For 17 years, people who have accessed healthcare services from British Columbia (BC), Canada's publicly funded healthcare system have had a voice in evaluating the quality and safety of their care through a program that invites patients to rate their satisfaction with the care received and to provide feedback about their experiences and outcomes of care.
The British Columbia Patient-Centred Measurement Steering Committee (BCPCMSC) oversees the planning and implementation of a large-scale patient survey program across sectors, including acute inpatient care, emergency department care, cancer care, mental health and substance use care, and long-term residential care. BC's provincially coordinated, scientifically rigorous measurement program is described in a value chain (see Figure 1) that includes survey selection or development, data collection, reporting and action planning. Learnings in BC have shown that only when patient and family feedback collected via surveys, both as quantitative and qualitative data, is analyzed and interpreted does it become information that will be used to guide improvement efforts at macro, meso, and micro levels of our healthcare system.
The BCPCMSC includes representation from the BC Ministry of Health, each of BC's seven health authorities, the academic and research community, and patients and their families with lived experience.
A key guiding principle of BC's patient-centred measurement strategy is that “at the heart of every data point in healthcare is a person”. The BCPCMSC ensures that in the reporting phase of BC's provincial survey cycle, statistics are not presented as “people with the tears wiped off ” (Cuthbertson, 2015). Qualitative feedback, presented as narratives (“patients' own words”), are used to illustrate quantitative scores, thereby putting a human face or story on the data. The goal is that clinicians, leaders, policy makers, researchers and analysts, the media, and the general public will see in the numbers someone's mother, father, son, daughter, partner or friend. Consider the call to action from a statistic about first needle stick success of 63%, and problems, such as bruising and pain associated with an intravenous (IV) insertion in the emergency department (ED) of 39%, when the numbers are presented along with the following comment:
“I had a horrible experience with everyone trying to access a vein. It took 6 nurses approximately 20 tries to locate a vein! It was awful! My arm was sooo very bruised and sore. I went from one person to the next and no one could draw blood or get a line for a CT scan.
I've never had such a horrible experience! Other than that, everything was wonderful.”
While a comment such as this represents the experiences of an “n of 1”, when the comment is presented together with data collected in a scientifically rigorous manner, the qualitative and quantitative data together act as a catalyst for further analysis and for implementation of tests of change with the goal of improving patient experiences, satisfaction and clinical outcomes. Secondary analysis of quantitative data, including linkage to other clinical and administrative datasets available in BC, provide further evidence to support actions that can lead to better care and better use of resources. In addition, when both qualitative and quantitative data are presented in “close to real time” via BC's web-based dynamic analysis and reporting tool (The DART), which is a repository for unweighted, deidentified responses to surveys from the province's large scale provincial patient-centred measurement program, it provides care providers with information to monitor local tests of change in order to improve the care provided to all patients in a particular region or location of care across all sector surveys conducted in the province.
A systematic review of evidence on the links between patient experience and clinical safety and effectiveness concluded that “patient experience is positively associated with clinical effectiveness and patient safety, and supported the case for the inclusion of patient experiences as one of the central pillars in healthcare” (Doyle et al, 2013).
Over its 17-year history, BC has heard from more than 17.9 million patients and this data is available for secondary analysis across 13 sectors and subsectors and all age groups. To drive accountability, support system level, regional and local quality improvement, and to make data available for evaluation and research, the voices of BC patients are available through public reports, BCPCMSC's website (https://www.bcpcm.ca/), through access to The DART (info.bcpcm@providencehealth.bc.ca; https://youtube/A5TJNnhwTPQ), and through Population Data BC data access requests (https://www.popdata.bc.ca/).
Up to 90% of patients entering hospital receive an IV (Helm et al., 2015). Up to 26% of all peripheral IV catheters “fail” and 40% of patients have at least one peripheral IV failure over a course of therapy (Rickard, 2013). The negative impact that IV device failures and complications can have on patients was a key driver for the development of a BC patient experience of IV therapy (IVT) survey. Because our healthcare systems in Canada are moving from price-based selection of products and vendors to selection that is value based, the cost of IV device failures was a second driver for the development of a BC patient experience of IVT survey. The goal was that feedback from the patient perspective would provide actionable data to improve patient outcomes and efficiencies of IVT.
Methods
In 2016, in partnership with the supplier and manufacturer of peripheral IV catheters, Becton Dickinson (BD), clinical experts and patients with lived experience of IVT, a patient journey map was co-created to inform a patient-reported experience measure (PREM) of IVT. Foundational to the development of the survey was a conceptual framework for IVT developed by the BD clinical team in 2015 (Gallagher, 2015) (see Figure 2). The framework identified the steps in a patient's IVT journey including: risk points for contamination, which could lead to infections, clinician's blood exposure, and inefficiencies.
For the first time in 2018, a provincially coordinated ED survey incorporated measurement of the experience of patients who self-reported having had at least one intravenous (IV) insertion during their ED visit.
Three factors led to the inclusion of the IVT patient survey to explore the experience of IVT in emergency departments:
The Lower Mainland IV Therapy Working Group, including vascular access clinical experts from the BC's Lower Mainland Health Authorities (Providence Health Care, Vancouver Coastal Health, Fraser Health, and Provincial Health Services Authority), measurement experts from the BC Office of Patient-Centred Management, and BD representatives, was convened in the Spring of 2017. Building on the IVT patient journey map co-created with patients, questions about IVT patient experiences were developed and cognitively tested with ED patients, culminating in the addition of eight IVT questions to the 2018 BC Emergency Department Survey (see Figure 3).
The module of eight IVT questions was fielded with randomly sampled patients who visited one of 108 BC EDs between January 1 and March 31, 2018, and consented to participate. Patients were contacted within one to three weeks following their ED visit and invited to complete the survey via a telephone interview or an online survey platform, using a unique access code for each patient. The survey was made available in nine languages, reflecting mother-tongue still spoken at home in BC. The ED 2018 survey yielded a 36% response rate (n=14,076) with 31% (n=4,391) reporting having had at least one IV while in an ambulance or emergency department. To the authors' knowledge, this represents the largest scientifically validated survey globally about the experiences of IVT from the patient perspective.
Weekly monitoring of patient responses, through The DART, revealed emerging themes and opportunities for improvement. Weekly trending reports were produced at regional and site (ED) levels. Scores from each of the eight IVT questions were displayed on run charts with narrative comments from patients inserted to “illustrate” the scores; comments with a positive valence or sentiment were inserted to illustrate scores that met or exceeded targets set by the Lower Mainland IVT Working Group for each question and comments with a negative valence or sentiment were inserted to illustrate scores that were below targets.
While the survey was still in the field, a PLAN-DOSTUDY-ACT cycle was implemented in two BC emergency departments in an effort to address initial results that showed poor scores in response to the IVT questions that asked if patients were told: “what to expect”, and “when to call a nurse”. Instructions for nurses and a communication card for distribution to patients prior to IV initiation (see Figure 4) were created and implemented for a two-week period to test the impact of these tools. Positive feedback was provided from both the patients and nursing teams and improvement was seen in scores during this period.
In addition to the quantitative data from the evaluative questions on the survey, an analysis of the qualitative data from the ED 2018 survey yielded 398 open text comments that referenced experiences related to “intravenous, IV/IVs, drip, needle/needles.” The patient comments below are examples of free text comments (emphasis added) arising from the open-ended question on the ED 2018 survey that asked, “What is the most important change we could make to improve care in XXX ED?”:
“The ER staff had trouble starting the IV on my infant son and appeared to lack experience in locating the proper IV equipment for infants and securing the IV once established. Multiple attempts were done before they realised they had too long a needle.”
“The care provider giving me the IV was inexperienced and I already have the fear of needles, she jammed it in my forearm around 10 times, I passed out. That was worse than the actual accident of being crushed by a forklift even. Apart from this experience everything was great. But this experience has got me skittish to go back.”
“The nurse that [my child] had was really good—she has a fear of needles and the nurse helped her get over fear of the IV.”
Results
Key findings arising from the eight evaluative questions of the IVT module include:
Patients were not consistently told what to do if they experienced a problem with their IV
While more than half of all patients who received an IV (53%) experienced a problem with their IV, just over half of these patients (56%) were advised to contact a nurse when experiencing a problem. This was well below the threshold of 80% established by the IVT Working Group as a conservative target.
In addition, less than half (40.3%) of patients who received an IV reported that care providers ALWAYS handled problems, such as pain, swelling, bruising, in a timely manner.
Patients reported that complications with IV therapy were common
Thirty-nine percent of patients reported complications with their IVs with bruising (23%), and pain and soreness (27%) being the most frequently reported.
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13% |
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8% |
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23% |
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14% |
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4% |
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9% |
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61% |
“I think the bad bruising I received after the IV was removed was due to the way it was removed more so than the way it was administered.”
Significant differences in pediatric vs adult experiences
Just more than one-third (37%) of pediatric patients reported successful insertion of the IV on the first attempt as compared with 63% of adult patients. In addition, 55% of pediatric patients experienced a complication compared to 39% of adult patients (see Figure 5).
First-stick success (scores reflect provincial results)
Adult (Figure 6):
Pediatric (Figure 7):
Discussion
British Columbia's experience of IVT patient survey questions have now been included in two additional provincially coordinated sector surveys: BC's 2019/20 Outpatient Cancer Care survey, fielded with patients who received IV chemotherapy in one of 47 community oncology hospitals or regional cancer centres, and BC's 2019/2020 Continuity Across Transitions in Care survey, fielded in 102 EDs and 78 acute care hospitals. The eight IVT questions have been augmented with question lines that explore patients' understanding of instructions to care for IV catheters in the home setting. Analyses of the additional data from these surveys will be used to validate the findings from the 2018 ED survey, to monitor if expanded use of the patient information card and script for nurses has positively impacted patient experiences of knowing when to call a nurse and what to expect with regards to their IV catheterization, and to identify further trends and opportunities for improvement of IVT in British Columbia and beyond. The survey instrument is adaptable to any care setting and available for use in the public domain.
The findings from BC's expanded use of the IVT patient experience module, across all emergency departments, all acute inpatient hospitals and all outpatient chemotherapy settings, will be used as indicators for the purpose of illustrating patient assessments of vascular access complications and the patient perspective on how variation in clinician skill and practice impact the patient's overall experience of care.
In addition, the findings from BC's IVT patient experience survey has prompted the Lower Mainland IVT Working Group to initiate discussions with Accreditation Canada/Health Services Organization (HSO) and the International Society for Quality in Healthcare (ISQua) to advocate for national and international accreditation standards for vascular access with the ultimate goal of promoting evidence-informed practices to improve the quality and safety of vascular access.
Conclusion
Embracing the concept of value-based healthcare in partnership with BD, the provincial supplier of IVT products in BC, the Lower Mainland IVT Working Group has established three work streams to inform future practice, knowledge translation and quality improvement strategies aimed at the following:
Psychometric evaluation of the IVT patient survey and analysis of results in the context of patient characteristics are the next steps in the evolution of our understanding of patient experiences of IVT.