted interventions are needed to address these system-level factors.

We compared the fluorescent gel removal rate using fewer high-touch surfaces (HTSs) and rooms and determined the optimum number of HTSs and rooms needed to ensure accuracy using 2,942 HTSs in 228 rooms on 13 units. Randomly selecting 3 HTS in 2 rooms predicted the optimal removal rate.

Supplemental material, Appendix for Reducing Three Infections Across Cardiac Surgery Programs: A Multisite Cross-Unit Collaboration by Bickey H. Chang, Yea-Jen Hsu, Michael A. Rosen, Ayse P. Gurses, Shu Huang, Anping Xie, Kathleen Speck, Jill A. Marsteller and David A. Thompson in American Journal of Medical Quality

Aim: To assess the utility of using external databases for quality improvement (QI) evaluations in the context of an innovative QI collaborative aimed to reduce three infections and improve patient safety across the cardiac surgery service line. Methods: We compared changes in each outcome between 15 intervention hospitals (infection reduction protocols plus safety culture intervention) and 52 propensity score-matched hospitals (feedback only). Results: Improvement trends in several outcomes among the intervention hospitals were not statistically different from those in comparison hospitals. Conclusion: Using external databases such as those of professional societies may permit comparative effectiveness assessment by providing concurrent comparison groups, additional outcome measures and longer follow-up. This can better inform evaluation of continuous QI in healthcare organizations.

Computerized clinical decision support (CCDS) significantly reduced Clostridioides difficile testing at 3 hospitals; from 12.6 to 9.5, from 10.1 to 6.4, and from 14.0 to 9.6 average weekly tests per 1000 inpatient days. There were no related adverse events. Senior providers were more likely than interns or residents to follow CCDS.

Multiple chronic conditions affect people’s health-related quality of life (QoL) and the distributions of the conditions may differ between genders. Our goal was to examine gender differences in chronic conditions and QoL among community-living elderly in Taiwan and to examine whether differences in QoL between genders, if present, were attributable to the distribution of chronic conditions. We used data from the Nutrition and Health Survey in Taiwan (NAHSIT, 2005–2008), which interviewed a representative sample of the Taiwanese population. The survey questions included the SF-36 questionnaire to assess participants’ QoL and items for participants’ medical history. We used multiple linear regressions to examine the difference in QoL between genders. We included 1179 elders for our analysis; men accounted for 52% (612/1179). The mean age was 73; women were slightly younger. The mean (standard deviation) of SF-36 physical and mental health component score (PCS and MCS) was 44.5 (11.1) and 55.6 (9.0), respectively, and women reported a significantly lower PCS than men (difference − 4.85, p

Introduction: Hypertension and diabetes control are leading modifiable risk factors for cardiovascular disease (CVD) risk. Contemporary epidemiological research suggests that individual and health system characteristics are associated with control. Yet, there is little evidence examining how the neighborhood environment influences hypertension or diabetes control among patients engaged in primary care. Methods: We analyzed data of adult patients (n = 5,711) with hypertension or diabetes who received primary care at 1 of 3 clinics of a statewide health care organization in Baltimore, MD and lived within the Baltimore city limits. The neighborhood environment exposures were tertiles of neighborhood socioeconomic status (SES), crime, and healthy food availability index (HFAI) assessed at the census tract level. Separate multivariate logistic regression models were constructed to estimate the odds ratio (OR) for each of these neighborhood environment characteristics and hypertension and diabetes control, adjusting for patient demographics, and health behaviors; and for physician demographic characteristics. Results: The overall mean age was 57.8 ± 14.3 years, 67.2% were female, and 89.6% were Black. There were 5,325 patients with hypertension and 2,094 patients with diabetes (not mutually exclusive). In bivariate analyses, high neighborhood SES (p= 0.030) and low crime (p= 0.006) were associated with hypertension control, and none of the neighborhood exposures were associated with diabetes control. In fully adjusted analyses, being Black was significantly associated with decreased odds of hypertension control in all models (OR range: 0.63 – 0.65), independent of neighborhood exposures. Among those with hypertension, living in a low or moderate SES neighborhood or a high crime neighborhood was associated with lower odds of hypertension control; however, these associations were attenuated in adjusted models. None of the neighborhood exposures were significantly associated with odds of diabetes control in models that adjusted for patient characteristics. Yet, compared to high SES neighborhoods, living in a low or moderate SES neighborhood (OR=0.74, 95% CI: 0.57 - 0.97 and OR=0.75, 95% CI: 0.57 - 0.98, respectively) was associated with reduced diabetes control after adjusting for both patient and physician characteristics. Conclusion: Exposure to neighborhood disadvantage may contribute to poor diabetes and hypertension control among patients in primary care, independent of patient and physician characteristics. Patient-centered risk assessments including measures of social need and preventive interventions adapted to neighborhood environments could be useful for optimizing hypertension and diabetes control in clinical settings.

Objectives Organizational culture change has been recognized as one of the promising ways to reduce error and increase safety. However, it is still unclear what factors support health care teams implementing interventions aimed to influence the cultural attributes that bolster continuous quality improvement. This study aimed to identify factors related to teams' adoption of the Comprehensive Unit-based Safety Program (CUSP), an approach to improving patient safety culture among intensive care units (ICUs) participating in a bloodstream infection reduction collaborative. Methods We analyzed data from the 103 ICUs participating in the Keystone ICU project. We conducted logistic regressions to assess baseline factors associated with ICU teams' use of CUSP. Predictors included safety climate scales (teamwork climate, safety climate, job satisfaction, stress recognition, perceptions of management, and working conditions) as measured by the Safety Attitudes Questionnaire, central line-associated bloodstream infection rates, bloodstream infection prevention intervention phase, ICU type, hospital bed size, and hospital teaching status. Results Intensive care units with lower perceived safety climate, greater stress recognition, higher perceptions of management, and better working conditions were more likely to adopt CUSP. Intensive care units that implemented the infection prevention interventions late were less likely to adopt CUSP. Mixed ICUs and ICUs in large hospitals were also less likely to use CUSP. Conclusions Staff-perceived safety climate, ICU type, and hospital size were related to ICUs' implementation of CUSP. Better baseline safety climate or lower perceived organizational support reduced uptake. The findings can help hospital leaders and collaborative experts identify units that are less likely to implement cultural interventions.

It is important to understand the effects of a new care model on health professionals' satisfaction, which may help inform organizations' decisions regarding the adoption of the model. This study evaluates the effect of the Guided Care model of primary care on physicians', Guided Care Nurses' and practice staff satisfaction with processes of care for chronically ill older patients. In Guided Care, a specially educated registered nurse works with 2–5 primary care physicians, performing 8 clinical activities for 50–60 chronically ill older patients. This model was tested in a 3-year matched-pair cluster-randomized controlled trial with 14 pods (teams of physicians and staff) randomly assigned, within pairs, to provide Guided Care or usual care. Physicians and Guided Care Nurses were surveyed at baseline and annually for 3 years. Staff were surveyed at baseline and 2 years later. Physicians' satisfaction with chronic care processes, knowledge of patients, and care coordination were measured, as well as Guided Care Nurses' satisfaction with chronic care processes and staff perceptions of quality of care. Findings suggest that Guided Care improved physician satisfaction with patient/family communication and management of chronic care, and it may bolster staff beliefs that care is patient oriented. Differences in other aspects of care were not statistically significant. (Population Health Management 2013;16:317–325)

OBJECTIVE: Little is known about how quality of life (QOL) changes over time after gastrectomy. We prospectively examined changes of QOL in Korean patients with gastric cancer after curative resection. BACKGROUND: As early detection and improved treatment have led to higher survival rates and an increasing number of long-term survivors, the importance of QOL has increased. METHODS: Patients newly diagnosed with gastric cancer, who were expected to undergo curative resection, were studied. QOL was assessed, using the European Organization for Research and Treatment of Cancer QLQ-C30 and its gastric module QLQ-STO22, before and after 3 and 12 months of gastrectomy. RESULTS: In total, 465 patients were included in the study, and 377 and 88 patients underwent subtotal gastrectomy and total gastrectomy, respectively. For most of the functional or symptom scales, the mean score deteriorated at 3 months and generally improved during follow-up period. Patients with total gastrectomy had more functional and symptomatic problems related to QOL than those with subtotal gastrectomy during the follow-up. For both groups, there were temporal, unrecovered, improved, and unchanged problems in QOL. Fatigue; digestive symptoms such as diarrhea, dysphagia, and eating restrictions; body image disturbance; and cognitive functioning were the representative unrecovered problems, which persisted at 12 months after surgery. CONCLUSIONS: Our findings show that there are various functional and symptomatic problems, which health care providers need to manage during the postsurgical period. We need to continuously address fatigue, diarrhea, dysphagia, eating restrictions, body image disturbance, and cognitive functioning. In addition, it would be necessary to inform patients about possible QOL outcomes while they are receiving information about surgery and signing informed consent for surgery.

To determine the causal effects of an intervention proven effective in pre-post studies in reducing central line-associated bloodstream infections in the intensive care unit.We conducted a multicenter, phased, cluster-randomized controlled trial in which hospitals were randomized into two groups. The intervention group started in March 2007 and the control group started in October 2007; the study period ended September 2008. Baseline data for both groups are from 2006.Forty-five intensive care units from 35 hospitals in two Adventist healthcare systems.A multifaceted intervention involving evidence-based practices to prevent central line-associated bloodstream infections and the Comprehensive Unit-based Safety Program to improve safety, teamwork, and communication.We measured central line-associated bloodstream infections per 1,000 central line days and reported quarterly rates. Baseline average central line-associated bloodstream infections per 1,000 central line days was 4.48 and 2.71, for the intervention and control groups (p = .28), respectively. By October to December 2007, the infection rate declined to 1.33 in the intervention group compared to 2.16 in the control group (adjusted incidence rate ratio 0.19; p = .003; 95% confidence interval 0.06-0.57). The intervention group sustained rates1/1,000 central line days at 19 months (an 81% reduction). The control group also reduced infection rates to1/1,000 central line days (a 69% reduction) at 12 months.This study demonstrated a causal relationship between the multifaceted intervention and the reduced central line-associated bloodstream infections. Both groups decreased infection rates after implementation and sustained these results over time, replicating the results found in previous, pre-post studies of this multifaceted intervention and providing further evidence that most central line-associated bloodstream infections are preventable.

Chronic pain is a prevalent chronic condition with significant burden and economic impact in the United States. Chronic pain is particularly abundant in primary care, with an estimated 52% of chronic pain patients obtaining care from primary care physicians (PCPs). However, PCPs often lack adequate training and have limited time and resources to effectively manage chronic pain. Chronic pain management is complex in nature because of high co-occurrence of psychiatric disorders and other medical comorbidities in patients. This article describes a quality improvement initiative conducted by the American College of Physicians (ACP), in collaboration with the Kentucky ACP Chapter, and the Center for Health Services and Outcomes Research at the Johns Hopkins Bloomberg School of Public Health, to enhance chronic pain management in 8 primary care practices participating in Accountable Care Organizations in Kentucky, with a goal of enhancing the screening, diagnosis, and treatment of patients with chronic pain.

This study aimed to describe cancer screening rates for second primary cancer among cancer survivors in Korea, and to compare these rates with those of two control groups: individuals without a history of cancer but with other chronic diseases, and individuals without a history of cancer and without other chronic diseases. The study is a cross-sectional analysis of 15,556 adults ≥30 years old who participated in the 2001, 2005, and 2007 Korean National Health and Nutrition Examination Surveys (KNHANES). The prevalence of breast, cervical, gastric, and colorectal cancer screening examinations according to national guidelines was assessed and compared to two control groups. Screening rates among cancer survivors were 48.5, 54.7, 34.7, and 28.6% for breast, cervical, gastric, and colorectal cancer screening, respectively. Cancer survivors showed higher screening rates for all four cancer sites compared with both control groups, but breast cancer screening was only statistically significant after adjusting gender, age, marital status, education, income, working status, health insurance, smoking and drinking status, and self-reported health status. Cancer survivors were more likely than individuals without a cancer history to obtain screening examinations according to recommended guidelines. Still, screening rates even among survivors were suboptimal, emphasizing the need for a more systematic approach to second primary cancer screening and prevention.

This tool can close the gap between hospital executives and frontline QI teams, improve knowledge of team activities, and help teams to identify and remedy barriers to progress.