Cleaning up the paper trail - our clinical notes in open view.

Purpose Ireland's physicians have a legal and an ethical duty to protect confidential patient information. Most healthcare records in Ireland remain paper based, so the purpose of this paper is to: assess the protection afforded to paper records; log highest risk records; note the variations that occurred during the working week; and observe the varying protection that occurred when staff, students and public members were present. Design/methodology/approach A customised audit tool was created using Sphinx software. Data were collected for three months. All wards included in the study were visited once during four discrete time periods across the working week. The medical records trolley's location was noted and total unattended medical records, total unattended nursing records, total unattended patient lists and when nursing personnel, medical students, public and a ward secretary were visibly present were recorded. Findings During 84 occasions when the authors visited wards, unattended medical records were identified on 33 per cent of occasions, 49 per cent were found during weekend visiting hours and just 4 per cent were found during morning rounds. The unattended medical records belonged to patients admitted to a medical specialty in 73 per cent of cases and a surgical specialty in 27 per cent. Medical records were found unattended in the nurses' station with much greater frequency when the ward secretary was off duty. Unattended nursing records were identified on 67 per cent of occasions the authors visited the ward and were most commonly found unattended in groups of six or more. Practical implications This study is a timely reminder that confidential patient information is at risk from inappropriate disclosure in the hospital. There are few context-specific standards for data protection to guide healthcare professionals, particularly paper records. Nursing records are left unattended with twice the frequency of medical records and are found unattended in greater numbers than medical records. Protection is strongest when ward secretaries are on duty. Over-reliance on vigilant ward secretaries could represent a threat to confidential patient information. Originality/value While other studies identified data protection as an issue, this study assesses how data security varies inside and outside conventional working hours. It provides a rationale and an impetus for specific changes across the whole working week. By identifying the on-duty ward secretary's favourable effect on medical record security, it highlights the need for alternative arrangements when the ward secretary is off duty. Data were collected prospectively in real time, giving a more accurate healthcare record security snapshot in each data collection point.

National early warning score (NEWS) - evaluation in surgery.

PURPOSE: The purpose of this paper is to evaluate staff opinion on the impact of the National Early Warning Score (NEWS) system on surgical wards. In 2012, the NEWS system was introduced to Irish hospitals on a phased basis as part of a national clinical programme in acute care. DESIGN/METHODOLOGY/APPROACH: A modified established questionnaire was given to surgical nursing staff, surgical registrars, surgical senior house officers and surgical interns for completion six months following the introduction of the NEWS system into an Irish university hospital. FINDINGS: Amongst the registrars, 89 per cent were unsure if the NEWS system would improve patient care. Less than half of staff felt consultants and surgical registrars supported the NEWS system. Staff felt the NEWS did not correlate well clinically with patients within the first 24 hours (Day zero) post-operatively. Furthermore, 78-85 per cent of nurses and registrars felt a rapid response team should be part of the escalation protocol. RESEARCH LIMITATIONS/IMPLICATIONS: Senior medical staff were not convinced that the NEWS system may improve patient care. Appropriate audit proving a beneficial impact of the NEWS system on patient outcome may be essential in gaining support from senior doctors. Deficiencies with the system were also observed including the absence of a rapid response team as part of the escalation protocol and a lack of concordance of the NEWS in patients Day zero post-operatively. These issues should be addressed moving forward. ORIGINALITY/VALUE: Appropriate audit of the impact of the NEWS system on patient outcome may be pertinent to obtain the support from senior doctors. Deficiencies with the system were also observed including the absence of a rapid response team as part of the escalation protocol and a lack of concordance of the NEWS in patients Day zero post-operatively. These issues should be addressed moving forward.

Why is your patient sedated?

PURPOSE: The purpose of this paper is to examine the recording of clinical indication for prescribed sedative/hypnotic (SH) medications in a large, acute tertiary referral hospital. DESIGN/METHODOLOGY/APPROACH: All hospital inpatients' medications (n = 367) were audited for prescription details regarding SH medications. Medical notes were then examined for evidence of a recorded indication for such medications. FINDINGS: SH medications were prescribed to many hospital inpatients (42.5 per cent) during admission. An indication was documented in the nursing or medical records for 24.4 per cent of patients who were prescribed such medications. Nurses rather than by doctors prescribed most SH medications (74 vs 26 per cent, respectively, p = 0.003). Some patients receiving SH medications were both over 65 and impaired in their mobility (19.2 per cent). The treatment indication was documented in 47 per cent. PRACTICAL IMPLICATIONS: Most patients prescribed SH medications have nothing in their medical record explaining why these drugs are being used, including half of the elderly, less mobile patients. All health professionals dealing with SH medications and doctors in particular need to justify the use of such medications in the medical record. For the particularly high-risk groups where SH medications are potentially more dangerous, explicit guidance on why and how such medications are to be used must be provided by prescribers. ORIGINALITY/VALUE: For the first time, data are presented on documentation rates for clinical indication of prescribed SH medications across a large acute hospital, and highlights significant shortcomings in practice. This study should inform other organisations of the need to be mindful of facilitating greater compliance with good prescribing practice.

Building FAIR Functionality: Annotating Events in Time Series Data Using Hierarchical Event Descriptors (HED).

Human electrophysiological and related time series data are often acquired in complex, event-rich environments. However, the resulting recorded brain or other dynamics are often interpreted in relation to more sparsely recorded or subsequently-noted events. Currently a substantial gap exists between the level of event description required by current digital data archiving standards and the level of annotation required for successful analysis of event-related data across studies, environments, and laboratories. Manifold challenges must be addressed, most prominently ontological clarity, vocabulary extensibility, annotation tool availability, and overall usability, to allow and promote sharing of data with an effective level of descriptive detail for labeled events. Motivating data authors to perform the work needed to adequately annotate their data is a key challenge. This paper describes new developments in the Hierarchical Event Descriptor (HED) system for addressing these issues. We recap the evolution of HED and its acceptance by the Brain Imaging Data Structure (BIDS) movement, describe the recent release of HED-3G, a third generation HED tools and design framework, and discuss directions for future development. Given consistent, sufficiently detailed, tool-enabled, field-relevant annotation of the nature of recorded events, prospects are bright for large-scale analysis and modeling of aggregated time series data, both in behavioral and brain imaging sciences and beyond.

Is it feasible to learn research skills in addition to audit skills through clinical audit? A mixed methods study in general practice.

BACKGROUND: Involving medical students in research in their undergraduate careers may increase the likelihood that they will be research active after graduation. To date, there has been a paucity of published research of students doing research in general practice. AIM: The study aims to evaluate the impact of general practice clinical audits on early-stage graduate entry students' audit and research self-efficacy and explore feasibility issues from the student and GP perspective. METHODS: Two student questionnaires (pre- and post-intervention), a qualitative GP survey of the 25 participating GPs and semi-structured interviews of a purposeful sample of GPs were conducted. RESULTS: Participating students who completed the follow-up survey found that it had a positive educational impact (55%), increased their understanding of the audit cycle (72%) and real-world prescribing (77%). Research confidence wise, there was a statistically significant difference in the student group who completed the audit project compared to those students who did not in knowledge of the audit cycle and the difference between research and audit (p = 0.001) but not in other research skills. Ninety-six percent of responding GPs would be happy for students to do future audits in their practice but some feasibility issues similar to other research initiatives in general practice were identified. CONCLUSION: We found this audit initiative feasible and useful in helping students learn about audit skills, patient safety and real-world prescribing. GPs and students would benefit more if it were linked to a substantial clinical placement, focussed on a topic of interest and given protected time. Separate research projects may be needed to develop research skills confidence.

Changing attitudes towards annual influenza vaccination amongst staff in a Tertiary Care Irish University Hospital.

BACKGROUND: Healthcare workers are encouraged annually to get vaccinated against influenza. This year in view of COVID-19 pandemic, attitudes of HCWs towards vaccination are particularly important. A cross-sectional study was completed to understand how to best encourage and facilitate the vaccination of HCWs based on the previous years' findings. METHODS: An online survey was disseminated to all hospital staff via electronic channels. The clinical audit sphinx software was used for data collection and analysis. RESULTS: The total number of responses was n = 728, almost double the rate from 2018 (N = 393). A total of 78% (N = 551) of participants were vaccinated last year. A total of 94% (N = 677) of participants reported their intention to be vaccinated this year. The main barriers listed were being unable to find time (32%, N = 36), side effects (30%, N = 33) and thinking that it does not work (21%, N = 23). The most popular suggestions for how to increase uptake were more mobile immunisation clinics (72%, N = 517) and more information on the vaccine (50%, N = 360). A total of 82% of participants (N = 590) agreed that healthcare workers should be vaccinated, with 56% (N = 405) agreeing that it should be mandatory. Of the participants who were not vaccinated last year (N = 159), 40% (N = 63) agreed that COVID-19 had changed their opinion on influenza immunisation with a further 11% (N = 18) strongly agreeing. DISCUSSION: In light of the increasing number of survey participants, more staff were interested in flu vaccination this year than ever before. The COVID-19 pandemic has had some influence on staff's likelihood to be vaccinated. Feasibility of immunisation and education posed the largest barriers to HCW vaccination.

Failure to attend out-patient clinics: is it in our DNA?

PURPOSE: This paper aims to determine the reasons why patients miss clinic appointments and to ascertain patients' views on the implementation of reminder systems and penalty fees to reduce the rates of did not attend (DNAs). Overall, the paper seeks to establish novel ways to run a more efficient out-patient department (OPD) service to improve waiting times and access for patients to limited neurology resources. DESIGN/METHODOLOGY/APPROACH: A questionnaire-based study was approved by the audit committee and was offered to 204 out-patients attending the neurology clinics over a three-month period (July to September 2009). The patients' demographic details and non-attendance records were reviewed. The paper aimed to ascertain, from the patients' perspective, why people failed to attend clinic appointments. Each participant was asked their views on how they felt their public hospital service might reduce the number of DNAs at their neurology OPD. FINDINGS: A total of 204 patients took part. Participants had a mean age of 31 years (range 25-75 years) with a modal peak in the 26 to 35 age bracket. Almost 10 per cent of those surveyed admitted to missing a hospital out-patient appointment in the past. The most common reason was that they simply "forgot" (28 per cent). DNA rates by age range were proportionally similar to the overall age profile of attenders. Over 55 per cent said they would like a pre-appointment reminder via a mobile telephone text message, 19 per cent preferred a pre-appointment telephone call, and 19 per cent an e-mail. Of those surveyed, 47 per cent said they would be willing to pay a fee on booking that could be refunded on attending for their appointment. The majority of these felt Euro 20 was the most appropriate amount (39 per cent). The rate of acceptance for various fee amounts was uniform across age ranges. Over half (52 per cent) said that they would agree to a "buddy" system whereby the appointment reminder was sent to the patient but also a nominated friend or relative. ORIGINALITY/VALUE: Non-attendance rates at the neurology clinics in our institution are high with almost 10 per cent of attendees admitting to missing an appointment. One of the main reasons why people did not attend was because they simply "forgot" that they had an appointment and the patients favoured a text messaging reminder system to help reduce non-attendance. Almost half of the respondents said that they would be willing to pay a refundable booking fee.

Quality of education at multidisciplinary case conferences in psychiatry.

PURPOSE: A large Dublin-based teaching hospital facilitates a weekly Psychiatric Case Presentation meeting, which is relatively unique in medicine and even in psychiatry, in that there is a large variety of attendees from various multidisciplinary groups: consultant psychiatrists, psychiatric trainees, nurses, psychologists and psychoanalytic psychotherapists, occupational therapists, social workers and pastoral care staff. The aim of this audit is to assess the quality of education for members of different disciplines at these meetings, and to highlight the differing learning needs of the attendees. DESIGN/METHODOLOGY/APPROACH: Group-structured assessments and Likert scale questionnaires were used to identify what attendees thought were educational and what needed to be improved. FINDINGS: Overall, the case conference is educationally worthwhile but there were several areas of dissatisfaction. Some felt that the case conference was overly medical in its orientation and that there was excessive medical jargon. The seating arrangements were not conducive to group discussion. Consultants and psychiatric trainees felt that the quality of the clinical presentations could be improved. Presentation skills teaching classes and topic-based classes would be useful inclusions. Feedback to the multidisciplinary group on the patients' progress and feedback to the patient is important. Changes were implemented in areas of dissatisfaction, and these changes evaluated. ORIGINALITY/VALUE: The educational qualities of multidisciplinary Case Conferences need to be constantly evaluated to ensure that the learning needs of the different disciplines who attend are being met.

An evaluation of optimal tutorial methodologies for neurology teaching at undergraduate level : Optimal tutorial methods for neurology.

AIM: We aim to determine the efficacy of an intensive week of large group tutorials in the teaching of neurology to medical students. We also look to compare teaching methods within our centre. METHODS: Students were asked to complete a questionnaire before and after large group tutorials ranking their confidence in neurology. Students from two consecutive years were studied, each using a different tutorial method. An 'intensive week' approach was then compared to a 'once a week' approach. RESULTS: Responses from pre and post the tutorial week were compared. Students reported an improvement in all domains following either method of delivering tutorials. There was no statistically significant difference between the two approaches. CONCLUSION: Large group tutorials are an effective way of delivering neurology teaching to undergraduate medical students.

Vaccine hesitancy among people with multiple sclerosis.

BACKGROUND: The current severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) pandemic has raised awareness of vaccine hesitancy. Specific reasons for vaccine hesitancy among people with multiple sclerosis (pwMS) have not been fully described. Notably, pwMS may experience higher morbidity from vaccine-preventable diseases such as influenza, pneumococcal disease, and human papillomavirus (HPV)-associated warts and malignancies. Furthermore, screening for immunity against measles, mumps and rubella (MMR) is not standard practice, despite a resurgence of measles and mumps outbreaks in Europe and worldwide. We aimed to evaluate general vaccination status among pwMS to better inform vaccine practices in this cohort. METHODS: This was a prospective audit of pwMS attending an Irish tertiary referral MS centre. We designed a questionnaire that explored awareness, uptake, and hesitancy for the influenza, pneumococcal, SARS-CoV-2, HPV, and MMR vaccines. The clinician administered the questionnaire during the outpatient MS clinic. RESULTS: One-hundred-and-five pwMS participated in the audit, mean (SD) age 47.3 (12.8) years, mean MS disease duration 14.1 (9.5) years, median Expanded Disability Severity Scale (EDSS) score 2.0 (IQR 1.0-6.0), forty-nine (46.7%) were taking either maintenance immunosuppressive or immune reconstitution therapies. SARS-CoV-2 vaccine willingness among pwMS was higher (90.5 vs 60-80%) than that reported in other Western countries, and higher than that for the influenza and pneumococcal vaccines (∼80%) for which perceived unnecessity and unfamiliarity respectively were the main limiting factors. The primary reason for SARS-CoV-2 vaccine hesitancy was safety concern. PwMS who were explicitly advised by a healthcare professional to obtain the influenza vaccine were more likely to do so than those who were not (odds ratio, 8.1, 95% CI 2.8 - 23.4, p<0.001). Of pwMS currently receiving B-cell therapy (ocrelizumab/rituximab, n=12), all but one (n=11, 91.7%) have never received the pneumococcal vaccine, and a quarter (n=3) were uncertain whether to obtain this in the future. Patient-reported uptake of HPV (1.0%) and MMR (51.4%) vaccines were suboptimal. Prevalence of vaccine promotion among healthcare professionals was low (influenza vaccine, 4.8 - 32.4%; pneumococcal vaccine, 0 - 18.1%). CONCLUSIONS: Vaccine hesitancy is common (10-20%) in pwMS, consequent to insufficient knowledge and misconceptions about vaccination among pwMS and suboptimal vaccine promotion by healthcare professionals who manage pwMS. Conscientious and context-specific vaccination counselling is necessary to tackle vaccine hesitancy among pwMS, including (i) avoiding infection-associated disability accrual during MS relapses, (ii) reducing the potentially higher risk of life-threatening/treatment-refractory complications that may be observed in those who develop vaccine-preventable infections while receiving certain DMTs, and (iii) avoiding attenuated vaccine responses or delayed/interrupted DMT with early pre-treatment vaccine delivery where possible.

Promoting hot debriefing in an emergency department.

INTRODUCTION: Debriefing is a process of communication that takes place between a team following a clinical case. Debriefing facilitates discussion of individual and team level performance and identifies points of excellence as well as potential errors made. This helps to develop plans to improve subsequent performance. While the American Heart Association and the UK Resuscitation Council recommend debriefing following every cardiac arrest attended by a healthcare professional, it has not become part of everyday practice. In the emergency department (ED), this is in part attributable to time pressures and workload. Hot debriefing is a form of debriefing which should occur 'there and then' following a clinical event. The aim of this quality improvement project was to introduce hot debriefing to our ED following all cardiac arrests. METHODS: A hot debriefing tool was designed following simulated cardiac arrest scenarios and team feedback. This tool was then introduced to the ED for use after all cardiac arrests. The team lead was asked to complete a debrief form. These completed hot debrief forms were collated monthly and compared with the department's cardiac arrest register. Any changes made to cardiac arrest management following hot debriefing were recorded. Qualitative feedback was obtained through questionnaires. RESULTS: During the 6-month study period, 42% of all cardiac arrest cases were followed by a hot debrief. Practice changes were made to resus room equipment, practitioners' non-technical skills and the department's educational activities. 95% of participants felt the hot debriefing tool was of 'just right' duration, 100% felt the process helped with their clinical practice, and 90% felt they benefited psychologically from the process. CONCLUSION: The introduction of a hot debriefing tool in our department has led to real-world changes to cardiac arrest care. The process benefits participants' clinical practice as well as psychological well-being.

A quality improvement intervention failed to significantly increase pneumococcal and influenza vaccination rates in immunosuppressed inflammatory arthritis patients.

OBJECTIVES: Pneumococcal and influenza vaccination rates have been suboptimal in studies of immunosuppressed patients. We aimed to assess barriers to and increase rates of 23-valent pneumococcal polysaccharide vaccine (PPSV23) and influenza vaccination in this group. The primary endpoint was a statistically significant increase in adequate PPSV23 and influenza vaccination. METHODS: In 2017, rheumatology outpatients completed an anonymous questionnaire recording vaccination knowledge, status, and barriers. Simultaneously, a low-cost multifaceted quality improvement (QI) intervention was performed. All outpatients on oral steroids, immunosuppressant conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) or biologics disease-modifying antirheumatic drugs (bDMARDs) were included in the study. In 2018, post-intervention, the clinic was re-assessed. Demographics, diagnosis, medications, smart phone access, and willingness to use this for vaccination reminders were assessed for independent vaccination predictors using binary logistic regression analysis. RESULTS: Four hundred twenty-five patients were included (72.6% rheumatoid arthritis, 74% women, 45.6% ≥ 60 years old). From 2017 to 2018, PPSV23 vaccination rates changed from 41.0 to 47.2% (P = 0.29) and influenza from 61.8 to 62.1% (P = 0.95). The most common reason for non-vaccination was lack of awareness. Following the intervention, this changed for influenza (36.7 to 34.2%) and PPSV23 (82.1 to 76.4%). General practitioners performed most vaccinations, only 3.6% were delivered in the hospital. Significant predictors of PPSV23 vaccination were older age {≥ 80 years had an OR 41.66 (95% CI 3.69-469.8, P = 0.003), compared with ≤ 39 years}, bDMARD use (OR 2.80, 95% CI 1.24-6.32, P = 0.013), and adequate influenza vaccination (OR 9.01, 95% CI 4.40-18.42, P < 0.001). Up-to-date PPSV23 vaccination (OR 8.93, 95% CI 4.39-18.17, P < 0.001) predicted influenza vaccination. CONCLUSIONS: PPSV23 and influenza vaccination rates were suboptimal. The intervention did not cause a statistically significant change in vaccination rates. Point-of-care vaccination may be more effective.Key Points• Low vaccination rates amongst immunosuppressed inflammatory arthritis outpatients• Less than 5% of vaccinations occurred in hospital• There was no statistically significant difference in the rates of adequate PPSV23 (41.0 to 47.2%) or influenza (61.8 to 62.1%) vaccination following our intervention.