Correlation of Colorectal Surgical Skill With Patient Outcomes: A Cautionary Tale.

BACKGROUND: Previous work has demonstrated a correlation between video ratings of surgical skill and clinical outcomes. Some have proposed the use of video review for technical skill assessment, credentialing, and quality improvement. OBJECTIVE: Before its adoption as a quality measure for colorectal surgeons, we must first determine whether video-based skill assessments can predict patient outcomes among specialty surgeons. DESIGN: Twenty-one surgeons submitted one representative video of a minimally invasive colectomy. Each video was edited to highlight key steps and then rated by 10 peer surgeons using a validated American Society of Colon and Rectal Surgeons assessment tool. Linking surgeons' ratings to a validated surgical outcomes registry, we assessed the relationship between skill and risk-adjusted complication rates. SETTINGS: The study was conducted with the Michigan Surgical Quality Collaborative, a statewide collaborative including 70 community, academic, and tertiary hospitals. PATIENTS: Patients included those who underwent minimally invasive colorectal resection performed by the participating surgeons. MAIN OUTCOME MEASURES: Main outcome measures included 30-day risk-adjusted postoperative complications. RESULTS: The average technical skill rating for each surgeon ranged from 2.6 to 4.6. Risk-adjusted complication rate per surgeon ranged from 9.9% to 33.1%. Patients of surgeons in the bottom quartile of overall skill ratings were older and more likely to have hypertension or to smoke; patients of surgeons in the top quartile were more likely to be immunosuppressed or have an ASA score of 3 or higher. After patient- and surgery-specific risk adjustment, there was no statistically significant difference in complication rates between the bottom and top quartile surgeons (17.5% vs 16.8%, respectively, p = 0.41). LIMITATIONS: Limitations included retrospective cohort design with short-term follow-up of sampled cases. Videos were edited to highlight key steps, and reviewers did not undergo training to establish norms. CONCLUSIONS: Our study demonstrates that video-based peer rating of minimally invasive colectomy was not correlated with postoperative complications among specialty surgeons. As such, the adoption of video review for use in credentialing should be approached with caution. See Video Abstract at http://links.lww.com/DCR/B802.CORRELACIÓN ENTRE LA HABILIDAD QUIRÚRGICA COLORRECTAL Y LOS RESULTADOS OBTENIDOS EN EL PACIENTE: RELATO PRECAUTORIOANTECEDENTES:Trabajos anteriores han demostrado una correlación entre la video-calificación de la habilidad quirúrgica y los resultados clínicos. Algunos autores han propuesto el uso de la revisión de videos para la evaluación de la habilidad técnica, la acreditación y la mejoría en la calidad quirúrgica.OBJETIVO:Antes de su adopción como medida de calidad entre los cirujanos colorrectales, primero debemos determinar si las evaluaciones de habilidades basadas en video pueden predecir los resultados clínicos de los pacientes entre cirujanos especializados.DISEÑO:Veintiún cirujanos enviaron un video representativo de una colectomía mínimamente invasiva. Cada video fue editado para resaltar los pasos clave y luego fué calificado por 10 cirujanos revisores utilizando una herramienta de evaluación validada por la ASCRS. Al vincular las calificaciones de los cirujanos al registro de resultados quirúrgicos aprobado, evaluamos la relación entre la habilidad y las tasas de complicaciones ajustadas al riesgo.AJUSTE:Colaboración en todo el estado incluyendo 70 hospitales comunitarios, académicos y terciarios, el Michigan Surgical Quality Collaborative.PACIENTES:Todos aquellos sometidos a resección colorrectal mínimamente invasiva realizada por los cirujanos participantes.MEDIDA DE RESULTADO PRINCIPAL:Complicaciones posoperatorias ajustadas al riesgo a los 30 días.RESULTADOS:La calificación de la habilidad técnica promedio de cada cirujano osciló entre 2.6 y 4.6. La tasa de complicaciones ajustada al riesgo por cirujano osciló entre el 9,9% y el 33,1%. Los pacientes operados por los cirujanos del cuartil inferior de las calificaciones generales de habilidades eran fumadores y añosos, y tambiés más propensos a la hipertensión arterial. Los pacientes operados por los cirujanos del cuartil superior tenían más probabilidades de ser inmunosuprimidos o tener una puntuación ASA> = 3. Después del ajuste de riesgo específico de la cirugía y el paciente, no hubo diferencias estadísticamente significativas en las tasas de complicaciones entre los cirujanos del cuartil inferior y superior (17,5% frente a 16,8%, respectivamente, p = 0,41).LIMITACIONES:Diseño de cohortes retrospectivo con seguimiento a corto plazo de los casos muestreados. Los videos se editaron para resaltar los pasos clave y los revisores no recibieron capacitación para establecer normas.CONCLUSIONES:Nuestro estudio demuestra que la evaluación realizada por los revisores basada en el video de la colectomía mínimamente invasiva no se correlacionó con las complicaciones post-operatorias entre los cirujanos especialistas. Por tanto, la adopción de la revisión del video quirúrgico para su uso en la acreditación profesional, debe abordarse con mucha precaución. Consulte Video Resumen en http://links.lww.com/DCR/B802. (Traducción-Dr. Xavier Delgadillo).

Automatic and Objective Assessment of Motor Skills Performance in Flexible Bronchoscopy.

BACKGROUND: Motor skills have been identified as a useful measure to evaluate competency in bronchoscopy. However, no automatic assessment system of motor skills with a clear pass/fail criterion in flexible bronchoscopy exists. OBJECTIVES: The objective of the study was to develop an objective and automatic measure of motor skills in bronchoscopy and set a pass/fail criterion. METHODS: Participants conducted 3 bronchoscopies each in a simulated setting. They were equipped with a Myo Armband that measured lower arm movements through an inertial measurement unit, and hand and finger motions through electromyography sensors. These measures were composed into an objective and automatic composite score of motor skills, the motor bronchoscopy skills score (MoBSS). RESULTS: Twelve novices, eleven intermediates, and ten expert bronchoscopy operators participated, resulting in 99 procedures available for assessment. MoBSS was correlated with a higher diagnostic completeness (Pearson's correlation, r = 0.43, p < 0.001) and a lower procedure time (Pearson's correlation, r = -0.90, p < 0.001). MoBSS was able to differentiate operator performance based on the experience level (one-way ANOVA, p < 0.001). Using the contrasting groups' method, a passing score of -0.08 MoBSS was defined that failed 30/36 (83%) novice, 5/33 (15%) intermediate, and 1/30 (3%) expert procedures. CONCLUSIONS: MoBSS can be used as an automatic and unbiased assessment tool for motor skills performance in flexible bronchoscopy. MoBSS has the potential to generate automatic feedback to help guide trainees toward expert performance.

Impact of surgeon work duration prior to distal pancreatectomy on perioperative outcomes: a propensity score matching analysis.

BACKGROUND: Surgeons are likely to get progressively fatigued during the course of a normal workday. The objective of this study was to evaluate the impact of surgeon work duration prior to performing distal pancreatectomy (DP) on the perioperative outcome, especially frequency of grade II or higher grade postoperative complications. METHODS: Patients undergoing DP for all causes were divided into two groups according to surgeon work hours prior to performing DP: group A (less than 5 h) and group B (5-10 h). Propensity score matching (PSM) analysis (1:1) were performed to balance the baseline characteristics between the two groups. Intraoperative complications were compared between the two groups. Postoperative complications and their severity were followed up for 60 days and mortality for 90 days. The study was powdered to identify a 15% difference in the incidence of grade II or higher grade complications. RESULTS: By using PSM analysis, the patients in group A (N = 202) and group B (N = 202) were well matched regarding demographics, comorbidities, operative technique, pancreatic texture and pathology. There was no significant difference in the incidence of grade II or higher grade complications between the two groups. There was no difference in clinically relevant postoperative pancreatic fistula, percutaneous drainage, readmission, reoperation, or morality. Group B was associated with a higher incidence of intraoperative organ injury, which could be managed successfully during the operation. CONCLUSION: The retrospective study demonstrated that the surgeon work duration did not significantly affect the clinical outcome of DP.

Maintaining High Professional Standards, morally, ethically and fairly: what doctors need to know right now.

Facing an investigation into performance concerns can be one of the most traumatic events in a doctor's career, and badly handled investigations can lead to severe distress. Yet there is no systematic way for National Health Service (NHS) Trusts to record the frequency of investigations, and extremely little data on the long-term outcomes of such action for the doctors. The document-Maintaining High Professional Standards in the Modern NHS (a framework for the initial investigation of concerns about doctors and dentists in the NHS)-should protect doctors from facing unfair or mismanaged performance management procedures, which include conduct, capability and health. Equally, it provides NHS Trusts with a framework that must be adhered to when managing performance concerns regarding doctors. Yet, very few doctors have even heard of it or know about the provisions it contains for their protection, and the implementation of the framework appears to be very variable across NHS Trusts. By empowering all doctors with the knowledge of what performance management procedures exist and how best practice should be implemented, we aim to ensure that they are informed participants in any investigation should it occur.

Disentangling the Relationship between Physician and Organizational Performance: A Signal Detection Approach.

Background. In previous research, we employed a signal detection approach to measure the performance of general practitioners (GPs) when deciding about urgent referral for suspected lung cancer. We also explored associations between provider and organizational performance. We found that GPs from practices with higher referral positive predictive value (PPV; chance of referrals identifying cancer) were more reluctant to refer than those from practices with lower PPV. Here, we test the generalizability of our findings to a different cancer. Methods. A total of 252 GPs responded to 48 vignettes describing patients with possible colorectal cancer. For each vignette, respondents decided whether urgent referral to a specialist was needed. They then completed the 8-item Stress from Uncertainty scale. We measured GPs' discrimination (d') and response bias (criterion; c) and their associations with organizational performance and GP demographics. We also measured correlations of d' and c between the 2 studies for the 165 GPs who participated in both. Results. As in the lung study, organizational PPV was associated with response bias: in practices with higher PPV, GPs had higher criterion (b = 0.05 [0.03 to 0.07]; P < 0.001), that is, they were less inclined to refer. As in the lung study, female GPs were more inclined to refer than males (b = -0.17 [-0.30 to -0.105]; P = 0.005). In a mediation model, stress from uncertainty did not explain the gender difference. Only response bias correlated between the 2 studies (r = 0.39, P < 0.001). Conclusions. This study confirms our previous findings regarding the relationship between provider and organizational performance and strengthens the finding of gender differences in referral decision making. It also provides evidence that response bias is a relatively stable feature of GP referral decision making.

Risk Adjustment of the Modified Low Back Pain Disability Questionnaire and Neck Disability Index to Benchmark Physical Therapist Performance: Analysis From an Outcomes Registry.

BACKGROUND: Patient-reported outcomes (PROs) have been touted as the ultimate assessment of quality medical care and have been proposed as performance measures after appropriate risk adjustment. Although spine conditions represent the most common orthopedic disorders, the most used PROs for disabilities related to the back and neck-the Modified Low Back Pain Disability Questionnaire (MDQ) and the Neck Disability Index (NDI)-have not been evaluated as performance measures. OBJECTIVE: The objective of this study was to benchmark physical therapists' performance in the management of spine conditions not involving surgery through the use of risk-adjusted MDQ and NDI outcomes. DESIGN: This was a retrospective observational study. METHODS: Data were accessed for patients seeking physical therapy with no history of related surgery for back or neck pain (315,274 treatment episodes) between January 2015 and June 2018. Patients with complete data, including initial and matched final MDQ or NDI, were considered for analysis (182,276 patients; 2799 physical therapists). Linear models controlling for baseline PRO and patient characteristics predicted PRO change for each patient. An aggregated performance ratio of actual PRO change to predicted PRO change was calculated for each physical therapist, and then empirical bootstrapping was used to develop the median performance ratio and its confidence intervals. Physical therapists who met a 40-patient threshold for either cohort (MDQ or NDI) were classified as "outperforming," "meeting expectations," or "underperforming" relative to predicted values using these 95% confidence intervals. RESULTS: Performance ratios indicated that 10% and 11% of physical therapists outperformed, 79% and 78% met expectations, and 11% and 11% underperformed relative to the risk-adjusted predicted change in the MDQ (1240 therapists; 97,908 patients) and NDI (461 therapists; 26,123 patients), respectively. To demonstrate the clinical importance of risk adjustment, clinical performance was evaluated in the seemingly homogeneous subset of 208 physical therapists within 0.5 SD of the median baseline MDQ and the median actual change in the MDQ. Following risk adjustment, 2 physical therapists were classified in each of the outperforming and underperforming cohorts. LIMITATIONS: The secondarily obtained observational data used were not collected for research purposes. Additionally, the analyses were limited by missing baseline information and follow-up PROs. CONCLUSIONS: The risk-adjusted performance ratios for the MDQ and NDI resulted in disparate conclusions regarding the quality of care compared with the raw, unadjusted change scores. According to the baseline and unadjusted change in the MDQ, even physical therapists in the most homogeneous sample were differentiated following appropriate risk adjustment. Clinically important improvements in actual PROs were observed in the outperforming but not in the underperforming physical therapists. Clinically meaningful differences in the performance ratio are unknown and are a limitation to clinical application and an opportunity for future research.

Performance Optimization Strategies for Complex Endourologic Procedures.

OBJECTIVE: To identify and address factors that may impact a surgeon's performance during endourologic procedures. METHODS: A literature review was performed for articles focusing on surgical ergonomics, education, sports and performance psychology. RESULTS: As urologists and trainees have become more comfortable approaching complex pathology endoscopically, there remains an opportunity to refine surgeon-related factors and optimize extrinsic factors to maximize efficiency and provide patients with the highest quality outcomes and safety. CONCLUSION: Medical centers and training programs should strive to include formal lessons on stress-coping mechanisms, communication, and dedicated ergonomic training, as these all play a role in physician well-being and may lead to improved clinical outcomes.

Influencia de la calidad de vida laboral sobre el desempeño de trabajadores de hospitales públicos de México: una visión desde la gestión directiva / Influence of the labor quality of life on the employee performance of public hospitals from Mexico: a vision based on the team management

Resumen: Objetivo: Evaluar la relación entre calidad de vida laboral (CVL) y el desempeño organizacional (DO) de trabajadores de siete hospitales públicos, a partir del análisis de la influencia de la gestión directiva (GD) como mediadora de esta relación. Material y métodos: Se realizó un estudio transversal en 866 profesionales y directivos de hospitales públicos de Tlaxcala y de la Ciudad de México. La CVL fue medida con un instrumento validado, el DO con 34 indicadores y la GD con un instrumento diseñado para este estudio. Resultados: Los puntajes de gestión directiva, CVL, DO y GD fueron significativamente menores en los trabajadores de Tlaxcala. Los participantes que percibieron adecuada GD incrementaron 2.7 veces más la probabilidad de percibir elevada CVL y los participantes categorizados en elevada CVL presentaron 69% mayor probabilidad de tener adecuado DO. Conclusiones: La adecuada GD se asoció con una mejor CVL, lo que mostró ser una variable mediadora de la relación positiva entre CVL y DO.

Abstract: Objective: To assess the relationship between labor quality of life (LQL) and organizational workers performance (OWP) from seven public hospitals, analyzing the influence of the personnel management (PM) as mediator of this relationship. Materials and methods: A cross-sectional study was conducted in 866 professionals and managers of public hospitals from Tlaxcala and Mexico City. The LQL was assessed with a validated questionnaire, OWP with 34 indicators, and PM with an instrument designed for this study. Results: Mean scores of LQL, were significantly lower among workers from Tlaxcala. Participants who perceived an adequate PM, they increased at 2.7 times their likelihood of having highest LQL, and participants categorized in the high LQL presented 69% higher likelihood of having an adequate OWP. Conclusions: The appropriate PM was associated with greater LQL, showing to be a mediator variable between the positive relationship of CVL and the OWP.

Professional burnout, work patterns and career satisfaction in medical oncologists in Ireland.

BACKGROUND: Burnout is an occupational syndrome frequently encountered within the healthcare profession. It is characterised by emotional exhaustion (EE), depersonalisation (DP) and a low sense of personal accomplishment (PA). Its negative impact extends to the physician, patient and overall service provision. AIMS: The aim of this study was to evaluate work patterns, the prevalence of burnout and its associations in medical oncology consultants and specialist registrars (SpRs) in Ireland. METHODS: Participants were invited to partake in an anonymised online survey. Burnout domains were measured using the validated Maslach Burnout Inventory. Associations between variables were evaluated using the Mann-Whitney U and Kruskal-Wallis tests (continuous), and chi-square and Fisher's exact testing (categorical). RESULTS: Seventy-four physicians were contacted to participate, 44 (59%) completed the survey. The majority (71%) work ≥ 50 h a week, with 57% having additional on-call commitments of ≥ 5 days/month. Burnout is defined by a high score in EE combined with a high DP and/or low PA was identified in 45% of consultants and 20% of SpRs. Longer working hours (≥ 60 h/ week) were found to be associated with both high EE (p = 0.049) and DP (p = 0.019). Higher EE scores were demonstrated in those ≥ 40 years (p = 0.04). The majority (86%) reported they would become an oncologist again. CONCLUSION: One or more of the symptoms of burnout is highly prevalent in medical oncologists in Ireland. With increasing pressure on resources, burnout is expected to increase. Attention to strategies for prevention needs to be prioritised within our healthcare system.

Implication of the training ad continuing education process for the interprofessional performance / Implicación del proceso de formácion e educación continua para la actuación interprofesional / Implicação do processo de formação e educação permanente para atuação interprofissional

ABSTRACT Objetives: to analyze the implication of the training/continuing education process of professionals of the Expanded Nucleus of Family Health and Basic Care (Portuguese acronym: Nasf-AB) for their interprofessional performance. Methods: a qualitative case study performed with Nasf-AB teams representative of four macro-regions of health of the state of Santa Catarina. Participation of 43 professionals, who answered collective interviews. The results were later submitted to thematic analysis. Results: the training is strongly influenced by the Biomedical Model, which acts as an obstacle to interprofessional performance, given the challenges in the daily routine of Nasf-AB professionals. Continuing education emerges as a potential for the successful collaborative work among teams, and between the teams and Family Health professionals. Final considerations: there are important limits in the training of professionals. However, the constant interprofessional development promoted by strategies of continuing education contributes to broaden the support and collaborative practices that qualify services and strengthen Basic Care.

RESUMEN Objetivos: analizar la implicación del proceso de formación/educación continua de los profesionales del Núcleo Ampliado de Salud de la Familia y Atención Básica (Nasf-AB) en su actuación interprofesional. Métodos: estudio de caso cualitativo realizado con equipos de Nasf-AB representativos de cuatro Macroregiones de Salud del Estado de Santa Catarina. Participación de 43 profesionales que respondieron a entrevistas colectivas. Los resultados fueron posteriormente sometidos al análisis temático. Resultados: hubo notable influencia del Modelo Biomédico en la formación, que funciona como obstáculo para la actuación interprofesional frente a los desafíos en el cotidiano del Nasf-AB. La educación continua emerge como potencia para el éxito del trabajo colaborativo entre los equipos, y de los equipos con los profesionales de la Salud de la Familia. Consideraciones finales: hay límites importantes en la formación de los profesionales. Sin embargo, el desarrollo interprofesional constante promovido por las estrategias de educación continua contribuye a ampliar el apoyo y las prácticas colaborativas que califican los servicios y fortalecen la Atención Básica.

RESUMO Objetivos: analisar a implicação do processo de formação/educação permanente dos profissionais do Núcleo Ampliado de Saúde da Família e Atenção Básica (Nasf-AB) para a sua atuação interprofisisonal. Métodos: estudo de caso de abordagem qualitativa, realizado com equipes de Nasf-AB representativas de quatro Macrorregiões de Saúde do Estado de Santa Catarina. Participação de 43 profissionais que responderam entrevistas coletivas. Os resultados foram posteriormente submetidos à análise temática. Resultados: identificou-se marcante influência do Modelo Biomédico na formação, que funciona como obstáculo para a atuação interprofissional frente aos desafios no cotidiano do Nasf-AB. A educação permanente emerge, marcantemente, como potência para o sucesso do trabalho colaborativo entre as equipes e destas com os profissionais da Saúde da Família. Considerações finais: há limites importantes na formação dos profissionais. Contudo, o desenvolvimento interprofissional constante promovido pelas estratégias de educação permanente contribui para ampliar o apoio e as práticas colaborativas que qualificam os serviços e fortalecem a Atenção Básica.

The effects of playing music during surgery on the performance of the surgical team: A systematic review.

BACKGROUND: Music is an economical, advantageous and reliable means of reducing stress or stress-related problems. OBJECTIVE: The present study aims to evaluate the effects of playing music during surgery on the performance of the surgical team through a systematic review of published studies. METHODS: The relevant databases of Medline/PubMed, Scopus and Science Direct were searched up to July 2018 to find related articles. The comprehensive literature search was reduced to 19 articles that met inclusion criteria. RESULTS: The articles comprised 13 studies and reported on the positive effects of music on the performance of the surgical team. The effects included a more relaxing and pleasant environment, more accurate and precise performance of tasks, a decrease in the mental workload and task completion time, increased situation awareness, a reduction in stress and anxiety and improved memory consolidation. Five studies reported on the negative effects of music during surgery as being a negative impact on task completion, poor auditory performance and increased likelihood of having to repeat requests. The remaining article reported no significant differences between groups compared. CONCLUSIONS: Most studies reported positive effects of music on the surgical team during surgery. These results indicate that it may be possible to improve the performance of the surgical team during surgery while playing controlled music.

A tool to improve the performance of multidisciplinary teams in cancer care.

Introduction: While multidisciplinary teams (MDTs) are well established in many healthcare institutions, both how they function and their role in decision-making vary widely. This study adopted an innovative methodology to assess multidisciplinary team performance and engage teams in performance improvement strategies. Methods: The study comprised a survey to evaluate MDT members' perceptions of their team's performance before the implementation of the programme and annually thereafter, and a maturity matrix designed as a self-assessment tool. Each MDT used the matrix to collectively assess its performance and identify areas for improvement. Results: In the first cycle, 180 member surveys from 19 MDTs were completed. This provided insights into team members' perceptions of performance. 12 of these teams continued with the study and all 12 completed the matrix. Most teams rated themselves at level one or two (low) on a scale of five for most items. Conclusions: The MDT survey and maturity matrix have the potential to be useful for cancer care teams to identify their strengths and weaknesses and monitor performance over time and also for management to review its performance against standard criteria and to identify priority areas for improvement and further support.

Design and recruitment of the randomized order safety trial evaluating resident-physician schedules (ROSTERS) study.

INTRODUCTION: While the Accreditation Council for Graduate Medical Education limited first year resident-physicians to 16 consecutive work hours from 2011 to 2017, resident-physicians in their second year or higher were permitted to work up to 28 h consecutively. This paper describes the Randomized Order Safety Trial Evaluating Resident-physician Schedules (ROSTERS) study, a clustered-randomized crossover clinical trial designed to evaluate the effectiveness of eliminating traditional shifts of 24 h or longer for second year or higher resident-physicians in pediatric intensive care units (PICUs). METHODS: ROSTERS was a multi-center non-blinded trial in 6 PICUs at US academic medical centers. The primary aim was to compare patient safety between the extended duration work roster (EDWR), which included shifts ≥24 h, and a rapidly cycling work roster (RCWR), where shifts were limited to a maximum of 16 h. Information on potential medical errors was gathered and used for classification by centrally trained physician reviewers who were blinded to the study arm. Secondary aims were to assess the relationship of the study arm to resident-physician sleep duration, work hours and neurobehavioral performance. RESULTS: The study involved 6577 patients with a total of 38,821 patient days (n = 18,749 EDWR, n = 20,072 RCWR). There were 413 resident-physician rotations included in the study (n = 203 EDWR, n = 210 RCWR). Resident-physician questionnaire data were over 95% complete. CONCLUSIONS: Results from data collected in the ROSTERS study will be evaluated for the impact of resident-physician schedule roster on patient safety outcomes in PICUs, and will allow for examination of a number of secondary outcome measures. ClinicalTrials.gov Identifier: NCT02134847.

Effective Implementation of Peri-operative Local Guidelines for Metabolic Surgery in Patients with Diabetes Mellitus in a Tier 4 Setting Demonstrate Improved Work Efficiency and Resource Allocation.

BACKGROUND: Dynamic changes in glycaemia predominate peri-operatively in patients with type 2 diabetes mellitus (T2DM) undergoing metabolic surgery. There is a lack of consensus and clear guidance on effective glycaemic management of such patients. The aim of this study was to design, pilot, and implement a proforma to improve consistency of glycaemic management and clarity of communication with healthcare professionals following metabolic surgery in patients with T2DM, thereby reducing unnecessary diabetes specialist nurse (DSN) referrals. METHODS: A proforma was designed and piloted for 12 months to guide healthcare professionals on managing glycaemic therapies for T2DM patients undergoing metabolic surgery. Glycaemic control (HbA1c) and glycaemic therapies were reviewed 3 weeks pre-operatively and a proforma was completed accordingly. RESULTS: Of the patients with T2DM (n = 34) who underwent metabolic surgery prior to the new proforma being implemented, 71% (n = 24) had a DSN referral. Half of these referrals were deemed unnecessary by the DSNs. Of the patients with T2DM (n = 33) who underwent metabolic surgery following implementation of the proforma, 21% (n = 7) had a DSN referral. Only 10% of these were deemed unnecessary. Despite the reduced DSN input, no diabetes-related complications were reported. CONCLUSION: Implementation of our proforma effectively halved the proportion of patients with T2DM requiring a DSN referral. Additionally, there was a 40% absolute reduction in the proportion of unnecessary DSN referrals. The proforma improved clarity of communication and guidance for healthcare professionals in the glycaemic management of patients. This also facilitated improved work efficiency and resource allocation.

Using clinical analysis to classify 30-day trauma readmissions.

BACKGROUND: Unplanned hospital readmissions are common across specialties. Descriptive readmission studies commonly query large administrative databases, which some speculate lack clinical granularity. This article provides the framework for a process improvement initiative aimed at identifying clinically meaningful reasons for trauma readmission. Our study hypothesizes an expected difference between the clinically abstracted reasons for readmission and those documented by the data processing staff in the trauma registry and that those differences will be the starting point to target performance improvement. METHODS: This is a retrospective, cohort study from 2014 to 2016 involving 18,998 trauma evaluations at a Level I trauma center. The systematic categorization of trauma readmissions was completed via clinical chart review. Readmissions were categorized following an organizational flowchart. The chart reviews ultimately resulted in two readmission categories: primary and secondary reasons for 30-day trauma readmission. RESULTS: There were 413 readmissions, an overall readmission rate of 2.7%. The highest rate of readmission, by mechanism of injury, was gunshot wounds (11%). Secondary reasons for readmission predominated (76.1%). Complications led (41%), followed by observation (8.8%) and pain (8.6%). Following readmission chart review and categorization, the trauma registry data were queried and categorized via the same method. When the two methods of data collection were compared, there was a significant difference (p < 0.0001). CONCLUSIONS: The granular dissection of readmission charts proved to assist in isolating clinically significant readmission variables, providing clarity into the reasons behind trauma readmission. If determined solely by the trauma registry data, our performance and quality improvement initiatives would be misguided. We recommend clinical oversight of databases, with clinical review of key areas in order to guide performance improvement.

Health- and Performance-Related Outcomes in Air Force Medical Service Personnel with a Post-Deployment Mental Health Condition.

Background: This study examined associations between incident post-deployment mental health (PDMH) conditions and health- and performance-related outcomes in the population of Air Force Medical Service personnel on active duty between 2003 and 2013 who had at least one deployment. Methods: Using a posttest-only with nonequivalent groups design, the study cohort was divided into two groups based on the occurrence of an incident PDMH condition, and the groups were then compared in terms of the following health- and performance-related outcomes: health care and pharmaceutical utilization, duty and mobility restrictions, and physical fitness assessment exemptions and composite fitness score. Archival data were extracted from existing databases and associations were assessed using both parametric and nonparametric approaches. Results: The cohort comprised 12,216 participants, from which subcohorts were drawn to assess specific outcome measures. Participants with an incident PDMH used health care at 1.8 times the rate and were 6.2 times more likely to be classified as a high utilizer of health care as compared with those without a PDMH condition (controls). They were 2.1-103.0 times more likely to be prescribed one of 22 therapeutic classes of medication and were 2.4 times more likely to have polypharmacy than controls. They were 2.5 times more likely to have a duty or mobility restriction, and the ratio of days spent with a restriction to days without a restriction was 1.8 times that of controls. Lastly, they were 2.4 times more likely to have a physical fitness assessment exemption, but there was no significant difference in the likelihood of a composite fitness score of <90 points. Conclusions: The presence of an incident PDMH condition was associated with increased health care and pharmaceutical utilization and decreased occupational performance as assessed in terms of restricted duty status and participation in physical fitness assessments.

Factors related to teamwork performance and stress of operating room nurses.

AIM: To evaluate operating room nurses' perception of teamwork performance and their level of mental stress and to identify related factors. BACKGROUND: Little is known about the factors affecting teamwork and the mental stress of surgical nurses, although the performance of the surgical team is essential for patient safety. METHODS: The questionnaire survey for operation room nurses consisted of simple questions about teamwork performance and mental stress. Multivariate analyses were used to identify factors causing a sense of teamwork performance or mental stress. RESULTS: A large number of surgical nurses had a sense of teamwork performance, but 30-40% of operation room nurses were mentally stressed during surgery. Neither the patient nor the operation factors were related to the sense of teamwork performance in both types of nurses. Among scrub nurses, endoscopic and abdominal surgery, body mass index, blood loss and the American Society of Anesthesiologists physical status class were related to their mental stress. Conversely, circulating nurses were stressed about teamwork performance. CONCLUSIONS: The factors related to teamwork performance and mental stress during surgery differed between scrub and circulating nurses. IMPLICATIONS FOR NURSING MANAGEMENT: Increased support for operation room nurses is necessary. The increased support leads to safer surgical procedures and better patient outcomes.

Burnout syndrome in nurses working in palliative care units: An analysis of associated factors.

AIMS: To analyse the association between psychological, labour and demographic factors and burnout in palliative care nursing. BACKGROUND: There is a lack of published research evaluating burnout in palliative care nursing. METHODS: This observational cross-sectional study involved 185 palliative care nurses in Mexico. The primary variables were burnout defined by its three dimensions (emotional exhaustion, depersonalization and personal accomplishment). As secondary variables, psychological, labour and demographic factors were considered. A binary logistic regression model was constructed to determine factors associated with burnout. RESULTS: A total of 69 nurses experienced high emotional exhaustion (37.3%), 65 had high depersonalization (35.1%) and 70 had low personal performance (37.8%). A higher proportion of burnout was found in the participants who were single parents, working >8 hr per day, with a medium/high workload, a lack of a high professional quality of life and a self-care deficit. CONCLUSION: Our multivariate models were very accurate in explaining burnout in palliative care nurses. These models must be externally validated to predict burnout and prevent future complications of the syndrome accurately. IMPLICATIONS FOR NURSING MANAGEMENT: Nurses who present the factors found should be the focus of interventions to reduce work stress.

Interactional Resources for Quality Improvement: Learning From Participants Through a Qualitative Study.

BACKGROUND: Implementing quality improvement in hospitals requires a multifaceted commitment from leaders, including financial, material, and personnel resources. However, little is known about the interactional resources needed for project implementation. The aim of this analysis was to identify the types of interactional support hospital teams sought in a surgical quality improvement project. METHODS: Hospital site visits were conducted using a combination of observations, interviews, and focus groups to explore the implementation of a surgical quality improvement project. Twenty-six site visits were conducted between October 2012 and August 2014 at a total of 16 hospitals that agreed to participate. All interviews were recorded, transcribed, and coded for themes using inductive analysis. RESULTS: We interviewed 321 respondents and conducted an additional 28 focus groups. Respondents reported needing the following types of interactional support during implementation of quality improvement interventions: (1) a critical outside perspective on their implementation progress; (2) opportunities to learn from peers, especially around clinical innovations; and (3) external validation to help establish visibility for and commitment to the project. CONCLUSIONS: Quality improvement in hospitals is both a clinical endeavor and a social endeavor. Our findings show that teams often desire interactional resources as they implement quality improvement initiatives. In-person site visits can provide these resources while also activating emotional energy for teams, which builds momentum and sustainability for quality improvement work. IMPLICATIONS: Policymakers and quality improvement leaders will benefit from developing strategies to maximize interactional learning and feedback for quality improvement teams. Further research should investigate the most effective methods for meeting these needs.