Attending Staff Research Articles

Understanding communication between emergency and consulting physicians: a qualitative study that describes and defines the essential elements of the emergency department consultation-referral process for the junior learner

To define the important elements of an emergency department (ED) consultation request and to develop a simple model of the process. From March to September 2010, 61 physicians (21 emergency medicine [EM], 20 general surgery [GS], 20 internal medicine [IM]; 31 residents, 30 attending staff) were questioned about how junior learners should be taught about ED consultation. Two investigators independently reviewed focus group and interview transcripts using grounded theory to generate an index of themes until saturation was reached. Disagreements were resolved by consensus, yielding an inventory of themes and subthemes. All transcripts were coded using this index of themes; 30% of transcripts were coded in duplicate to determine the agreement. A total of 245 themes and subthemes were identified. The agreement between reviewers was 77%. Important themes in the process were as follows: initial preparation and review of investigations by EM physician (overall endorsement 87% [range 70-100% in different groups]); identification of involved parties (patient and involved physicians) (100%); hypothesis of patient's diagnosis (75% [range 62-83%]) or question for the consulting physician (70% [range 55-95%]); urgency (100%) and stability (74% [range 62-80%]); questions from the consultant (100%); discussion/communication (98% [range 95-100%]); and feedback (98% [range 95-100%]). These components were reorganized into a simple framework (PIQUED). Each clinical specialty significantly contributed to the model (χ2 = 7.9; p value = 0.019). Each group contributed uniquely to the final list of important elements (percent contributions: EM, 57%; GS, 41%; IM, 64%). We define important elements of an ED consultation with input from emergency and consulting physicians. We propose a model that organizes these elements into a simple framework (PIQUED) that may be valuable for junior learners.

Piecing Together the Maternal Death Puzzle through Narratives: The Three Delays Model Revisited

BackgroundIn Malawi maternal mortality continues to be a major public health challenge. Going beyond the numbers to form a more complete view of why women die is critical to improving access to and quality of emergency obstetric care. The objective of the current study was to identify the socio-cultural and facility-based factors that contributed to maternal deaths in the district of Lilongwe, Malawi.MethodsRetrospectively, 32 maternal death cases that occurred between January 1, 2011 and June 30, 2011 were reviewed independently by two gynecologists/obstetricians. Interviews were conducted with healthcare staff, family members, neighbors, and traditional birth attendants. Guided by the grounded theory approach, interview transcripts were analyzed manually and continuously. Emerging, recurring themes were identified and excerpts from the transcripts were categorized according to the Three Delays Model (3Ds).ResultsSixteen deaths were due to direct obstetric complications, sepsis and hemorrhage being most common. Sixteen deaths were due to indirect causes with the main cause being anemia, followed by HIV and heart disease. Lack of recognizing signs, symptoms, and severity of the situation; using traditional Birth Attendant services; low female literacy level; delayed access to transport; hardship of long distance and physical terrain; delayed prompt quality emergency obstetric care; and delayed care while at the hospital due to patient refusal or concealment were observed. According to the 3Ds, the most common delay observed was in receiving treatment upon reaching the facility due to referral delays, missed diagnoses, lack of blood, lack of drugs, or inadequate care, and severe mismanagement.

Making pharmacists’ patient care services consistent, predictable, measurable

Making pharmacists’ patient care services consistent, predictable, measurable

Neonatal Family Care for 24 Hours per Day

In family care (FC) program for neonatal intensive care units (NICUs), parents are encouraged to reside together with their infant for 24 hours a day to actively be involved in the care. The aim of this study was to assess the impact of FC on maternal confidence and breast-feeding. Maternal confidence and rate of breast-feeding were assessed in 31 mothers offered FC that included special family rooms in the NICU, and in 30 mothers from a comparable NICU providing traditional care without such facilities. One week prior to hospital discharge, mothers in the FC group felt better informed regarding nursing issues and had more confidence in interpretation of the infants regarding feeding issues and in caregiving without staff attendance (P < .05). They also reported a higher level of empowerment (P < .05). Three months after discharge, the mothers in the FC group had a higher self-reported skill level for interpretation of the infant's signals and knowledge about breast-feeding (P < .05). Despite similar rate of breast-feeding at discharge, more infants in the FC group were breastfed 3 months after discharge (P < .05). An FC program in the NICU promoted better maternal confidence during the hospital stay and 3 months after discharge compared with traditional care.

Residents as Role Models

Although researchers have investigated the value of physician role models, residents as role models have received less attention. The objectives of this study were to (1) investigate the importance of resident role models in the education and career choices of medical students, (2) examine the types of factors students judge to be most important in selecting resident role models, and (3) evaluate the specific attributes (within each factor type) that students perceive to be most important, comparing these attributes with those previously published on physician role models. This was a cross-sectional, survey-based study, conducted in 2011, in which graduating medical students at McGill University completed a questionnaire on their perceptions of resident role models. The authors analyzed data using descriptive statistics and, for items with scalar responses, repeated measures analysis of variance. Of 165 possible student respondents, 151 (92%) completed the questionnaire. The findings suggest that (1) resident role models play an important role in both the education and career choice of medical students, (2) resident and attending staff role models are equally important to the education of medical students, although attending staff role models appear to be more important for students' career choices, and (3) the factors and specific attributes important in selecting resident role models align with those in previously published literature on physician role models. This study, suggesting that resident and attending physician role models are equally important to undergraduate education, highlights the importance of supporting residents in their status as role models.

Mode of Delivery After Epidural Analgesia in a Cohort of Low-risk Nulliparas

Abstract: Background: Although epidural analgesia is widespread and very effective for alleviating labor pain, its use is still controversial, as the literature is inconsistent about the risk of adverse birth outcome after administration of epidural analgesia. The aim of this study was to explore associations between epidural analgesia and mode of delivery. Methods: Data were obtained from a prospective cohort from nine Danish labor wards and comprised 2,721 term nulliparous women with spontaneous onset of labor and a singleton fetus in cephalic presentation. Information about epidural analgesia, mode of delivery, and birth complications was obtained by the staff attending labor. Additional information was provided from self-administered questionnaires in gestational week 37. Multiple logistic regression analyses were used to estimate the association between epidural analgesia and birth outcomes. Results are presented as crude and adjusted odds ratios (OR [95% CI]). Results: Of the total cohort, 21.6 percent required epidural analgesia, 8.7 percent had emergency cesarean section, and 14.9 percent had vacuum extraction. Women with epidural analgesia had a higher risk of emergency cesarean section (adjusted OR: 5.8; 95% CI: 4.1–8.1), and vacuum extraction (adjusted OR: 1.7; 95% CI: 1.3–2.2). In a subgroup of the cohort with a very low overall risk of cesarean section, 3.4 percent had emergency cesarean section and an increased risk of emergency cesarean section was also found in this group (adjusted OR: 3.5; 95% CI: 1.5–8.2). Conclusions: In nulliparous women of a very low-risk population, use of epidural analgesia for labor pain was associated with higher risks of emergency cesarean section and vacuum extraction. (BIRTH 38:4 December 2011)

Is it worth investing in online continuous education for healthcare staff?

Educational activities for hospital staff don't easily match with the congestive rhythm of healthcare personnel working life. Online learning could make it easier for healthcare personnel to attend courses, but there is still uncertainty about the feasibility of using distance learning to effectively meet education goals in healthcare institutions. Fondazione Salvatore Maugeri (FSM) started an online educational program, as pilot project, in October 2010. The present study hence is aimed at evaluating the impact of this initiative (in terms of extent and intensity of healthcare staff attendance; objective and subjective effectiveness) in order to take informed decisions for the future. In 15 months, 5 elearning courses have been provided to 2261 potential users of 14 FSM hospitals, in parallel with traditional education. 1099 users from all the hospital have intensively attended the courses (58% of nurses, 50% of therapists, 44%, of technicians, 25% of physicians) for a total of 27459 CME credits. Effectiveness in terms of knowledge gain is satisfactory and subjective evaluation is good (more than 95% of satisfied users). Elearning is not appropriate for all the educational needs and is not a panacea, but the reported results point out that it may be an effective and economically convenient mean to support massive educational interventions reaching results hardly attainable with traditional education. Users should be better educated about how to exploit online education at best.

A pilot project: evaluating community nurses' knowledge and understanding of the Adult Support and Protection (Scotland) Act 2007

PurposeThis paper's aim is to evaluate understanding and knowledge of the Adult Support and Protection (Scotland) Act 2007 in a sample of community nurses working in learning disability services in Scotland.Design/methodology/approachTen community nurses who worked in learning disability services in one NHS area were tested at two time points, four months apart using a questionnaire designed for this study by researchers and practitioners. Level of previous national training in the Adult Support and Protection Act and length of time working with people with learning disabilities were recorded. Three domains of adult protection were included in the questionnaire: Principles of the Act and definitions; Adults at risk of harm; Protection, assessment, removal and banning orders.FindingsQuestionnaire scores varied widely overall and across the three domains. There was no correlation between individual scores and training or length of work experience. The level of knowledge was below what might have been expected for this group, given the level of training and experience. Carefully designed verification of the impact of nationally approved adult support and protection training is needed.Originality/valueThere is an absence of research in evaluating the impact of the approved Scottish Government training materials on staff knowledge and understanding of the 2007 Act, with staff attendance being taken as the main measure of training compliance. This was a small scale pilot study and recommendations are made for the scope and methods of evaluation.

The influence of unit-based nurse practitioners on hospital outcomes and readmission rates for patients with trauma

With the increased restrictions on resident work hours, hospitals increasingly are relying on advance practice nurses and physician assistants to help meet the patient care demand. We have created a workflow model wherein unit-based nurse practitioners (UBNPs) provide the minute-to-minute care for patients with trauma in one specific unit in our hospital, with supervision by the attending surgeons. Patients with trauma may also be admitted to other units, where the care model is a traditional resident-run (RR) service, again with supervision by the attending staff. Our aim was to determine if there were differences between the care provided by UBNPs and residents. We queried our trauma database for all patients admitted to our urban, academic, Level I trauma center from January 1, 2007, to August 31, 2010. Patients discharged alive from the trauma service were identified and cross-referenced with an administrative database to collect demographics, injury characteristics, comorbidities, complications, and discharge information. Patients cared for by the UBNPs were compared with those cared for by the RR service. χ², Fisher's exact, and Student's t tests were used to determine significance. Significant factors were then tested with a multivariate linear regression analysis. p < 0.05 was considered significant. During the study period, 3,859 patients were discharged alive from the trauma service, 2,759 (71.5%) from the UBNPs service, and 1,100 (28.5%) from the RR service. Demographic data and mean Injury Severity Score (11.6 vs. 11.1, p = 0.24) were similar for the two groups, although mean abdominal Abbreviated Injury Score was higher for the UBNP group (0.6 vs. 0.5, p = 0.02). UBNP patients were more likely to be diagnosed with deep venous thrombosis (4% vs. 2.5%, p = 0.02) and were more likely to be discharged to home (67% vs. 60%, p = 0.002). Mean (SD) length of stay for UBNP patients was 6.5 (8.8) days compared with 7 (10.8) days for RR patients, although this difference did not reach statistical significance ( p = 0.17). The 30-day hospital readmission rates were similar for both groups (4.0% vs. 4.4%, p = 0.63). Care provided by UBNPs is equivalent to that provided by residents. With the restriction on resident work hours and greater reliance on nurse practitioners, patient care does not suffer. Moreover, a difference of 0.5 days in mean length of stay for the UBNP patients equates with more than 1,300 fewer patient care days. This difference, although not statistically significant, may be clinically relevant to physicians and administrators and may offset the cost of hiring UBNPs to help meet the patient care demand.

Evaluation of time, attendance of medical staff, and resources during stereotactic radiotherapy/radiosurgery

The German Society of Radiation Oncology ("Deutsche Gesellschaft für Radioonkologie", DEGRO) initiated a multicenter trial to develop and evaluate adequate modules to assert core processes and subprocesses in radiotherapy. The aim of this prospective evaluation was to methodical assess the required resources (technical equipment and medical staff) for stereotactic radiotherapy/radiosurgery. At two radiotherapy centers of excellence (University Hospitals of Heidelberg and Marburg/Giessen), the manpower and time required for the implementation of intra- and extracranial stereotactic radiotherapy was prospectively collected consistently over a 3-month period. The data were collected using specifically developed process acquisition tools and standard forms and were evaluated using specific process analysis tools. For intracranial (extracranial) fractionated stereotactic radiotherapy (FSRT) and radiosurgery (RS), a total of 1,925 (270) and 199 (36) records, respectively, could be evaluated. The approximate time needed to customize the immobilization device was median 37 min (89 min) for FRST and 31 min (26 min) for RS, for the contrast enhanced planning studies 22 and 27 min (25 and 28 min), for physical treatment planning 122 and 59 min (187 and 27 min), for the first and routine radiotherapy sessions for FSRT 40 and 13 min (58 and 31 min), respectively. The median time needed for the RS session was 58 min (45 min). The corresponding minimal manpower needed was 2 technicians for customization of the immobilization device, 2.5 technicians and 1 consultant for the contrast-enhanced planning studies, 1 consultant, 0.5 resident and 0.67 medical physics expert (MPE) for physical treatment planning, as well as 1 consultant, 0.5 resident, and 2.5 technicians for the first radiotherapy treatment and 2.33 technicians for routine radiotherapy sessions. For the first time, the resource requirements for a radiotherapy department for the maintenance, protection and optimization of operational readiness for the application of intra- and extracranial stereotactic radiotherapy was determined methodically.

Women and men's satisfaction with care related to induced abortion

Objectives To investigate satisfaction with abortion care among women and their male partners, and to identify factors associated with high overall contentment with the care received.Methods A multi-centre cross-sectional questionnaire survey conducted in 2009 among 798 Swedish abortion-seeking women and 590 male partners was analysed with logistic regression.Results Overall care satisfaction was rated high by two-thirds (74%) of the women and half (52%) of the men. For women, factors associated with high overall satisfaction with care were: to be well treated by the health care staff (Odds Ratio [OR] = 11.78), sufficient pain relief (OR = 3.87), adequate information about the gynaecological examination (OR = 2.25), suitable contraceptive counselling (OR = 2.23), and ease of access to the clinic by phone (OR = 1.91). For men, the factors were to be well treated by the health care staff (OR = 5.32), and adequate information about the abortion procedure (OR = 2.64).Conclusion Most women and half of the men were pleased with the attention they had received, but one in four women and half the men were not, or not completely, suggesting improvement is needed, especially with regard to men. For both women and men the human aspect of the care, namely, the consideration showed by the attending staff, appears to be the most important factor associated with satisfaction regarding abortion care.

Top Leaders Embrace Change in Their Facilities

Top Leaders Embrace Change in Their Facilities

Text Messaging Among Residents and Faculty in a University General Surgery Residency Program: Prevalence, Purpose, and Patient Care

There is little information about the use of text messaging (texting) devices among resident and faculty physicians for patient-related care (PRC). To determine the prevalence, frequency, purpose, and concerns regarding texting among resident and attending surgeons and to identify factors associated with PRC texting. E-mail survey. University medical center and its affiliated hospitals. Surgery resident and attending staff. Prevalence, frequency, purpose, and concerns regarding patient-related care text messaging. Overall, 73 (65%) surveyed physicians responded, including 45 resident (66%) and 28 attending surgeons (62%). All respondents owned a texting device. Majority of surgery residents (88%) and attendings (71%) texted residents, whereas only 59% of residents and 65% of attendings texted other faculty. Most resident to resident text occurred at a frequency of 3-5 times/d (43%) compared with most attending to resident texts, which occurred 1-2 times/d (33%). Most resident to attending (25%) and attending to attending (30%) texts occurred 1-2 times/d. Among those that texted, PRC was the most frequently reported purpose for resident to resident (46%), resident to attending (64%), attending to resident (82%), and attending to other attending staff (60%) texting. Texting was the most preferred method to communicate about routine PRC (47% of residents vs 44% of attendings). Age (OR: 0.86, 95% CI: 0.79-0.95; p = 0.003), but not sex, specialty/clinical rotation, academic rank, or postgraduate year (PGY) level predicted PRC texting. Most resident and attending staff surveyed utilize texting, mostly for PRC. Texting was preferred for communicating routine PRC information. Our data may facilitate the development of guidelines for the appropriate use of PRC texting.

Fostering an Atmosphere of Professionalism in a Residency Program: Learning How to Address the Unprofessional Behavior of Colleagues Through OSCEs

Abstract Introduction Professionalism training and assessment have received much attention. Multiple strategies have been devised to help educational programs deal with unprofessional behavior, whi...

Practical obstetric management training – an innovative approach

BackgroundObstetric and midwifery practice requires a highly skilled, informed team, who communicate effectively within an environment prepared for acute emergencies. Frontline staff can be exposed to Obstetric emergencies infrequently, so...

Morbidity and mortality conferences: their place in quality assessments

This article aims to analyze morbidity and mortality conferences (M&MCs) in a university-affiliated hospital, notably their format and progression since the 1990s. A cross-sectional study was conducted and M&MC characteristics were collected using three methods: a questionnaire to all department heads to identify past M&MCs; semi-structured interviews with each M&MC leader; and when available, meeting reports were analyzed. Of 189 questionnaires sent to department heads, 105 were completed and returned (55.6 per cent). A total of 27 M&MCs were identified; five times more than in 1994. The M&MC format varied greatly between departments. In surgical units, cases per conference tended to be higher than in intensive care or medical units and paramedical staff were invited less often. Compared with 1998, head nurses (70.4 vs 27.3 percent, p = 0.03) and paramedical staff (63.0 vs 18.2 percent, p = 0.03) attendance increased significantly. Physicians considered M&MCs important for improving service quality, patient safety and enhancing team cohesion. Patient outcomes were not assessed. Although undefined formats allowed leaders to conduct M&MCs according to their objectives, how these conferences are conducted should impact healthcare quality and safety. Results indicate that M&MCs have evolved over the past 20 years, showing them to be valuable quality and safety improvement methods.

Defining impact of a rapid response team: qualitative study with nurses, physicians and hospital administrators

ObjectiveThe objective of this study was to qualitatively describe the impact of a Rapid Response Team (RRT) at a 944-bed, university-affiliated hospital.MethodsWe analysed 49 open-ended interviews with administrators, primary team...

Republished: Defining impact of a rapid response team: qualitative study with nurses, physicians and hospital administrators

ObjectiveThe objective of this study was to qualitatively describe the impact of a Rapid Response Team (RRT) at a 944-bed, university-affiliated hospital.MethodsWe analysed 49 open-ended interviews with administrators, primary team...

Defining the Ideal Nasolabial Angle

The nasolabial angle is defined as the angle between the line drawn through the midpoint of the nostril aperture and a line drawn perpendicular to the Frankfurt horizontal while intersecting subnasale. An arbitrary range of 90 to 120 degrees for the nasolabial angle is usually stated in the literature. The purpose of this study was to objectively define the ideal nasolabial angle. Life-sized, lateral photographs of 10 men and 10 women who had undergone rhinoplasty performed by the senior surgeon were selected. The photographs were electronically altered to change the nasolabial angle by 4 degrees. For men and women, these angles were 90, 94, 98, 102, 106, and 110 degrees. Sixteen raters, including plastic surgery attending staff, residents, and office staff, selected their most aesthetically pleasing nasolabial angle. Data analysis was done using the distribution of means of the first preference nasolabial angle values based on all 16 raters. The mean angle for ideal male nasolabial angle was 95.96 degrees ± 2.57 degrees (mean ± SD). The mean angle for women was 97.7 ± 2.32 degrees. Based on these standard deviations, the ideal nasolabial angle would be 93.4 to 98.5 degrees for men and 95.5 to 100.1 degrees for women. The authors' results indicate a much closer range of nasolabial angle between men and women than previously reported in the literature. This study is the first of its type to objectively define the ideal aesthetic nasolabial angle. In addition, the ideal nasolabial angle for women was found to be less obtuse than previously thought.

Evaluation of time, attendance of medical staff, and resources during radiotherapy for breast cancer patients

To conform to recommendations regarding the treatment of breast cancer, an estimation of costs and personnel to assure treatment is required. To date no recommendations based on real time measurements are available. The DEGRO (German Society of Radiation Oncology), therefore, initiated a prospective multicenter evaluation of core procedures of radiotherapy. In this analysis, the results regarding human resources and room occupation during the treatment of breast cancer are presented. Three academic radiation oncology centers (Erlangen, Münster, Mannheim) prospectively documented their workflow and working time for all breast cancer patients from July-October 2008. Subsequently, a statistical analysis was performed. The longest working time of physicians was the definition of the target volume and organs at risk (mean 33min). Furthermore, physicians needed much time for general tasks, which included conversations. Physicists needed the most time for treatment planning and authorization (64min), whereas technicians were mostly needed in day-to-day radiotherapy treatment (15min, 31min including verification). Despite significant differences in specific steps between centers, overall working times and room occupation were comparable and representative. Special procedures (intraoperative radiotherapy/multicatheter brachytherapy) required considerable amounts of additional working time of physicians and physicists. In this prospective analysis, data of human resources and room occupation during treatment of breast cancer are presented for the first time. Each patient consumes about 12h of human resources for treatment and 3.75h for general tasks (physicians 4.7h, physicists 1.8h, and technicians 9.2h).