English title dissertation SAFE or SORRY?: A programme to implement multiple guidelines simultaneously
Name PhD (surname first) van Gaal, Betsie
Doctor is (has been) nurse
Date of promotion 05/04/2011
University Radboud University
Promotores Prof. dr. T. van Achterberg; Prof. dr. R.T.C.M. Koopmans; Dr. L. Schoonhoven; Dr. J.A.J. Mintjes-de Groot
Abstract (English)

In this thesis, we wanted to move beyond "single project thinking". Usually, patient care guidelines are implemented one at a time. We wanted to know if it is possible to implement multiple guidelines for the prevention of adverse events simultaneously. Methods: A cluster randomised trial was conducted between September 2006 and November 2008. The study was performed on 10 wards in 4 hospitals and ten wards in 6 nursing homes, in the Netherlands. Hospital wards were internal medicine (n=4) and surgical wards (n=6). Nursing home wards included patients with physical impairments (no dementia) (n=7) and need for rehabilitation (n=3). The 10 hospital wards and 10 nursing home wards were randomly assigned to an intervention or usual care group.
Study population: During baseline and follow-up data collection periods, all adult patients admitted to the wards were asked to participate. Hospital patients with an expected length of stay of at least five days were asked to participate within 48 hours after admission. Nursing home patients were asked to participate at the start of the data collection periods, or within two weeks after admission. After written informed consent, research assistants visited the patients weekly, until discharge, death or the end of the data collection period.
Outcome measures: The primary outcome was the incidence of pressure ulcers, urinary tract infections and falls. The secondary outcome measures were 1) the percentage of patients that received preventive care and 2) nurses' knowledge regarding the three topics.
Data collection: During the baseline and follow-up period, the patient data were collected in two ways: by a weekly visit and by additional observations on every ward. During the weekly visits, we screened the patients' file for data on the occurrence of urinary tract infections and falls, and the preventive care given. We observed the patients for the presence of preventive measures and the patients' skin for the occurrence of pressure ulcer. During the additional observations we collected data to estimate the utilisation of adequate preventive care. Research assistants visited every ward three times.
Statistics: The results for hospitals and nursing homes were analysed separately. The incidence rate of adverse events was defined as the number of new adverse events per patient week. The results were clustered at ward level and we used a random effects Poisson regression model to estimate the rate ratio of the adverse events in the intervention and usual care group at follow-up.
Results: The baseline period was from September to the end of November 2006. Eight hundred and eighty seven hospital patients and 241 nursing home patients participated. Regarding the incidence of the three adverse events, this study showed that 77 hospital patients (11%) and 111 nursing home patients (46%) developed one or more adverse events. The incidence rate for both was 9% adverse events per patient week. Regarding the preventive care given, this study showed that in hospitals, 34% of the patients at risk for pressure ulcers, 47% of the patients at risk for urinary tract infections and none of the patients at risk for falls received adequate preventive care. In nursing homes, 18% of the patients at risk for pressure ulcers, 42% of the patients at risk for urinary tract infections and less than 1% of the patients at risk for falls received adequate preventive care.
The nine-month follow-up period started in March 2008. A total of 2201 hospital patients with 3358 patient weeks and 392 nursing home patients with 5799 patients weeks were observed during the follow-up of the study. The results showed an incidence rate ratio for the development of an adverse event in favour of the intervention group of 0.57 (95% CI: 0.34 to 0.95) and 0.67 (95% CI: 0.48 to 0.99) for the hospital patients and nursing home patients, respectively. Patients in the intervention groups had 43% and 33% fewer adverse events compared to the usual care group in hospitals and nursing homes respectively. The study showed no overall difference in preventive pressure ulcer measures between intervention and usual care group in hospitals and nursing homes. For urinary tract infections, even statistically significantly fewer hospital patients at risk received preventive care. For falls in hospitals and nursing homes, no more patients at risk received preventive care.
In conclusion, it is possible to develop and implement a multiple guideline based patient safety programme in hospitals and nursing homes. The result of this study is promising for the future, because it allows organisations to implement more than one guideline simultaneously, and thus improve patient safety. Since this is the first study that investigates the effectiveness of such a comprehensive programme, more research is necessary to underline the results of this study.

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