Improving clinical reasoning and communication during handover: An intervention study of the BRIEF-C tool.

BACKGROUND: Existing handover communication tools often lack a clear theoretical foundation, have limited psychometric evidence, and overlook effective communication strategies for enhancing diagnostic reasoning. This oversight becomes critical as communication breakdowns during handovers have been implicated in poor patient care. To address these issues, we developed a structured communication tool: Background, Responsible diagnosis, Included differential diagnosis, Excluded differential diagnosis, Follow-up, and Communication (BRIEF-C). It is informed by cognitive bias theory, shows evidence of reliability and validity of its scores, and includes strategies for actively sending and receiving information in medical handovers. DESIGN: A pre-test post-test intervention study. SETTING: Inpatient internal medicine and orthopaedic surgery units at one tertiary care hospital. INTERVENTION: The BRIEF-C tool was presented to internal medicine and orthopaedic surgery faculty and residents who participated in an in-person educational session, followed by a 2-week period where they practised using it with feedback. MEASUREMENTS: Clinical handovers were audiorecorded over 1 week for the pre- and again for the post-periods, then transcribed for analysis. Two faculty raters from internal medicine and orthopaedic surgery scored the transcripts of handovers using the BRIEF-C framework. The two raters were blinded to the time periods. RESULTS: A principal component analysis identified two subscales on the BRIEF-C: diagnostic clinical reasoning and communication, with high interitem consistency (Cronbach's alpha of 0.82 and 0.99, respectively). One sample t-test indicated significant improvement in diagnostic clinical reasoning (pre-test: M=0.97, SD=0.50; post-test: M=1.31, SD=0.64; t(64)=4.26, p<0.05, medium to large Cohen's d=0.63) and communication (pre-test: M=0.02, SD=0.16; post-test: M=0.48, SD=0.83); t(64)=4.52, p<0.05, large Cohen's d=0.83). CONCLUSION: This study demonstrates evidence supporting the reliability and validity of scores on the BRIEF-C as good indicators of diagnostic clinical reasoning and communication shared during handovers.

Patient-Reported Experiences With Coronary Artery Bypass Grafting and Valve Replacement.

BACKGROUND: The Canadian Patient Experience Survey-Inpatient Care is a validated measure for adult inpatient experience. Linking surveys with administrative data can examine the experience of patients in specific demographic or clinical groups. METHODS: We examined survey responses obtained over a 4-year period from patients who underwent coronary artery bypass graft and/or valve replacement in Alberta. The 56-question telephone survey was administered within 6 weeks of discharge. Surveys were linked with administrative records to identify the Canadian Classification of Intervention procedure codes, which were in scope. Responses to each question were reported as percentage in "top box," where "top box" represents the most positive answer choice (eg, "always" and "yes"). RESULTS: From April 2014 to March 2018, 1082 surveys were completed by patients who underwent coronary artery bypass graft and/or valve replacement. Respondents were predominantly male (73.8%), with a mean age of 64.7 ± 11.9 years. Overall, 73.3% of respondents rated their hospital care as 9 or 10 out of 10 (best), and 86.2% would "definitely recommend" the hospital to friends/family members. Top performing questions pertained to having a discussion about help needed after discharge (96.6% responding "yes") and receiving written discharge information (93.2% responding "yes"). Lack of quietness of the hospital environment at night (34.8% responding "always") and lack of staff sufficiently describing side effects of new medications (44.9% responding "always") were identified as potential areas for improvement. CONCLUSIONS: Our results provide patient-reported experiences about inpatient cardiac care in Alberta hospitals. The findings could inform quality improvement initiatives that are patient-centred.

Outcomes of surgical treatment alone in patients with superficial soft tissue sarcoma regardless of size or grade.

BACKGROUND AND OBJECTIVES: Currently, standard treatment of soft tissue sarcoma (STS) is wide local excision and adjuvant radiation, but radiation may be unnecessary in superficial STS. The primary objective is to assess local recurrence rates in patients treated with surgical management alone for superficial STS. METHODS: A retrospective cancer registry review of patients treated with surgery alone for superficial STS at the Tom Baker Cancer Center (TBCC) was performed. Patient and tumor characteristics as well as recurrence data were collected. RESULTS: Sixty-one patients met study criteria. Local and overall recurrence rates were 7/61 (11.5%) and 12/61 (19.7%), respectively. The proportion with a T2 tumor was 38.8% versus 33.3% (P = 0.69), with Grade 2 or 3 tumors was 59.2% versus 83.3% (P = 0.14), and with resection margins <1 cm was 28.6% versus 75.0% (P = 0.008) for patients without and with recurrence, respectively. Median time to recurrence was 1.7 (0.4-5.2) years. CONCLUSIONS: Surgical resection alone appears to be a viable option for superficial STS that can save patients from potential side effects of radiation. The association between recurrence and inadequate margins (<1 cm) requires additional treatment be offered to this subset of patients.

Vertical Scar Breast Reduction: Does Gathering the Incision Matter?

BACKGROUND: The vertical scar bilateral breast reduction is a highly effective technique to reduce breast volume and create long-lasting aesthetic improvements. A cited disadvantage is the inability to adequately shorten the vertical scar, leading to chest wall scars or inframammary puckers. Gathering or cinching sutures have been described as a strategy to confront this issue. This article aims to determine if suture gathering is an effective methods to (1) reduce the incision length, (2) shorten the areola-to-inframammary fold (IMF) distance, and (3) reduce the pucker revision rate. METHODS: All patients undergoing vertical breast reduction performed by the senior author (E.H.F.) from 2001 to 2007 were included. The patient population was divided into "gather" and "no gather" groups depending on how the vertical incision was closed. RESULTS: There were 203 patients in the "no gather" group and 193 in the "gather" group. Age, body mass index, and resection weight were statistically but not clinically different. The percent reduction in vertical incision length was significantly greater in the "gather" group (34.2 ± 9.9% vs. 12.2 ± 5.9%). Both groups showed a gradual lengthening of areola-to-IMF distance postoperatively. Suture gathering had no impact on the pucker revision rate but increased healing complications. CONCLUSION: Gathering sutures significantly reduce the incision length in the operating room but do not change the areola-to-IMF distance or pucker revision rate. Gathering negatively influences skin vascularity and wound healing. It is acceptable and necessary to have a longer areola-to-IMF distance in a vertical reduction to accommodate increased projection.

The incidence of proximal deep vein thrombosis after elective hip arthroscopy: a prospective cohort study in low risk patients.

Prospectively assess the incidence of deep venous thrombosis (DVT) using Doppler Ultrasound, in patients receiving elective hip arthroscopy without pharmacologic/mechanical prophylaxis. One hundred and fifteen consecutive patients (mean 35.4 years, SD = 10.3) underwent elective hip arthroscopy. Patients with previous major risk factors for DVT were excluded. Signs/symptoms of DVT/pulmonary embolism were assessed at 2-week post-operatively. A bilateral whole leg Duplex color (Doppler) Ultrasonography was scheduled between 10- and 22-day post-op. The primary outcome was frequency of DVT. Secondary outcomes assessed surgical risk factors. One hundred and ten patients (mean = 34.3 years, SD = 10.1) did not get a DVT. Five patients (mean = 43.8 years, SD = 12.1) were diagnosed with a DVT, 2- to 22-day post-operatively. All DVT patients received arthroscopy in the supine position (n = 76), versus no patients in the lateral position (n = 39). Average traction time was 38 (SD = 4) and 61 (SD = 4) minutes for patients with and without a DVT, respectively. All other a priori defined risk factors were similar. Four out of five patients presented with symptoms of a DVT, confirmed by ultrasound. One patient was without symptoms/clinical findings. Four patients had a DVT restricted to the calf veins; one patient had involvement of the popliteal vein. No patients had proximal extension into the thigh or pelvis. No pulmonary emboli were suspected or occurred. The incidence of deep venous thromboembolism is 4.3%. The majority of patients had symptomatic and distal venous thromboembolic events. This study provides supportive evidence that routine prophylaxis and/or screening may not be necessary in low risk patients undergoing elective hip arthroscopy.

Systematic review of the quality of economic evaluations in the otolaryngology literature.

OBJECTIVE: To evaluate the quality of economic evaluations published in the otolaryngology--head and neck surgery literature, which will identify methodologic weaknesses that can be improved on in future studies. A secondary objective is to identify factors that may be associated with higher quality economic evaluations. DATA SOURCES: Ovid Medline (including PubMed), Embase, and the National Health Services Economic Evaluation databases. REVIEW METHODS: A systematic search was performed of the aforementioned databases according to PRISMA guidelines. The search was performed using otolaryngology key terms combined with the term cost. A manual search of 36 otolaryngology journals was also performed. Included studies were graded using the Quality of Health Economics Studies instrument, a 16-item checklist providing a total quality score of 100. RESULTS: Fifty studies were identified, and the mean quality rating was 54.7/100 (SD = 30.9). The most commonly omitted methodology components were a lack of discussion of limitations and biases, failure to address the negative outcomes of examined interventions, and a lack of a robust sensitivity analysis. Higher quality economic evaluations were associated with a higher journal impact factor (correlation coefficient r = 0.62, P = .0001), having an author with a PhD in health economics (r = 0.56, P = .0001), and having authors who have published prior economic evaluations (r = 0.46, P = .001). CONCLUSION: Results from this study have demonstrated that there are several methodological domains that can be improved on when publishing economic evaluations in the otolaryngology literature. Authors should follow recommended methodological and reporting guidelines to optimize the transparency and accuracy of the overall conclusions.

The effect of simulation in improving students' performance in laparoscopic surgery: a meta-analysis.

BACKGROUND: There is increasing interest in using simulators for laparoscopic surgery training, and simulators have rapidly become an integral part of surgical education. METHODS: We searched MEDLINE, EMBASE, Cochrane Library, and Google Scholar for randomized controlled studies that compared the use of different types of simulators. The inclusion criteria were peer-reviewed published randomized clinical trials that compared simulators versus standard apprenticeship surgical training of surgical trainees with little or no prior laparoscopic experience. Of the 551 relevant studies found, 17 trials fulfilled all inclusion criteria. The effect sizes (ES) with 95 % confidence intervals [CI] were calculated for multiple psychometric skill outcome measures. RESULTS: Data were combined by means of both fixed- and random-effects models. Meta-analytic combined effect size estimates showed that novice students who trained on simulators were superior in their performance and skill scores (d = 1.98, 95 % CI: 1.20-2.77; P < 0.01), were more careful in handling various body tissue (d = 1.08, 95 % CI: 0.36-1.80; P < 0.01), and had a higher accuracy score in conducting laparoscopic tasks (d = 1.38, 95 % CI: 0.30-2.47; P < 0.05). CONCLUSION: Simulators have been shown to provide better laparoscopic surgery skills training for trainees than the traditional standard apprenticeship approach to skill development. Surgical residency programs are highly encouraged to adopt the use of simulators in teaching laparoscopic surgery skills to novice students.