title: Improving and sustaining a reduction in iatrogenic pneumothorax through a multifaceted quality-improvement approach.
abstract: BACKGROUND
  The Agency for Healthcare Research and Quality has adopted iatrogenic pneumothorax (IAP) as a Patient Safety Indicator. In 2006, in response to a low performance ranking for IAP rate from the University Healthsystem Consortium (UHC), the authors established a multidisciplinary team to reduce our institution's IAP rate. Root-cause analysis found that subclavian insertion of central venous catheterization (CVC) was the most common procedure associated with IAP OBJECTIVE: Our short-term goal was a 50% reduction of both CVC-associated and all-cause IAP rates within 18 months, with long-term goals of sustained reduction.
  
  
  METHODS
  Observational study.
  
  
  METHODS
  Academic tertiary care hospital.
  
  
  METHODS
  Consecutive inpatients from 2006 to 2014.
  
  
  METHODS
  Our multifaceted intervention included: (1) clinical and documentation standards based on evidence, (2) cognitive aids, (3) simulation training, (4) purchase and deployment of ultrasound equipment, and (5) feedback to clinical services.
  
  
  METHODS
  CVC-associated IAP, all-cause IAP rate.
  
  
  RESULTS
  We achieved both a short-term (years 2006 to 2008) and long-term (years 2006 to 2008-2014) reduction in our CVC-associated and all-cause IAP rates. Our short-term reduction in our CVC-associated IAP was 53% (P = 0.088), and our long-term reduction was 85% (P < 0.0001). Our short-term reduction in the all-cause IAP rate was 26% (P < 0.0001), and our long-term reduction was 61% (P < 0.0001).
  
  
  CONCLUSIONS
  A multidisciplinary team, focused on evidence, patient safety, and standardization, can use a set of multifaceted interventions to sustainably improve patient outcomes for several years after implementation. Our hospital was in the highest performance UHC quartile for all-cause IAP in 2012 to 2014.
authors.affiliation: Department of Medicine, Stanford University School of Medicine, Stanford, California.
authors.forename: Lisa
authors.initials: L
authors.lastname: Shieh
authors.affiliation: Department of Medicine, Stanford University School of Medicine, Stanford, California.
authors.forename: Minjoung
authors.initials: M
authors.lastname: Go
authors.affiliation: Department of Anesthesia, Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Daniel
authors.initials: D
authors.lastname: Gessner
authors.affiliation: Center for Innovation to Implementation (Ci2i), Veterans Affairs Palo Alto Health Care System, Palo Alto, California, and Center for Primary Care and Outcomes Research (PCOR), Stanford University, Stanford, California.
authors.forename: Jonathan H
authors.initials: JH
authors.lastname: Chen
authors.affiliation: Department of Medicine, Stanford University School of Medicine, Stanford, California.
authors.forename: Joseph
authors.initials: J
authors.lastname: Hopkins
authors.affiliation: Department of Surgery, Stanford University School of Medicine, Stanford, California.
authors.forename: Paul
authors.initials: P
authors.lastname: Maggio
mesh_terms: D055499:Catheter-Related Infections / Q000150:complications / Q000517:prevention & control; D002405:Catheterization, Central Venous / Q000009:adverse effects; D055317:Evidence-Based Practice; D005260:Female; D006801:Humans; D007049:Iatrogenic Disease / Q000517:prevention & control; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D011030:Pneumothorax / Q000000981:diagnostic imaging / Q000517:prevention & control* / Q000628:therapy; D058996:Quality Improvement; D000066908:Simulation Training / Q000379:methods; D014463:Ultrasonography; D014481:United States