Improving communication and patient information recall via a question prompt list: randomized clinical trial.

BACKGROUND: Patient-surgeon communication is an important component of the success of a consultation and is known to impact patient outcomes. The aim of this study was to investigate whether a document called a question prompt list, containing suggested questions that a patient may like to ask their doctor, improved communication. METHODS: A prospective RCT was conducted from October 2021 to October 2022 at The Queen Elizabeth Hospital, Adelaide, Australia. Patients 16 years or older, seeing a general surgeon for a pre-surgical consultation, not requiring a translator, were randomized to receive a question prompt list (intervention) or standard care without a question prompt list (control). The primary outcomes were number of questions asked, talk time, and mutual eye gaze. Secondary outcomes were patient recall of information, anxiety, and consultation duration. Randomization was achieved using a computer program, with allocation concealment by opaque sequentially numbered envelopes. Patients were blinded to study group; surgeons were aware of study group, but blinded to outcomes. RESULTS: Patients (59) were randomly allocated to receive the question prompt list (31) or to the control group (28). A patient from the intervention group withdrew before consultation, resulting in 58 patients being included in the analysis. In the question prompt list consultations, 24 per cent more questions were asked (incidence rate ratio = 1.25, 95 per cent c.i. 1.10 to 1.42; P = 0.001). The intervention group recalled 9 per cent more items than the control group (incidence rate ratio = 1.09, 95 per cent c.i. 1.02 to 1.17; P = 0.012). The control group were 26 per cent less likely to correctly recall information about surgical treatment (OR = 0.26, 95 per cent c.i. 0.10 to 0.68; P = 0.006). No statistically significant differences between study arms for talk time, mutual eye gaze, anxiety, or consultation duration were demonstrated. CONCLUSION: The question prompt list was associated with increased question asking and greater patient recall of medical information. It did not increase patient anxiety or consultation duration. REGISTRATION NUMBER: ACTRN12623000089639 (http://www.ANZCTR.org.au).

Patient Satisfaction in Emergency General Surgery: A Prospective Cross-Sectional Study.

BACKGROUND: The importance of the patient experience is increasingly being recognised. However, there is a dearth of studies regarding factors affecting patient-reported outcomes in emergency general surgery (EGS), including none from the Southern Hemisphere. We aim to prospectively assess factors associated with patient satisfaction in this setting. METHODS: In this prospective cross-sectional study, all consecutive adult patients admitted to an acute surgical unit over four weeks were invited to complete a validated Patient-Reported Experience Measures questionnaire. These were completed either in person when discharge was imminent or by telephone <4 weeks post-discharge. Responses were used to determine factors associated with overall patient satisfaction. RESULTS: From 146 eligible patients, 100 (68%) completed the questionnaire, with a mean overall satisfaction score of 8.3/10. On multivariate analyses, eight factors were significantly associated with increased overall satisfaction. Five of these were similar to those previously prescribed by other like studies, being patient age >50 years, sufficient analgesia, satisfaction with the level of senior medical staff, important questions answered by nurses and confidence in decisions made about treatment. Three identified factors were new: sufficient privacy in the emergency department, sufficient notice prior to discharge and feeling well looked after in hospital. CONCLUSIONS: Factors associated with patient satisfaction were identified at multiple points of the patient journey. While some of these have been reported in similar studies, most differed. Hospitals should assess factors valued by their EGS population prior to implementing initiatives to improve patient satisfaction.

Patient focused interventions and communication in the surgical clinic: a systematic review and meta-analysis.

Background: Communication is the foundation of a strong doctor-patient relationship. Holistic care of the patient involves good communication and empathy. There are various tools and interventions aimed at increasing the Surgeon's performance, but these have the drawback of heavy cost and time commitments. In contrast, patient focused interventions are often simple and cheap. In surgery this is an evolving field, and little is known about the impact these interventions have on clinical encounters. The aim of this review is to determine how patient focussed interventions impact communication in the Surgical Outpatient Consultation. Methods: In this systematic review and meta-analysis, two reviewers independently searched MEDLINE (incl. PubMed), EMBASE, EMCARE, CINAHL, and the Cochrane Library for the period starting 01 February 1990 to 01 February 2022. Filtration and screening was performed in accordance with PRISMA guidelines. Conflicts were resolved by discussion. Risk of Bias was assessed using the RoB 2 tool. Meta-analyses were conducted by an independent statistician using Stata Statistical Software. This systematic review was prospectively registered with PROSPERO (ID CRD42022311112). Findings: After screening, 38 papers were included in the final analysis. These involved 6392 patients consisting of 32 randomised controlled trials (RCT), one crossover RCT, three non-randomised experimental studies, and three cohort studies. All articles were published between 1999 and 2022. Four types of intervention were identified: Patient Decision Aids, Educational Materials, Question Prompt Lists and Patient Reported Outcome Measures. There was much heterogeneity in the reported results but ultimately four recurring domains for assessing quality of communication were identified: Patient knowledge; decisional conflict; satisfaction; and anxiety. Meta-analyses showed that patient focussed interventions increased patient knowledge and reduced decisional conflict. Meta-regression demonstrated significant knowledge increases in females compared with males. Results regarding satisfaction and anxiety were not statistically significant. Interpretation: Our study suggested that patient focused interventions demonstrate promising results for increasing patient engagement and improving communication. Further multicentre randomised controlled trials with consistent validated endpoints should be conducted to evaluate this evolving field. Funding: There was no funding source for this study.

A systematic review of dedicated models of care for emergency urological patients.

OBJECTIVE: To systematically evaluate the spectrum of models providing dedicated resources for emergency urological patients (EUPs). METHODS: A search of Cochrane, Embase, Medline and grey literature from January 1, 2000 to March 26, 2019 was performed using methods pre-published on PROSPERO. Reporting followed Preferred Reporting Items for Systematic Review and meta-analysis guidelines. Eligible studies were articles or abstracts published in English describing dedicated models of care for EUPs, which reported at least one secondary outcome. Studies were excluded if they examined pathways dedicated only to single presentations, such as torsion, or outpatient solutions, such as rapid access clinics. The primary outcome was the spectrum of models. Secondary outcomes were time-to-theatre, length of stay, complications and cost. RESULTS: Seven studies were identified, totalling 487 patients. Six studies were conference abstracts, while one study was of full-text length but published in grey literature. Four distinct models were described. These included consultant urologists allocated solely to the care of EUPs ("Acute Urological Unit") or dedicated registrars or operating theatres ("Hybrid structures"). In some services, EUPs bypassed emergency department assessment and were referred directly to urology ("Urological Assessment Unit") or were managed by other dedicated means. Allocating services to EUPs was associated with reduced time-to-theatre, length of stay and hospital cost, and improved supervision of junior medical staff. CONCLUSION: Multiple dedicated models of care exist for EUPs. Low-level evidence suggests these may improve outcomes for patients, staff and hospitals. Higher quality studies are required to explore patient outcomes and minimum requirements to establish these models.

The acute surgical unit: An updated systematic review and meta-analysis.

OBJECTIVE: To systematically review comparative studies on the acute surgical unit (ASU) model. METHODS: Searches were performed of Cochrane, Embase, Medline and grey literature. Eligible articles were comparative studies of the Acute Surgical Unit (ASU) model published 01/01/2000-12/03/2020. Amongst patients with any diagnosis, primary outcomes were length of stay, after-hours operating, complications and cost. Secondary outcomes were time to surgical review, time to theatre, mortality and re-admission for patients with any diagnosis, and cholecystectomy during index admission for patients with biliary disease. Additional analyses were planned for specific cohorts, such as patients with appendicitis or cholecystitis. RESULTS: Searches returned 9,677 results from which 77 eligible publications were identified, representing 150,981 unique patients. Cohorts were adequately homogenous for meta-analysis of all outcomes except cost. For patients with any diagnosis, compared with the Traditional model, the introduction of an ASU model was associated with reduced length of stay (mean difference [MD] 0.68 days; 95% confidence interval [CI] 0.38-0.98), after-hours operating rates (odds ratio [OR] 0.56; 95% CI 0.46-0.69) and complications (OR 0.48, 95% CI 0.33-0.70). Regarding cost, two studies reported savings following ASU introduction, while one found no difference. Amongst secondary outcomes, for patients with any diagnosis, ASU commencement was associated with reduced time to surgical review, time to theatre and mortality. Re-admissions were unchanged. For patients with biliary disease, ASU establishment was associated with superior rates of index cholecystectomy. CONCLUSION: Compared to the Traditional structure, the ASU model is superior for most metrics. ASU introduction should be promoted in policy for widespread benefit.

Loin to groin pain -A case report of an intermittent obturator hernia mimicking ureteric colic.

INTRODUCTION: Obturator hernia is a rare condition and can cause significant diagnostic challenges due to a lack of reliable clinical examination signs. Presentations can have a variety of features and it is a diagnosis that needs to be considered - especially in elderly multiparous women. PRESENTATION OF CASE: We present a 76-year-old female who has multiple presentations to the Emergency Department (ED) with transient episodes of severe loin to groin pain. Imaging Computer Tomography (CT) initially demonstrated a mild left hydronephrosis and she underwent an unremarkable ureteroscopy and stenting. Following stent removal she continued to have recurrent episodes of the pain. She presented to the ED with one such episode. A repeat CT scan was performed and this demonstrated an obturator hernia with partial small bowel obstruction. She underwent a laparoscopy by which time the hernia had reduced and her pain had settled. Laparoscopy revealed bilateral obturator herniae with the one on left larger than the right. Both were repaired laparoscopically and she made an uneventful recovery. DISCUSSION: Obturator hernia is an uncommon condition and can have a varied presentation. Comprehensive review of literature demonstrates the difficulty in making accurate diagnosis. Open intervention was the initial gold standard of treatment but there is a growing body of evidence advocating for the use of laparoscopy in an emergency setting. CONCLUSION: Early diagnostic imaging with CT while a patient is symptomatic can aid in making an accurate diagnosis. Laparoscopic repair can be safely used with good outcome in the context of an incarcerated obturator hernia.

The importance of wearing a seatbelt correctly - A case report of blunt trauma causing complete shearing transection of the gastroduodenal junction.

INTRODUCTION: Global mortality as a result of road traffic accidents (RTA) has reduced significantly since mandatory implementation of seatbelts. Whilst seatbelt related injury, or "seatbelt syndrome," is a recognised phenomenon, unrestrained passengers have considerably worse survival outcomes. Improper positioning of seatbelts, as is discussed in the following case, can cause extensive injury. PRESENTATION OF CASE: Our patient is a 35-year-old female who was a restrained front seat passenger in a car vs. tree collision at 80 km/h. Her seat belt was worn with the shoulder strap under her left axilla. She sustained multiple injuries including complete transection of the gastroduodenal junction. In addition to this she had splenic, liver, transverse colonic, left lower rib and humeral injury. She underwent damage control laparotomy with splenectomy; re-look with gastrojejunostomy and transverse colonic resection with defunctioning ileostomy. She made a good recovery and was discharged after a 4 week admission. DISCUSSION: Improperly worn seatbelts redistribute decelerative forces to sensitive regions. A multidisciplinary approach is required to effectively manage complex multi-system trauma. In trauma the simplest reconstructive measures can be the most effective and minimise risk of further complications for the patient. CONCLUSION: Improperly worn seatbelts pose a significant risk to patients. A traumatic complete gastroduodenal transection can be effectively reconstructed with gastrojejunostomy anastomosis.

Emergency general surgery models in Australia: a cross-sectional study.

Objective Emergency general surgery (EGS) patients experience superior outcomes when cared for within an acute surgical unit (ASU) model. EGS structures in most Australian hospitals remain unknown. This study aimed to describe the national spectrum of EGS models. Methods A cross-sectional study was performed of all Australian public hospitals of medium or greater peer group (>2000 patient separations per annum). The primary outcome was the incidence of each EGS model. Secondary outcomes were the relationship of the EGS model to objective hospital variables, and qualitative reasons for the choice of model. Results Of the 120 eligible hospitals, 119 (99%) participated. Sixty-four hospitals reported using an ASU (28%) or hybrid EGS model (26%), whereas the remaining 55 (46%) used a traditional model. ASU implementation was significantly more common among hospitals of greater peer group, bed number, surgeon pool and trauma service sophistication. Leading drivers for ASU commencement were aims to improve patient care and decrease after-hours operating, whereas common barriers against uptake were insufficient EGS patient load or surgeon on-call pool. Conclusions ASU or hybrid models of care may be more widespread than currently reported. The introduction of such structures is heavily dependent on hospital and staff size, trauma subspecialisation and EGS patient throughput. What is known about the topic? Traditionally, general surgical staff were rostered to elective operating and clinic duties, with emergency patients managed on an ad hoc basis. An ASU model, with a surgeon dedicated to EGS patients, has been associated with superior outcomes. However, the Australian uptake of this model is unknown. What does this paper add? This study enrolled 119 of 120 (99%) Australian public hospitals of medium or greater peer group (>2000 patient separations per annum). Uptake of the ASU or hybrid model was more widespread than expected, existing in 64 of 119 (54%) centres. Factors for and against ASU implementation were also assessed. What are the implications for practitioners? Hospitals considering implementing an ASU or hybrid model will be reassured by the common reports of improved patient outcomes and decreased after-hours operating. However, potential hospitals must assess the suitability of the ASU model to their surgeon pool and EGS patient load.

Does emergency general surgery model affect staff satisfaction, training and working hours?

BACKGROUND: Few studies have assessed the relationship between different emergency general surgery models and staff satisfaction, operative experience or working hours. The Royal Australasian College of Surgeons recommends maximum on-call frequency of one-in-four for surgeons and registrars. METHODS: A cross-sectional study was conducted of all medium- to major-sized Australian public hospitals offering elective general surgery. At each site, an on-call general surgery registrar and senior surgeon were invited to participate. Primary outcomes were staff satisfaction and registrar-perceived operative exposure. Secondary outcomes were working hours. RESULTS: Among eligible hospitals, 119/120 (99%) were enrolled. Compared with traditional emergency general surgery models, hybrid or acute surgical unit models were associated with greater surgeon and registrar satisfaction on quantitative (P = 0.012) and qualitative measures. Registrar-perceived operating exposure was unaffected by emergency general surgery model. Longest duration on-duty was higher among traditional structures for both registrars (mean 22 versus 15 h; P = 0.0003) and surgeons (mean 59 versus 41 h; P = 0.020). On-call frequency greater than one-in-four was more common in traditional structures for registrars (51% versus 28%; P = 0.012) but not surgeons (6% versus 0%; P = 0.089). Data on average hours per day off-duty were obtained for registrars only, and were lower in traditional structures (13 versus 15 h; P = 0.00002). CONCLUSION: Hybrid or acute surgical unit models may improve staff satisfaction without sacrificing perceived operative exposure. While average maximum duration on-duty exceeded hazardous thresholds for surgeons regardless of model, unsafe working hours for registrars were more common in traditional structures. General surgical departments should review on-call rostering to optimize staff and patient safety.