Staff Doctors Research Articles

L'observance thérapeutique : déterminants et modèles théoriques

The aim of this paper is to examine a certain number of parameters which are classically implicated in the emergence of therapeutic observance behavior. This health behavior can be defined as the consequence of a process of a patient's conforming to medical instructions issued by the medical authority in the framework of treating his illness. However, the determinants of following these medical instructions are numerous and interdependent. Therefore, this paper will attempt to present the concept of observance by proposing certain definitions with a rather vague outline. We will then present three principal models specifically devoted to its study. A study of the determinants of observance versus non-observance will then be envisaged and will treat the characteristics peculiar to the sick, as well as the quality of the relation which is maintained between them and the medical staff–doctors. Far from being exhaustive in the presentation of the concept of observance, we will emphasize more the difficulty in truly understanding such behavior; a problematic which finds a new originality for psychology and the human sciences by its focus on the field of health and illness.

Parental Understanding of the Role of Trainees in the Ophthalmic Care of Their Children

To examine parental knowledge and expectations regarding the roles of trainees involved in their child's ophthalmic care. Prospective survey. Parents of 128 children attending outpatient pediatric ophthalmology clinics at The Hospital for Sick Children in Toronto. A questionnaire was given prospectively to parents (and 1 custodial grandparent). They were asked to identify, using a checklist, the roles and responsibilities of medical students, residents, and fellows and to explore their expectations regarding trainee participation using a multiple choice questionnaire. Parental knowledge and expectations regarding the roles and participation of medical trainees in the ophthalmic care of their children as measured by survey questionnaire. Parental knowledge about the roles of trainees was very limited with one exception: more than 95% knew that medical students are learning to be doctors and most had a good knowledge of the medical student role. More than 76% wanted to be asked specifically if they would allow trainees involved in their child's care. Seventy-five percent were happy to have capable trainees involved, provided that the trainees discuss all decisions with the responsible staff doctor. Parents wanted health care providers to identify themselves by name (77%) and position (86%). Only 3% did not want trainees involved in any part of their child's care. Although parental knowledge regarding the relative roles of trainees is poor, parents generally are willing to have trainees involved in their child's medical and surgical care, provided they are adequately supervised and that the parent is aware of their participation.

The health beliefs of hospital staff and the reporting of needlestick injury

The aim of this study is to examine the connection between the health beliefs of hospital staff (doctors, nurses and auxiliary staff) and their failure to report needlestick injuries. Needlestick injury to hospital staff is quite frequent and can result in infections and disease, but staff frequently do not report the injury despite their awareness of the risk of blood-borne pathogens. Five questionnaires were constructed based on three existing research tools and were tested for validity and reliability. Two hundred and forty questionnaires were distributed to eight randomly chosen departments of a single Israeli hospital. Seventy-six percent of the questionnaires were anonymously completed and returned. Nurses had the highest rate of needlestick injury, followed by auxiliary staff and doctors. Auxiliary staff showed the highest rate of compliance with the duty to report such injuries, while doctors showed the lowest. Perceived severity of contractable disease, the perceived efficacy of reporting injuries and overall motivation to maintain health were the best predictors of reporting compliance. Non-compliers emphasized the negative aspects of reporting the injuries, primarily that it took up too much time. The solution to non-compliance with the duty to report must be a targeted investment in training and education. Relevance to clinical practice. Finding the reasons for compliance and non-compliance with the duty to report needlestick injuries will help in designing educational programmes for hospital staff and in determining a strategy for improving health behaviour.

Preoperative cardiac drug administration in general surgical patients: a completed audit

The aim of this study was to audit the preoperative administration of regular cardiac medication in general surgical patients and to determine if this can be improved with simple ward-based education. The notes and drug charts of 102 general surgical adult inpatients undergoing elective operations were analysed prospectively. It was noted whether the patient was on regular morning cardiac medication, whether this was given and, if not, whether a reason was recorded on the drug chart. An information sheet and brief verbal reinforcement was given to nursing staff and junior doctors and the review repeated in 111 patients. There was no significant difference in the number of patients on regular cardiac medication between the two review groups; 42% patients had one or more drugs omitted in the initial review. After education this reduced significantly to 20% (p = 0.023). When omissions on medical instruction were excluded, this became highly significant (p = 0.0029). There was also a significant decrease in the number of times 'nil by mouth' was stated as the reason for omission. As a general principle, all regular cardiac medication should be given preoperatively even when nil by mouth as there is evidence that abrupt withdrawal can have serious consequences. This audit demonstrates that with simple education, the proportion of regular cardiac drugs administered preoperatively can be significantly increased.

Is primary care ready to embrace e-health? A qualitative study of staff in a London primary care trust

e-Health refers to the organisation and delivery of health services and information using the internet and related technologies. We investigated the perceptions of primary care staff towards e-health initiatives in the NHS Connecting for Health programme and whether front-line staff are ready to implement such changes. Twenty participants from different professional groups were purposively selected for interview, based on their current computer usage. The same practice staff were subsequently observed in order to gain an insight into how they use computers. Practice staff (doctors, nurses, practice managers and receptionists) who will be expected to use new information technology and primary care trust (PCT) staff who are involved in its implementation were selected to participate in this study. A north London PCT with 62 general practices. Four practices were selected for the study. Analysis of the interviews and the observational data yielded six recurrent themes that have a bearing on readiness to use information and communication systems to support clinical care: perceptions of technology and NHS Connecting for Health; issues relating to resources; patient choice; matters relating to confidentiality and security; political pressures; and how information technology is currently used within primary care. At the time of the study the systems that form part of NHS Connecting for Health, apart from the Quality Management and Analysis System (QMAS), were not implemented across the PCT. All the practices in the study acknowledged the benefits new technology would bring to the workplace, but there were also some common concerns, which suggest that staff working in primary care practices are not ready for e-health. Successful implementation of the NHS Connecting for Health programme rests on identifying, acknowledging and overcoming these concerns. A different approach might be required for those practices that have made very little progress in using email or moving towards an electronic patient record. This study suggests that a mistrust of technology and fears as to the heavy initial workload involved in becoming fully computerised have dissuaded some practices from embracing e-health. If NHS Connecting for Health is to be a success, implementation teams might need to focus initially on practices that have been reluctant to use technology to support both clinical care and the day-to-day work of the practice.

Provider and Health Facility Influences on Contraceptive Adoption in Urban Pakistan

Although the vast majority of Pakistani women are familiar with family planning methods, use of contraceptives remains low. Identifying the characteristics of family planning providers and health facilities that are associated with women's initiation of contraception may help program administrators devise interventions to increase contraceptive use. Logistic regression analysis of data from a survey of urban Pakistani health facilities, their clients and their staff was used to identify individual, provider and health facility characteristics that predict women's receipt of contraceptives during visits to urban clinics. Women who had a secondary or higher level of education and three or more children had elevated odds of receiving a method (odds ratios, 1.8-9.3). Women had reduced odds of receiving contraceptives when visiting facilities where providers had higher levels of family planning experience. They had higher odds of receiving services at facilities that displayed educational materials about family planning than at those that did not (1.8), and those odds increased with the proportion of contraceptive methods offered that were in stock, the number of staff doctors and the number of staff members who provided family planning (1.2-2.4). Providers should be aware of the contraceptive needs of women with all levels of education and parity. Additionally, family planning facilities may be able to increase clients' contraceptive use by providing diversity in method choice, keeping offered methods in stock, displaying informational materials, and raising staff levels.

Referral to and discharge from cardiac rehabilitation: key informant views on continuity of care

To assess the system-level barriers and facilitators of continuity of care from acute care to cardiac rehabilitation (CR), and from CR discharge to follow-up with primary health care providers. Semi-structured individual interviews with 24 key informants including CR staff, research scientists, policy makers, cardiologists and other doctors from a regional to international level were conducted regarding the processes of referral to and discharge from cardiac rehabilitation. Key informant interviews were audio taped, transcribed, and imported into QSR N6 software for Grounded analysis. Themes that emerged related to communication, referral and discharge processes, health care provider practices, inter- and intra-institutional relationships, and alternative models of delivery to improve continuity. Ramifications for enhancing referral of patients to beneficial CR services and follow-up by primary care providers to ensure maintenance of functional and health-related gains are discussed.

Reducing hypnotic use on two older adult functional wards: an effective audit?

Aims and MethodWe undertook an audit of hypnotic use on two functional older adult wards, followed by an educational intervention to all nursing staff and junior doctors. We then repeated the audit.ResultsOur pre-intervention audit showed a hypnotic use of 48%. This decreased to 26% for the first month following the educational intervention. Usage increased gradually in proportion to time from intervention. However, over the 4-month post-intervention period hypnotic use remained significantly lower than pre-intervention throughout the time period studied.Clinical ImplicationsAs the study is an audit there is no control group, but our results suggest regular staff education is needed to sustain a reduction in hypnotic use.

Comparison of dimension reduction methods using patient satisfaction data

Abstract In this study, we compared classical principal components analysis (PCA), generalized principal components analysis (GPCA), linear principal components analysis using neural networks (PCA-NN), and non-linear principal components analysis using neural networks (NLPCA-NN). Data were extracted from the patient satisfaction query with regard to the satisfaction of patients from hospital staff, which was applied in 2005 at the outpatient clinics of Trakya University Medical Faculty. We found that percentages of explained variance of principal components from PCA-NN and NLPCA-NN were highest for doctor, nurse, radiology technician, laboratory technician, and other staff using a patient satisfaction data set. Results show that methods using NN which have higher percentages of explained variances than classical methods could be used for dimension reduction.

Survey of the implementation of the recommendations in the Health Service Circular 2002/009 ‘Better Blood Transfusion’

This report describes the results of questionnaire surveys in 2003 and 2004 on the implementation of the recommendations of the Health Service Circular (HSC) 'Better Blood Transfusion' 2002/009 for improving transfusion practice. These followed a similar survey in 2001 to determine the progress with the implementation of recommendations in the previous Health Service Circular (HSC) 'Better Blood Transfusion' 1998/224. There was a disappointing response rate (47%) to the 2003 survey and evidence for incomplete compliance with the action plan. It was repeated in April 2004 with a systematic approach to encouraging returns, and the response rate was 95%. The results indicate progress in the implementation of Better Blood Transfusion between 2001 and 2004 in relation to increases in the proportion of hospitals with Hospital Transfusion Committees, the training of some staff groups, the number of hospitals with transfusion practitioners, the development of protocols for the use of blood and audit activity. However, the results also indicate the need for further progress in the training of some staff groups, particularly nurses and doctors, the development of Hospital Transfusion Teams, the development of protocols for the appropriate use of blood, the provision of information to patients and the use of peri-operative cell salvage. This information should be used to plan further local, regional and national initiatives to implement the Better Blood Transfusion action plan and improve transfusion practice.

Risk Perception and Impact of Severe Acute Respiratory Syndrome (SARS) on Work and Personal Lives of Healthcare Workers in Singapore

Healthcare workers (HCWs) were at the frontline during the battle against Severe Acute Respiratory Syndrome (SARS). Understanding their fears and anxieties may hold lessons for handling future outbreaks, including acts of bioterrorism. We measured risk perception and impact on personal and work life of 15,025 HCWs from 9 major healthcare institutions during the SARS epidemic in Singapore using a self-administered questionnaire and Impact of Events Scale and analyzed the results with bivariate and multivariate statistics. From 10,511 valid questionnaires (70% response), we found that although the majority (76%) perceived a great personal risk of falling ill with SARS, they (69.5%) also accepted the risk as part of their job. Clinical staff (doctors and nurses), staff in daily contact with SARS patients, and staff from SARS-affected institutions expressed significantly higher levels of anxiety. More than half reported increased work stress (56%) and work load (53%). Many experienced social stigmatization (49%) and ostracism by family members (31%), but most (77%) felt appreciated by society. Most felt that the personal protective measures implemented were effective (96%) and that the institutional policies and protocols were clear (93%) and timely (90%). During epidemics, healthcare institutions have a duty to protect HCWs and help them cope with their personal fears and the very stressful work situation. Singapore's experience shows that simple protective measures based on sound epidemiological principles, when implemented in a timely manner, go a long way to reassure HCWs.

Cost-effective Selection of H2 Receptor Antagonists for Upper Gastrointestinal Hemorrhage in Japanese Hospital Setting

The aim of this study was to identify the most favorable H2RA (H2 receptor antagonist) for the treatment of upper gastrointestinal hemorrhage (non-phlebeurysm). A decision tree was constructed to evaluate cost-effectiveness among an existing treatment (control), roxatidine, famotidine and ranitidine from the viewpoints of the payer and the medical facility. Clinical parameters used as transition probabilities were obtained from the results of the domestic RCT (Randomized Controlled Trial) of each drug. The cost items consisted of the direct medical cost, capital cost, and medical staff (doctors and nurses) personnel costs. The time horizon was set at 12.3 days on average and there was therefore no discount. Of the three drugs, at approximately 140, 000 yen less than the control, ranitidine was estimated to be most cost-saving for the payer. In percentage terms, ranitidine had the highest earnings rate among the H2RAs of 46.0% and roxatidine had the highest earnings in money terms among the H2RAs of approximately 120, 000 yen. A one-way sensitivity analysis used for investigating extra periods of hospitalization showed that this had no impact on the base case. A two-way analysis showed that ranitidine had the highest efficiency of about 55 % for the cases analyzed. When a threshold analysis was conducted, it was found that, while there would be no change in the hemostatic rate in substitutive plans, the hemostatic rate of 0.60 for famotidine (ceiling total cost : 375, 801 yen) and that of 0.61 for ranitidine (ceiling total cost : 406, 271 yen) were the thresholds affecting the results of analysis. It is therefore likely that selecting ranitidine first in preference to roxatidine or famotidine would be more cost-effective.

医療従事者の薬物相互作用に対する意識調査―グレープフルーツと薬物の相互作用について―

Drug interactions broadly fall into two categories : drug-drug interactions, which occur when two or more drugs react with each other, and drug-food/beverage interactions, which occur when drugs react with a food or beverage taken concurrently. These interactions may profoundly affect drug pharmacokinetics, pharmacologic actions and efficacy, and may cause adverse reactions. To avoid the risks of drug interactions, it is important that not only medical professionals but also patients be fully aware of potential interactions, and also that consistent information be given to patients. The achievement of these two objectives can reduce the frequency of the adverse effects and improve outcomes.We selected the example of the widely discussed interactions between grapefruits and certain drugs and investigated the extent to which medical staff (doctors, nurses, dietitians, and pharmacists) were aware of them and informed their patients about them, by means of a questionnaire. From the findings, it was clear that awareness of the interactions among medical professionals varied greatly and the amount of information given to patients also varied greatly, implying that awareness of the interactions and the information provided to patients on them were both inadequate.The absence of consistent information will lead to patient confusion and is disadvantageous from a therapeutic viewpoint. We therefore believe that an important role of pharmacists' in drug therapy is to proactively provide appropriate information on drug interactions to medical professionals and patients before they have the chance to occur.

68 Medication Errors in A Neonatal Unit

Background: The magnitude and consequences of medical errors are controversial issues; nevertheless, there is a consensus on the preventability of medication errors and their frequent occurrence. Aim: To determine the frequency of different types of error in medical prescriptions and to estimate its occurrence as a function of characteristics and circumstances of the prescriptions. Methods: Cross-sectional study of hand-written prescriptions for newborn infants admitted to a third level neonatal unit during a 5 months study period (july–november 2003). Data were extracted from all prescriptions written on 53 randomly sampled days. Outcome variables: different elements were assessed to describe the correction of a prescription (drug name, dose, units, administration route, interval, legibility); a prescription was considered correct when all its elements were present. Determinants: characteristics and circumstances of the prescriptions (type of drug, day of the week, night/day shift, training of the prescriber and clinical profile of the patient). Data analysis: Proportions and logistic regression adjusted odds ratio (95% confidence interval). Results: 4132 hand-written prescriptions were reviewed. 58.6% of the prescriptions fullfilled the correction criteria. 88% of incorrect prescriptions were intercepted. No adverse effect was related to a prescription error. Dose calculation was incorrect in 12.3% of the prescriptions. An incorrect abbreviation of the units was used in 8.4%; 4% did not stated dose interval and 2.8% stated an incorrect interval. At least one of the elements of the prescription was considered illegible or uncertain in 13.7%. The route of administration was not stated in 12.7%, and it was not correct in 0.7%. The drugs with the higher proportion of incorrect prescriptions were caffeine and erythropoietin. Prescriptions were more frequently correct for newborns admitted to intensive vs. intermediate care, 1.5 (1.3–1.7); birth weight over 2500 g, 1.9 (1.5–2.4); on week-ends vs. rest of the week, 1.3 (1.1–1.5); on afternoon/night vs. morning shifts, 1.8 (1.4–2.3); and when written by intraining vs. staff doctors, 1.5 (1.4–1.8). Conclusion: More than half of prescriptions written out by hand in a neonatal unit were not considered correct. A higher workload is not related with a higher number of incorrect prescriptions. Professional experience does not reduce, in general, the number of prescription errors. The occurrence of miscalculation of dose was higher for medication prescribed daily or routinely.

Assessment of patient management skills and clinical skills of practising doctors using computer-based case simulations and standardised patients.

Standardised assessments of practising doctors are receiving growing support, but theoretical and logistical issues pose serious obstacles. To obtain reference performance levels from experienced doctors on computer-based case simulation (CCS) and standardised patient-based (SP) methods, and to evaluate the utility of these methods in diagnostic assessment. The study was carried out at a military tertiary care facility and involved 54 residents and credentialed staff from the emergency medicine, general surgery and internal medicine departments. Doctors completed 8 CCS and 8 SP cases targeted at doctors entering the profession. Standardised patient performances were compared to archived Year 4 medical student data. While staff doctors and residents performed well on both CCS and SP cases, a wide range of scores was exhibited on all cases. There were no significant differences between the scores of participants from differing specialties or of varying experience. Among participants who completed both CCS and SP testing (n = 44), a moderate positive correlation between CCS and SP checklist scores was observed. There was a negative correlation between doctor experience and SP checklist scores. Whereas the time students spent with SPs varied little with clinical task, doctors appeared to spend more time on communication/counselling cases than on cases involving acute/chronic medical problems. Computer-based case simulations and standardised patient-based assessments may be useful as part of a multimodal programme to evaluate practising doctors. Additional study is needed on SP standard setting and scoring methods. Establishing empirical likelihoods for a range of performances on assessments of this character should receive priority.

Accidentes biológicos en quirófanos y salas de parto. Proyecto EPINETAC 1996–2000

Surgical areas have long been considered risky with regard to occupational exposures to blood-borne pathogens. The objective of study was to describe and evaluate the risk of occupational exposure to blood-borne pathogens at operating and delivery rooms, from reports of injuries in health care workers. Transversal study of percutaneous injuries occurring in operating and delivery rooms which were registered in the Spanish surveillance system EPINETAC (Exposure Prevention Information Network Accidents) between 1996 and 2000. We recorded data from the exposed health care worker, from the accident itself and from the exposure source. The risk of exposition was calculated by logistic regression. The dependent variable was the exposition in operating/delivery rooms. We calculated the rate of exposure, total and by occupational categories, per 10,000 surgical procedures in 3 surgical specialties. There were 3,625 percutaneous injuries reported. The exposure risk was higher in midwives [OR 36.6 (CI 95% 19.61-68.52)] than in staff [OR 12.6 (CI 95% 10.21-15.71)] or training doctors [OR 12.8 (CI 95% 10.34-15.98)]. The highest risk turned up during use of material [OR 1.37 (CI 95% 1.05-1.79)] and during preparation of material for reuse [OR 1.81 (CI 95% 1.27-2.59)]. The exposure rate, in gynecologic procedures, was 34.36 injuries per 10,000, in digestive surgery it was 24.61 per 10,000, and in trauma surgery it was 18.92 per 10,000 surgical procedures. The risk of occupational exposure to blood-borne pathogens in staff and training doctors was higher in operating and delivery rooms than in others areas. Obstetric and gynecologic procedures exhibited the highest risk of exposure.

Directing student response to early patient contact by questionnaire.

First year medical students experienced early patient contact by observing outpatient consultations. To evaluate a questionnaire designed to examine emerging attitudes during the development of a doctor-patient relationship. First year medical students participated in medical outpatient consultations as observers. These consultations represented a total of 295 registered clinical appointments. After each observation, the students completed a questionnaire surveying themes related to the doctor-patient encounter. An instructor met the students at the end of the appointments to discuss the questions raised. The Dundee Ready Education Environment Measure was used to assess the course environment. Students found the activity useful and enjoyable. They reported increased self-esteem and enhanced enthusiasm for the study of medicine. They completed write-ups describing and evaluating the questionnaire data. The questionnaire notes showed homogeneity among the students. The Dundee Measure indicated the students regarded the learning environment positively (62.2%); social and ambient conditions were rated highly (64.6% and 64.7%, respectively). The teaching of humanitarian attitudes by observation of the doctor-patient relationship in practice was welcomed by students. The environment in which this educational programme was carried out was considered adequate. The outpatient service schedule and the limited time available for student instruction on the part of staff doctors made this activity productive. The programme motivated students towards higher achievement and the pursuit of medical responsibility as well as more developed humanitarian behaviour patterns.

Ascertaining women's choice of title during pregnancy and childbirth

We set out to determine how women in pregnancy would like to be addressed and also to ascertain their preferred choice of title during pregnancy. A questionnaire was administered to 925 women attending the antenatal clinics at the Unified Maternity Hospitals, the private rooms of the consultants of these hospitals and the private rooms of the consultants of the Bons Secour Hospital. Midwifery and medical staff (183 in total) were also invited to respond to a similar questionnaire. The response rate was 71.2% from the survey of women. The vast majority (82.1%) preferred to be addressed by their first name. Only 1.7% expressed a preference for a formal mode of address and the remainder (16.1%) did not mind. The women were in favour of being called ‘patient’ (32.8%), followed closely by ‘mother’ (28.9%) and then ‘lady’ (12.1%) as their first choice. Women wishing to be called ‘patient’ for first choice did not significantly differ from the remainder of the study group in age and gestation but were significantly more likely to have a lower number of previous pregnancies and less children (P < 0.05). First choice of title was not significantly influenced by category of patient (public vs. private). The staff survey yielded a response rate of 73.8%. The majority (83.5%) of health professionals preferred to address women by their first name, 6% preferred to address them more formally and 10.5% did not mind. ‘Mother’ (29.2%) was the most popular first choice, followed by ‘lady’ (22.3%), ‘woman’ (16.9%) and then ‘patient’ (13.8%). Medical staff (doctors) were significantly more likely to choose ‘patient’ (OR 26.5, 95% CI 7.8, 89.7; P < 0.001) when compared to midwives.

Predictors of retention among HIV/hemophilia health care professionals

Health care professionals working with individuals with chronic medical illness, especially those infected with the Human Immunodeficiency Virus (HIV), may be at risk for burnout and departure due to various job stresses such as the death of patients and social stigma. Factors that prevent burnout and employee attrition are seldom studied. Two hundred thirteen staff (doctors, nurses and mental health workers) at a representative sample of Hemophilia Treatment Centers (HTC) completed instruments to measure Burnout (Maslach Burnout Inventory), and perceived job stresses and satisfaction (job tasks, interactions with colleagues and patient care). The staff were surveyed again after two years and their job status determined after 4 years. After 4 years, 35% of the staff had left the field of Hemophilia/HIV care. Univariate tests found that retention was significantly associated with initial job satisfaction, being married and low levels of stress with colleagues. Burnout, as measured by the Maslach Burnout Inventory, at baseline, was unrelated to job retention over 4 years. An adjusted multiple logistic regression of all significant variables found that colleague support was most related to retention (OR=2.8, CI=1.49,5.1). We conclude that attrition of highly trained staff is a significant issue for patients and HTCs. These data suggest the important role that a well-functioning team can have in buffering the inevitable stresses associated with HIV care. Mental Health professionals have considerable expertise in addressing these issues.

Comparison of search strategies and quality of medical information of the internet: a study relating to ankle sprain

Objectives: to evaluate the quality of web sites on ankle sprain diagnosis and treatment and to assess the impact of Internet search expertise on quality of retrieved information. Method: two internet search strategies were conducted — one developed by an experienced information officer (expert's search) and the other based on the search terms used by orthopaedic medical staff (doctors’ search). Results: the expert's search revealed 32 web sites, of which nine were relevant, whereas the doctors’ search revealed 61 web sites of which 27 were relevant. Of the relevant web sites in the expert's search, one complied with all quality criteria, whereas none of the web sites in the doctors’ search complied with all criteria (11 vs. 0%, P=0.25). The web sites identified by expert's search had higher credibility (median scores 70 vs. 44, P=0.01) and accuracy of content (median scores 50 vs. 35, P=0.24). Conclusion: the quality of medical information on the internet is generally poor and information experts can capture higher quality web sites compared with doctors.