Baby bottle steam sterilizers for disinfecting home nebulizers inoculated with non-tuberculous mycobacteria.

Non-tuberculous mycobacteria (NTMb), present in environmental water sources, can contribute to respiratory infection in patients with chronic pulmonary disease. Contaminated nebulizers are a potential source of respiratory infection. Treatment with baby bottle steam sterilizers disinfects home nebulizers inoculated with bacterial pathogens but whether this method works for disinfection of NTMb is unclear. Baby bottle steam sterilization was compared with vigorous water washing for disinfecting home nebulizers inoculated with NTMb mixed with cystic fibrosis sputum. No NTMb was recovered from any nebulizers after steam treatment whereas viable NTMb grew after water washing, demonstrating that steam sterilization effectively disinfects NTMb-inoculated nebulizers.

Use of imipenem to detect KPC, NDM, OXA, IMP, and VIM carbapenemase activity from gram-negative rods in 75 minutes using liquid chromatography-tandem mass spectrometry.

Resistance to extended-spectrum ß-lactam antibiotics has led to a greater reliance upon carbapenems, but the expression of carbapenemases threatens to limit the utility of these drugs. Current methods to detect carbapenemase activity are suboptimal, requiring prolonged incubations during which ineffective therapy may be prescribed. We previously described a sensitive and specific assay for the detection of carbapenemase activity using ertapenem and liquid chromatography-tandem mass spectrometry (LC-MS/MS). In this study, we assessed 402 Gram-negative rods, including both Enterobacteriaceae and non-Enterobacteriaceae expressing IMP, VIM, KPC, NDM, and/or OXA carbapenemases, by using imipenem, meropenem, and ertapenem with LC-MS/MS assays. LC-MS/MS methods for the detection of intact and hydrolyzed carbapenems from an enrichment broth were developed. No ion suppression was observed, and the limits of detection for all three drugs were below 0.04 µg/ml. The sensitivity and specificity of meropenem and ertapenem for carbapenemase activity among non-Enterobacteriaceae were low, but imipenem demonstrated a sensitivity and specificity of 96% and 95%, respectively, among all Gram-negative rods (GNR) tested, including both Enterobacteriaceae and non-Enterobacteriaceae. LC-MS/MS allows for the analysis of more complex matrices, and this LC-MS/MS assay could easily be adapted for use with primary specimens requiring growth enrichment.

Audit and summative assessment: a completed audit cycle.

OBJECTIVE: To develop and test a system for delivering a completed audit cycle for summative assessment of general practitioner registrars in the United Kingdom. DESIGN: A trainer-based questionnaire on criteria for a completed audit cycle, followed by two marking exercises of audit projects submitted by general practice registrars. SETTING: Training practices in the West of Scotland between 1997 and 1998. SUBJECTS: Trainers and registrars in the above practices. RESULTS: 116 (89%) agreed that two collections of data were an essential or desirable part of an audit project. All 57 registrars who started in August 1997 successfully completed an audit cycle, seven (12%) after resubmission. Using two rather than three independent assessors to screen the projects, the marking instrument was shown to have a sensitivity of 95% (95% confidence interval (CI) +/-3.9%) and a specificity of 77% (95% CI +/-7.5%). All assessors found the new system easier to mark and 47 registrars (87%) found completing an audit cycle as or easier than expected. CONCLUSION: Evidence from the pilot project has shown that a general practice registrar's ability to review and critically analyse a piece of his/her work, with appropriate management of any necessary change, can be tested feasibly by means of a completed audit cycle within the registrar year. The process retains adequate levels of sensitivity and specificity and requires fewer assessors for marking the projects.

Clinical skills assessment.

BACKGROUND: From September 1996, all GP registrars completing vocational training in the United Kingdom must demonstrate competence by means of a four-part assessment procedure. AIM: To look at the accuracy of one of the components of vocational training: the trainer's report. METHOD: Seventy-five registrars completing their general practice training at the end of July 1997 were invited to take part in a practical skills workshop. Eight stations were designed to test practical skills and diagnostic interpretations that were included in the trainer's report, and a clinical vignette accompanied each task. The marking schedule used was developed from the minimum standards required in the trainer's report. Twenty-nine registrars (38%) took part in the workshop. RESULTS: Only one registrar passed all eight stations. The maximum number of stations failed by any one individual was five and this doctor was the only one of the sample to ultimately fail summative assessment. The majority of registrars failed by being unable to interpret clinical findings. Twenty-five registrars (86%) responded to the follow-up questionnaire. Of these, only six felt that the stations were unrealistic. All but two registrars had spent at least six months in their hospital training doing obstetrics and gynaecology but, in spite of this, only 31% of registrars were above minimum competence for vaginal and speculum examination. CONCLUSION: With one exception, registrars passed all aspects of the trainer's report. Discrepancy was found between the trainer's report and the doctor's ability to carry out clinical procedures. There is an assumption that many of these clinical skills are being taught and assessed at undergraduate level and during the hospital component, but this cannot be taken for granted. Doubt must also be cast on whether the trainers are using the trainer's report appropriately, and whether this is a valid and reliable tool to identify skills deficient in registrars for summative assessment.

The development and evaluation of a personal learning log for senior house officers.

OBJECT: To develop and evaluate the effect of having a personal learning log on Senior House Officers knowledge and confidence. METHODS: A multiple choice paper and a confidence checklist for two hospital specialties were developed to assess knowledge and confidence. These were administered to a control group and to an intervention group who had the learning log. Both groups completed an evaluation at the end of the post. SETTING: The study took place in Accident & Emergency and Obstetric & Gynaecology posts in Greater Glasgow and Lanarkshire. SUBJECTS: 79 Senior House Officers in Accident & Emergency and 78 Senior House Officers in Obstetrics & Gynaecology. RESULTS: The mean scores in the MCQ and the mode in the confidence checklist increased significantly in both specialties during the post, but there was no significant difference between the control and intervention groups. Forty two learning logs were returned at the end of the study and analysis of these revealed that there was great scope for learning but few documented the specific learning achieved. Evaluation of the posts revealed that some improvements had taken place in teaching and assessment frequency, however, there was scope for further improvement. CONCLUSION: While the problems of hospital training are well documented, an attempt to improve the situation using a learning log did not have a statistically significant impact on SHO knowledge or confidence. A six-month hospital post appears to present many opportunities for learning but these are not exploited. It is suggested that three things are needed. Firstly, active participation by and personalized feedback from a senior member of staff, with training where needed. Secondly, protected time for tutorials with a planned system of formative assessment, and thirdly, a more positive approach to learning by both SHOs and consultants. Once this occurs, a learning log may have a more significant impact on training.

Supporting practice-based audit: a price to be paid for collecting data.

BACKGROUND: There has been considerable investment by health authorities in the funding of support staff whose job is to collect data for audit purposes. It is important to understand what costs are involved in such a data collection exercise. The cost advantages of using existing practice staff or externally funded staff are not known. AIM: To assess the cost of transposing data on workload to computer software for audit purposes and retrieving data on five chronic diseases from case records. METHOD: Four audit support staff monitored the time taken to collect specific data as part of a broad audit programme in 12 training practices within one health board area in the West of Scotland in 1997. The time taken was used to estimate comparative costs for using a receptionist or practice nurse for carrying out a similar exercise. RESULTS: Average costs for collecting data per 1000 patients for waiting time, appointments, recall, and telephone audits were 5.24 Pounds for reception staff, 5.64 Pounds for audit support staff, and 9.68 Pounds for a practice nurse. The average cost for collecting data per patient with diabetes, asthma, epilepsy, hypertension, or rheumatoid arthritis was 1.48 Pounds for reception staff, 1.60 Pounds for audit support staff, and 2.74 Pounds for a practice nurse. CONCLUSIONS: The cost of collecting data varies considerably depending on which staff are chosen for the purpose. Practices should consider carefully how best to collect data for audit in terms of cost.

Training for audit: lessons still to be learned.

BACKGROUND: Audit is a criterion for training in general practice, and registrars are reliant on their trainers' teaching of basic audit methods. Their ability to teach this had been assumed, but registrars' projects submitted as part of summative assessment offered an opportunity to test this. AIM: To test trainers' knowledge of basic audit methods. Their knowledge was based on an ability to recognize key audit criteria using a marking schedule that they had helped to create. METHOD: All 158 trainers in the west of Scotland were asked to mark five general practice registrar audit projects using a marking schedule consisting of five independent criteria. Each project had one criterion that was below a level of minimum competence, as agreed by a group of 'expert' assessors. RESULTS: A total of 114 trainers (72%) completed the marking exercise of five audit projects. Three (3%) correctly identified the five criteria that were below minimum competence. They did this by highlighting many other criteria not below minimum competence. For all trainers, there was a direct relationship between the number of criteria they correctly identified as being below minimum competence and the total number of other criteria that they incorrectly identified. CONCLUSION: Trainers are failing to recognize basic audit methodology using a marking schedule they themselves helped to design. This has implications for their ability to teach audit to their registrars and may explain some of the difficulty in implementing audit.

Audit and summative assessment: system development and testing.

Registrars in general practice have to submit an audit project as one of four parts of summative assessment. A criterion-referenced marking schedule has been developed in the West of Scotland, consisting of five independent criteria all of which have to be judged above minimum competence to pass. A system was developed to test the instrument using a marking exercise which calculated the sensitivity and specificity of the assessment process, for different combinations of assessors. One hundred and two registrar audit projects were then assessed by three independent assessors. Ninety-two (90%) passed and 10 projects (10%) were referred back to the registrar as being below minimum competence. After resubmission six projects (6%) passed, two projects (2%) were still below minimum competence, and two (2%) were not resubmitted. A referral process for assessing the audit projects of general practice registrars has been developed to maximize the opportunity of finding a project below minimum competence.

Teaching audit--lessons from summmative assessment.

In 1995 and 1996, 9% of registrars in the West of Scotland failed to demonstrate minimum competence in their audit project for summative assessment. Adverse trainer advice was implicated. This study set out to assess trainers' and registrars' confidence with audit teaching, the methods of teaching audit, and the perceived needs of both groups.

Scottish general practice registrars--their views on psychotherapy training.

BACKGROUND: Psychological problems constitute between 10% and 30% of general practice workload. In 1993, the Royal Colleges of General Practitioners and Psychiatrists published guidelines on the psychiatric component of vocational training for general practice, recognizing the need for training in the psychological aspects of patient care and knowledge of the psychotherapies. Little is known as to how much these guidelines have been followed. AIM: To determine Scottish general practice registrars' views on whether the above training objectives had been met. METHOD: An anonymous self-report questionnaire was sent to all general practice registrars in west and south-east Scotland one month before the end of their trainee year with a 95% response rate. This provided basic descriptive information on the population surveyed and their attitudes to psychotherapy training. RESULTS: Altogether, 53% had spent time in psychiatry and half of these had had access to a consultant psychotherapist, but only 9% had been involved in using a psychological approach to treatment. A total of 51% disagreed that they had had enough psychotherapy experience, and 44% did not feel confident in assessing patients for psychotherapy, 15% saying that lack of knowledge would prevent them from referring patients. Of the whole sample, 88% felt that further psychotherapy training would be helpful. CONCLUSION: The majority of general practice registrars in Scotland did not feel that training objectives had been met regarding the attainment of skills in the psychotherapies.