Defining Practice Readiness in Pediatric Surgery Fellowship: A Qualitative Analysis.

INTRODUCTION: While competency-based training is at the forefront of educational innovation in General Surgery, Pediatric Surgery training programs should not wait for downstream changes. There is currently no consensus on what it means for a pediatric surgery fellow to be "practice-ready". In this study, we aimed to provide a framework for better defining competency and practice readiness in a way that can support the Milestones system and allow for improved assessment of pediatric surgery fellows. METHODS: For this exploratory qualitative study, we developed an interview guide with nine questions focused on how faculty recognize competency and advance autonomy among pediatric surgery fellows. Demographic information was collected using an anonymous online survey platform. We iteratively reviewed data from each interview to ensure adequate information power was achieved to answer the research question. We used inductive reasoning and thematic analysis to determine appropriate codes. Additionally, the Dreyfus model was used as a framework to guide interpretation and contextualize the responses. Through this method, we generated common themes. RESULTS: A total of 19 pediatric surgeons were interviewed. We identified four major themes from 127 codes that practicing pediatric surgeons associate with practice-readiness of a fellow: skill-based competency, the recognition and benefits of struggle, developing expertise and facilitating autonomy, and difficulties in variability of evaluation. While variability in evaluation is not typically included in the concept of practice readiness, assessment and evaluation were described by study participants as essential aspects of how practicing pediatric surgeons perceive practice readiness and competency in pediatric surgery fellows. Competency was further divided into interpersonal versus technical skills. Sub-themes within struggle included personal and professional struggle, benefits of struggle and how to identify and assist those who are struggling. Autonomy was commonly stated as variable based on the attending. CONCLUSION: Our analysis yielded several themes associated with practice readiness of pediatric surgery fellows. We aim to further refine our list of themes using the Dreyfus Model as our interpretive framework and establish consensus amongst the community of pediatric surgeons in order to define competency and key elements that make a fellow practice-ready. Further work will then focus on establishing assessment metrics and educational interventions directed at achieving such key elements.

Insights from linking police domestic abuse data and health data in South Wales, UK: a linked routine data analysis using decision tree classification.

BACKGROUND: Exposure to domestic abuse can lead to long-term negative impacts on the victim's physical and psychological wellbeing. The 1998 Crime and Disorder Act requires agencies to collaborate on crime reduction strategies, including data sharing. Although data sharing is feasible for individuals, rarely are whole-agency data linked. This study aimed to examine the knowledge obtained by integrating information from police and health-care datasets through data linkage and analyse associated risk factor clusters. METHODS: This retrospective cohort study analyses data from residents of South Wales who were victims of domestic abuse resulting in a Public Protection Notification (PPN) submission between Aug 12, 2015 and March 31, 2020. The study links these data with the victims' health records, collated within the Secure Anonymised Information Linkage databank, to examine factors associated with the outcome of an Emergency Department attendance, emergency hospital admission, or death within 12 months of the PPN submission. To assess the time to outcome for domestic abuse victims after the index PPN submission, we used Kaplan-Meier survival analysis. We used multivariable Cox regression models to identify which factors contributed the highest risk of experiencing an outcome after the index PPN submission. Finally, we created decision trees to describe specific groups of individuals who are at risk of experiencing a domestic abuse incident and subsequent outcome. FINDINGS: After excluding individuals with multiple PPN records, duplicates, and records with a poor matching score or missing fields, the resulting clean dataset consisted of 8709 domestic abuse victims, of whom 6257 (71·8%) were female. Within a year of a domestic abuse incident, 3650 (41·9%) individuals had an outcome. Factors associated with experiencing an outcome within 12 months of the PPN included younger victim age (hazard ratio 1·183 [95% CI 1·053-1·329], p=0·0048), further PPN submissions after the initial referral (1·383 [1·295-1·476]; p<0·0001), injury at the scene (1·484 [1·368-1·609]; p<0·0001), assessed high risk (1·600 [1·444-1·773]; p<0·0001), referral to other agencies (1·518 [1·358-1·697]; p<0·0001), history of violence (1·229 [1·134-1·333]; p<0·0001), attempted strangulation (1·311 [1·148-1·497]; p<0·0001), and pregnancy (1·372 [1·142-1·648]; p=0·0007). Health-care data before the index PPN established that previous Emergency Department and hospital admissions, smoking, smoking cessation advice, obstetric codes, and prescription of antidepressants and antibiotics were associated with having a future outcome following a domestic abuse incident. INTERPRETATION: The results indicate that vulnerable individuals are detectable in multiple datasets before and after involvement of the police. Operationalising these findings could reduce police callouts and future Emergency Department or hospital admissions, and improve outcomes for those who are vulnerable. Strategies include querying previous Emergency Department and hospital admissions, giving a high-risk assessment for a pregnant victim, and facilitating data linkage to identify vulnerable individuals. FUNDING: National Institute for Health Research.

Not Just Bystanders: A Qualitative Study on the Vicarious Effects of Surgical Training on the Wellness of Support Persons for Trainees.

OBJECTIVE: To obtain insights into the effects of surgical training on the well-being of support persons. SUMMARY BACKGROUND DATA: Surgical trainee wellness is a critical priority among surgical educators and leaders. The impact of surgical training on the wellness of loved ones who support trainees has not been previously studied. METHODS: This qualitative study employs semi-structured interviews of 32 support persons of surgical trainees at a single tertiary care center with multiple surgical specialty training programs. Interviews focused on perceptions about supporting a surgical trainee. Transcripts underwent thematic analysis with semantic and conceptual coding. Key themes regarding the effects that caring for a trainee has on support persons are reported. RESULTS: Three key themes were identified: (1) Sacrifices-support persons report significant tangible and intangible sacrifices, (2) Delaying life-life is placed on hold to prioritize training, and (3) A disconnect-there is a disconnect and a lack of recognition of support person needs that require greater awareness and targeted interventions. CONCLUSIONS: The impact of surgical training can extend beyond trainees and can affect the wellness of their support persons who endure the effects of training alongside trainees. Programs should be aware of these effects and develop meaningful strategies to aid trainees and their support persons.

Comparing cognitive assessment service provision between Aboriginal and Torres Strait Islanders and non-Indigenous Australians at a metropolitan health service.

OBJECTIVE: Aboriginal and Torres Strait Islander populations are at a significantly higher risk of neurological and cognitive impairment from a range of aetiologies. In order to better identify and support Indigenous Australians with cognitive impairment, culturally appropriate screening, management and referral processes are critical. The primary aim of this study was to investigate the frequency of presentations and type of cognitive screening conducted with Indigenous Australians presenting to health services. METHODS: Hospital data for 30 Indigenous Australians presenting with neurological symptoms to Emergency Departments within a large metropolitan health service were compared with a group of 30 non-Indigenous, Australian-born, English-speaking, age-, gender- and diagnosis-matched individuals. RESULTS: Only two individuals, one from each group, received cognitive screening. This was likely related to a surprisingly large proportion of Indigenous Australians presenting to hospital with headache and migraine. Significantly more Indigenous Australians (36.7%) were consulted by a member of the multidisciplinary team compared to 10% of the non-Indigenous group. No differences in follow-up referrals were observed. CONCLUSIONS: Results indicated a lack of cognitive screening practices being undertaken in both groups. It was encouraging to see Indigenous Australians receiving consultations from multidisciplinary team members at a higher rate, with a similar follow-up pathway being observed. This study further highlights the need for adoption of screening practices in primary health care settings and the development and use of culturally appropriate cognitive screening measures. SO WHAT?: This study investigates the cognitive screening practices of a metropolitan health service and highlights the need for culturally appropriate cognitive screening methods to be developed and implemented to facilitate the identification of cognitive impairment in Indigenous Australians presenting for treatment.

Comparison of time utilization in an academic inpatient versus an outpatient vascular laboratory.

PURPOSE: Efficient, cost-effective services in vascular laboratories (VLs) will be required in tomorrow's health care environment. Inpatient VLs (IPVL) are burdened with complex patients, excessive workload, and a high percentage of bedside tests. Outpatient VLs (OPVL) are therefore presumed to be more productive and efficient. We compared time utilization in OPVLs and IPVL to test this hypothesis. METHODS: Vascular sonographers at an academic IPVL and OPVL were asked to track their daily activities during five consecutive weekdays. Test type, scan time, delays in patient arrival, preparation for the test, computer entry, and administrative time (patient- and non-patient-related) were logged. RESULTS: Delay in patient arrival and non-patient-related administration activities were both significantly greater in the OPVL (p < 0.01 and 0.03, respectively). Actual scan time occupied only 38.8% of the technologist's day, with the rest spent on patient- and non-patient-related activities. CONCLUSIONS: No appreciable differences were noted between IPVL and OPVL in most of the efficiency parameters measured. General administration time and delay in patient arrival were greater in the OPVL. Thus, OPVL were not more efficient than IPVL. In order to maximize efficiency in the OPVL, non-patient-related activities, which occupy over a quarter of the daily workday, must be shifted from technologists to support staff. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 44:540-544, 2016.

Acute costs and predictors of higher treatment costs for major paediatric trauma in New South Wales, Australia.

AIMS: To describe the costs of acute trauma admissions for children aged ≤15 years in trauma centres; to identify predictors of higher treatment costs and quantify differences in actual and state-wide average cost in New South Wales (NSW), Australia. METHOD: Admitted trauma patient data provided by 12 trauma centres was linked with financial data for 2008-2009. Demographic, injury details and injury severity scores (ISS) were obtained from trauma registries. Individual patient costs, Australian Refined Diagnostic Related Groups (AR-DRG) and state-wide average costs were obtained. Actual costs incurred by each hospital were compared with state-wide AR-DRG average costs. Multivariate multiple linear regression identified predictors of cost. RESULTS: There were 3493 patients with a total cost of AUD$20.2 million. Falls (AUD$6.7 million) and road trauma (AUD$4.4 million) had the highest total expenditure. The reduction in cost between ISS < 9 compared to ISS 9-12 and ISS > 12 was significant (P < 0.0001). The median cost of injury increased with every additional body region injured (P < 0.0001). For each additional day spent in hospital, there was an increased cost of AUD$1898 and patients admitted to an intensive care unit (ICU) cost AUD$7358 more than patients not admitted to ICU. The total costs incurred by trauma centres were AUD$1.4 million above the NSW peer group average cost estimates. CONCLUSIONS: The high financial cost of paediatric patient treatment highlights the need to ensure prevention remains a priority in Australia. Hospitals tasked with providing trauma care should be appropriately funded and future funding models should consider trauma severity.

Epidemiology of traumatic deaths: comprehensive population-based assessment.

BACKGROUND: The epidemiology of traumatic deaths was periodically described during the development of the American trauma system between 1977 and 1995. Recognizing the impact of aging populations and the potential changes in injury mechanisms, the purpose of this work was to provide a comprehensive, prospective, population-based study of Australian trauma-related deaths and compare the results with those of landmark studies. METHODS: All prehospitalization and in-hospital trauma deaths occurring in an inclusive trauma system at a single Level 1 trauma center [400 patients with an injury severity score (ISS) >15/year] underwent autopsy and were prospectively evaluated during 2005. High-energy (HE) and low-energy (LE) deaths were categorized based on the mechanism of the injury, time frame (prehospitalization, <48 hours, 2-7 days, >7 days), and cause [which was determined by an expert panel and included central nervous system-related (CNS), exsanguination, CNS + exsanguination, airway, multiple organ failure (MOF)]. Data are presented as a percent or the mean +/- SEM. RESULTS: There were 175 deaths during the 12-month period. For the 103 HE fatalities (age 43 +/- 2 years, ISS 49 +/- 2, male 63%), the predominant mechanisms were motor vehicle related (72%), falls (4%), gunshots (8%), stabs (6%), and burns (5%). In all, 66% of the patients died during the prehospital phase, 27% died after <48 hours in hospital, 5% died after 3 to 7 days in hospital, and 2% died after >7 days. CNS (33%) and exsanguination (33%) were the most common causes of deaths, followed by CNS + exsanguination (17%) and airway compromise 8%; MOF occurred in only 3%. Six percent of the deaths were undetermined. All LE deaths (n = 72, age 83 +/- 1 years, ISS 14 +/- 1, male 45%) were due to low falls. All LE patients died in hospital (20% <48 hours, 32% after 3-7 days, 48% after 7 days). The causes of deaths were head injury (26%) and complications of skeletal injuries (74%). CONCLUSIONS: The HE injury mechanisms, time frames, and causes in our study are different from those in the earlier, seminal reports. The classic trimodal death distribution is much more skewed to early death. Exsanguination became as frequent as lethal head injuries, but the incidence of fatal MOF is lower than reported earlier. LE trauma is responsible for 41% of the postinjury mortality, with distinct epidemiology. The LE group deserves more attention and further investigation.

Global clinical data interchange standards are here!

The Clinical Data Interchange Standards Consortium (CDISC) has succeeded in developing global clinical data interchange standards that are ready for implementation. The various CDISC models are identified and explained in this article as well as how these models work together. In addition to developing the CDISC standards, CDISC is involved actively in many collaborative projects with other organizations as a result of their numerous alliances and partnerships. CDISC standards are supporting not only the pharmaceutical industry but also other initiatives and services in healthcare.

Improving patient outcomes using a diabetic foot assessment tool.

Diabetes is the most common cause of end-stage renal disease, and the number of renal patients with diabetes-related problems is increasing. Anecdotal evidence from a 27-bed nephrology ward highlighted an increase in diabetic foot complications often leading to amputation. Preventive measures using an assessment tool have been initiated to improve outcomes for renal patients with diabetes. The aim of the tool is to highlight problems or those at risk of developing problems.

Results and cost of meeting the National Service Framework for Coronary Heart Disease requirement for 12 month follow-up after acute coronary events.

BACKGROUND: The National Service Framework (NSF) for Coronary Heart Disease (CHD) set standards, targets and milestones. In the case of acute myocardial infarction (AMI) or coronary revascularization, Milestone 3 of Standard 12 requires a 12 month audit of exercise and smoking habit and of body mass index (BMI) for patients who have attended cardiac rehabilitation (CR). The targets are that 50 per cent of patients should be exercising regularly, not smoking and have a BMI of <30 kg/m(2). The purpose of this study was to find out whether the targets are realistic and to measure the cost of retrieving the data. METHODS: A postal questionnaire was used to follow up all the patients who attended our CR programme over a 12 month period. The project was costed. RESULTS: Four hundred and three CHD patients who had attended the programme between April 2001 and March 2002 were sent questionnaires 12 months after their index event. Their diagnoses were AMI in 147 (36.5 per cent), coronary artery surgery in 157 (39 per cent) and angioplasty in 99 (24.5 per cent). Completed questionnaires were received from 358 (89 per cent). Of the responders, 69 per cent were exercising regularly, 91.6 per cent were not smoking (73 per cent had been non-smokers before their index cardiac event) and 79 per cent had a BMI of <30 kg/m(2)(the figure at the start of rehabilitation had been 79 per cent). The cost of performing the audit was pounds sterling 1204. CONCLUSION: This audit is inexpensive. The targets for smoking and BMI set by the NSF were achieved by a very large margin before either the index cardiac event or starting CR.

GP recruitment and retention: a qualitative analysis of doctors' comments about training for and working in general practice.

BACKGROUND AND AIMS: General practice in the UK is experiencing difficulty with medical staff recruitment and retention, with reduced numbers choosing careers in general practice or entering principalships, and increases in less-than-full-time working, career breaks, early retirement and locum employment. Information is scarce about the reasons for these changes and factors that could increase recruitment and retention. The UK Medical Careers Research Group (UKMCRG) regularly surveys cohorts of UK medical graduates to determine their career choices and progression. We also invite written comments from respondents about their careers and the factors that influence them. Most respondents report high levels of job satisfaction. A noteworthy minority, however, make critical comments about general practice. Although their views may not represent those of all general practitioners (GPs), they nonetheless indicate a range of concerns that deserve to be understood. This paper reports on respondents' comments about general practice. ANALYSIS OF DOCTORS' COMMENTS: Training Greater exposure to general practice at undergraduate level could help to promote general practice careers and better inform career decisions. Postgraduate general practice training in hospital-based posts was seen as poor quality, irrelevant and run as if it were of secondary importance to service commitments. In contrast, general practice-based postgraduate training was widely praised for good formal teaching that met educational needs. The quality of vocational training was dependent upon the skills and enthusiasm of individual trainers. Recruitment problems Perceived deterrents to choosing general practice were its portrayal, by some hospital-based teachers, as a second class career compared to hospital medicine, and a perception of low morale amongst current GPs. The choice of a career in general practice was commonly made for lifestyle reasons rather than professional aspirations. Some GPs had encountered difficulties in obtaining posts in general practice suited to their needs, while others perceived discrimination. Newly qualified GPs often sought work as non-principals because they felt too inexperienced for partnership or because their domestic situation prevented them from settling in a particular area. Changes to general practice The 1990 National Health Service (NHS) reforms were largely viewed unfavourably, partly because they had led to a substantial increase in GPs' workloads that was compounded by growing public expectations, and partly because the two-tier system of fund-holding was considered unfair. Fund-holding and, more recently, GP commissioning threatened the GP's role as patient advocate by shifting the responsibility for rationing of health care from government to GPs. Some concerns were also expressed about the introduction of primary care groups (PCGs) and trusts (PCTs). Together, increased workload and the continual process of change had, for some, resulted in work-related stress, low morale, reduced job satisfaction and quality of life. These problems had been partially alleviated by the formation of GP co-operatives. Retention difficulties Loss of GPs' time from the NHS workforce occurs in four ways: reduced working hours, temporary career breaks, leaving the NHS to work elsewhere and early retirement. Child rearing and a desire to pursue interests outside medicine were cited as reasons for seeking shorter working hours or career breaks. A desire to reduce pressure of work was a common reason for seeking shorter working hours, taking career breaks, early retirement or leaving NHS general practice. Other reasons for leaving NHS general practice, temporarily or permanently, were difficulty in finding a GP post suited to individual needs and a desire to work abroad. CONCLUSIONS: A cultural change amongst medical educationalists is needed to promote general practice as a career choice that is equally attractive as hospital practice. The introduction of Pre-Registration House Officer (PRHO) placements in general practice and improved flexibility of GP vocational training schemes, together with plans to improve the quality of Senior House Officer (SHO) training in the future, are welcome developments and should address some of the concerns about poor quality GP training raised by our respondents. The reluctance of newly qualified GPs to enter principalships, and the increasing demand from experienced GPs for less-than-full-time work, indicates a need for a greater variety of contractual arrangements to reflect doctors' desires for more flexible patterns of working in general practice.