Top 10 Articles of 2022, #1-5

In this post, we’re offering summaries and comments on articles from BMJ Quality & Safety’s Top 10 Articles of 2022. To check out the full list of our 24 finalists, click here, and to see more on Articles #6-10, click here. Additionally, to learn more about the Top Article selection process, click here. To briefly summarize, the editors and the Editorial Board used data such as citation rates and social media engagement to create the finalist article list, which was then scored by the editorial team on novelty, generalizability/addition to understanding, rigor of methods, and importance to clinical practice to arrive at the Top 10. As in past years, these articles demonstrate the wonderful breadth of valuable articles published in BMJ Quality & Safety.

  1. Implications of resource constraints and high workload on speaking up about threats to patient safety: a qualitative study of surgical teams in Ghana by EK Mawuena et al. BMJ Quality & Safety 2022;31:662-669. Accompanying editorial available here.

Willingness and the ability to speak up to identify safety concerns are important components of a culture of safety. In situations with excessive workloads or limited resources, however, both pointing out and following up on such perceived safety threats may be less likely. In this article, Mawuena and Mannion interviewed surgical professionals in Ghana, using Conservation of Resources theory to explore how high workloads and resource constraints affected frontline staff in voicing safety concerns. The research team reached data saturation after 91 interviews, which generated four overall themes undermining employee voice: 1) Resource and logistical constraints; 2) Transgressing normalised work boundaries; 3) High workload and unsupportive atmosphere for raising concerns; and 4) Silence as avoidance of additional work. Overall, the authors documented that these issues can collectively create an unsupportive environment for raising and acting on concerns about patient care that reduces the overall voicing of such concerns, particularly in settings with steep authority gradients. Understanding the specific local contexts relating to each of the four themes will be important for countering them and operationalising increases in the employee voice, such as with the authors’ suggestion to support ‘hearer’ courage to listen to frontline workers and take actions to improve patient safety.

  1. Nurse staffing and inpatient mortality in the English National Health Service: a retrospective longitudinal study by B Zaranko (@BenZaranko) et al. Published Online First: 27 September 2022. Accompanying editorial available here.

The optimal mix of nursing personnel – usually separated into registered nurses (RNs) and healthcare support workers (HCSWs) – and their staffing ratios is currently unknown. Zaranko and colleagues retrospectively linked electronic staff rosters and patient records from more than 19,000 hospitalised patient ward-days across 53 wards in three English hospitals to assess the effects of nursing team size and composition on patient mortality, based on scheduled nursing shift ‘fill-rate’. The studied overall shift fill-rate was greater than 95%, with roughly two-thirds of shift hours covered by permanent staff, 20% by bank staff and 7% by agency staffing. Even with the high filling of scheduled shifts, however, more than a third of shifts lacked at least 8 hours of scheduled nursing personnel time, and 10% of shifts lacked at least 16 hours. When analysed further, there was no significant association between the overall fill-rate and mortality, or between HCSW staffing and mortality; however, a percentage point increase in RN staffing fill-rate reduced the odds of patient death by 1.2%, which was amplified if the nurse was more senior and in a higher pay band (eg one extra percentage point of planned staffing filled by a band 5 nurse reduced the odds of patient death by 1.1%, while filling with a band 7-8 nurse reduced these odds by 2.4%). Extrapolating this general finding to actual staffing decisions, filling one extra 12-hour shift with an RN would reduce the odds of experiencing a patient death by almost 10%, although substituting a temporary RN in place of an RN permanently working on that ward attenuated this effect. A shortage of nursing personnel hours led to a significant increase in the odds of a patient death when staffing dropped below a threshold of 16 planned hours or more for the target hours during a shift, peaking at a 37% increase in odds of a patient death with more than 24 hours of unfilled RN care. Thus, overall RN staffing levels, the seniority of the RN and their presumed familiarity with the unit are all associated with the odds of patient death, which has profound implications for inpatient care and patient safety given the current nursing shortages in many countries.

  1. Negotiating the polypharmacy paradox: a video-reflexive ethnography study of polypharmacy and its practices in primary care by D Swinglehurst et al. BMJ Quality & Safety 2023;32:150-159. Accompanying editorial available here.

Millions of people worldwide experience polypharmacy. In England, structured medication reviews (SMRs) are required in patients prescribed 10 or more medications, although it is unclear how these actually are undertaken in clinical settings. Swinglehurst and colleagues performed a video-reflexive ethnography study to clarify how SMRs are practically conducted and understand how polypharmacy might be better managed. The team filmed 18 SMR consultations at 3 clinics and then prepared clips of different challenges and approaches that were shown to 34 participants in seven workshops. In the workshops, the authors noted a transition from participants initially considering SMRs to be mundane, technical work to being an ongoing, iterative process. The research team elucidated that few participants had organised strategies for performing SMRs, the vast majority of SMR consultations required more than the time allotted and often stretched across multiple appointments, and meaningful progress toward reducing polypharmacy was believed to be best approached via small, incremental changes over time. Ultimately, polypharmacy was framed by participants as a relational, emotional dialogue that was difficult to negotiate and required knowing the patient’s history, goals and priorities. Such continuity-focused strategies are difficult to achieve in modern clinical practice, and so further work is needed on coordinating medication management longitudinally across multidisciplinary teams.

  1. Effectiveness of a multifaceted quality improvement intervention to improve patient outcomes after total hip and knee arthroplasty: a registry nested cluster randomised controlled trial by P van Schie et al. BMJ Quality & Safety 2023;32:34-46. Accompanying editorial available here.

Total hip and knee arthroplasties are common procedures worldwide and have increasingly been the focus of audit-and-feedback efforts, mostly centred on procedural revision rates. Van Schie and colleagues randomised 20 hospitals in the Netherlands to an expanded audit-and-feedback intervention including data on one-year revisions, 30-day readmissions, 30-day complications, and patients with length of stay greater than the 75th percentile, as well as an action implementation toolbox suggesting strategies to approach each outcome, versus usual access to performance data available in dashboards. Although both groups showed improvements in the Textbook Outcome (TO) rate (patients who suffered none of the four outcomes above), hospitals in the intervention group improved significantly more with an absolute probability of TO increase of more than 4% (ratio of adjusted ORs 1.24). Eight of the ten hospitals randomised to the expanded feedback and toolkit implemented at least one initiative from the toolkit, most often around reducing length of stay. The eight hospitals implementing these initiatives collectively significantly improved their TO rates relative to control hospitals, while the two hospitals that did not implement anything from the toolkit ended up having no relative improvement in their performance. Pairing similar tailored, evidence-based initiatives with specific feedback outcomes may be key to amplifying the effectiveness of audit and feedback methodologies and engaging and empowering busy clinicians.

  1. Prioritising Responses Of Nurses To deteriorating patient Observations (PRONTO): a pragmatic cluster randomised controlled trial evaluating the effectiveness of a facilitation intervention on recognition and response to clinical deterioration by TK Bucknall (@nursedecisions) et al. BMJ Quality & Safety 2022;31:818-830. Accompanying editorial available here.

Failure to rescue patients suffering clinical deterioration remains a nearly universal problem in healthcare, despite innovations to better identify patients at risk of such deterioration and creation of rapid response systems (RRS) at many hospitals to respond at the point-of-care. In the PRONTO trial, Bucknall and colleagues studied a facilitation intervention aimed at improving nurses’ adherence to clinical practice guidelines (CPG) for early recognition and response to patient deterioration and subsequent escalation of care. Thirty-six wards across four hospitals with a three-tier RRS in Australia were randomised to multi-level facilitation of the CPG at the ward, hospital and external levels for six months or dissemination of the CPG alone. Across more than 10,000 patient audit days, 2,680 had escalation to at least one RRS. The facilitation intervention group had significantly higher odds of patients having appropriate escalation in care at the six months, but this difference was not sustained at one year. There was no difference in change in escalation rates between groups at either follow-up time point. Vital sign assessment increased significantly in the intervention group at one year, but the differences between groups was not significant. The intervention group also had a significantly reduced length of stay relative to the control group at one year, although the between-groups differences analysis for mortality favored the control group. Results of a subsequent program evaluation may help us understand aspects of nursing decision-making and facilitation that led to these results; however, we may gain little insight into how and why the control group also improved. Hopefully, some of the innovations around identifying those at risk of deterioration will integrate with decision support tools to optimise responses across multidisciplinary clinical teams.

Joel Boggan

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