Impacto de la implementación de un método de traspaso de información estandarizada interdisciplinar en sala de partos y unidad de cuidados obstétricos intermedios / Impact of the implementation of a standardised interdisciplinary information transfer method in the Delivery room and Intermediate Obstetric Care Unit

Objetivo Este estudio tiene como objetivo describir la implementación de la metodología estandarizada en la transferencia de información en sala de partos y unidad de cuidados obstétricos intermedios en un hospital de tercer nivel de Barcelona e identificar el impacto de esta implementación en los factores que actúan como facilitadores y barreras en el procedimiento. Método Estudio cuasiexperimental tipo pretest-postest sin grupo control en la unidad de cuidados obstétricos intermedios y sala de partos del servicio de Medicina Maternofetal de un hospital de tercer nivel de Barcelona. El personal sanitario autocumplimentó un cuestionario ad hoc antes y después de implementar la metodología estandarizada IDEAS en el servicio durante 2019 y 2020. Se evaluó la autopercepción personal en el procedimiento de transferencia de información. El test de Wilcoxon por pares se utilizó para la comparación antes y después. Resultados El uso de una metodología estandarizada ha mostrado un impacto en la mejora de la transmisión de la información. Se detectaron diferencias significativas antes y después de la intervención en las siguientes dimensiones: ubicación, personas implicadas, periodo de tiempo del procedimiento, estructurada ordenada y clara y tiempo suficiente para preguntas (p<0,001); mientras que no se observaron diferencias en transmisión al profesional referente, actuaciones bien definidas y realización de un resumen. Conclusiones Existen factores, como aspectos estructurales, organizativos y falta de tiempo, que dificultan la comunicación efectiva, por tanto, actúan como barreras en la transferencia de información. La implementación de una metodología con las personas implicadas, el tiempo y el espacio adecuado permite mejorar aspectos en la comunicación en el equipo multiprofesional y, por tanto, la seguridad del paciente. (AU)

Aim This study aims to describe the implementation of the standard methodology for information transfer in the labour ward and Intermediate Obstetric Care Unit and to identify the impact of this implementation on the factors that act as facilitators and barriers in the procedure. Method Quasi-experimental pretest-posttest study without a control group in an Intermediate Obstetric Care Unit and delivery room of the Maternal-Fetal Medicine Service of a tertiary hospital in Barcelona. Healthcare staff self-completed an ad hoc questionnaire before and after implementing the standardised IDEAS methodology in the service during 2019 and 2020. Personal self-perception in the information transfer procedure was assessed. The Wilcoxon pairwise test was used for comparison before and after. Results The use of a standardised methodology has shown an impact on improving the transmission of information. Significant differences were detected before and after the intervention in the following dimensions: location, people involved, time period of the procedure, structured, orderly and clear, and sufficient time for questions (p<0.001); while no differences were observed in: transmission to the referring professional, well-defined actions, and completion of a summary. Conclusions There are factors such as structural and organisational aspects and lack of time that hinder effective communication and therefore act as barriers to the transfer of information. The implementation of a methodology with the health professionals involved, the time and the appropriate space allows for the improvement of communication aspects in the multiprofessional team and, therefore, patient safety. (AU)

Ceftazidime Plasma Concentrations and Neurotoxicity: The Importance of Therapeutic Drug Monitoring in Patients Undergoing Different Modalities of Renal Replacement Therapy. A Grand Round.

ABSTRACT: Ceftazidime-avibactam (CTZ-AVM) is a novel cephalosporin/beta-lactamase inhibitor with broad-spectrum activity against multidrug-resistant Pseudomonas aeruginosa . Ceftazidime-induced neurotoxicity is a well-described adverse effect, particularly in patients with renal insufficiency. However, appropriate dosing of ceftazidime-avibactam in patients undergoing renal replacement therapy (RRT) is sparsely investigated, and therapeutic drug monitoring to guide dosing remains lacking. Furthermore, when dose adjustment for impaired renal function is based on CTZ-AVM product information, inferior cure rates have been obtained compared with those with the standard therapy for intra-abdominal infections. Maintaining an effective dose while avoiding toxicity in these patients is challenging. Here, the authors describe the case of a critically ill patient, undergoing 2 modalities of RRT, who developed ceftazidime-induced neurotoxicity as confirmed using ceftazidime therapeutic drug monitoring. This case illustrates a therapeutic drug monitoring-based approach for guiding ceftazidime-avibactam dosing in this context and in diagnosing the cause of neurological symptoms and signs.

The relationships between clinical teaching behaviour and transition shock in newly graduated nurses.

AIM: To explore the relationships between clinical teaching behaviour and transition shock in newly graduated nurses and significant differences in the northwest and northeast China. DESIGN: A cross-sectional design. METHODS: A total of 211 (nurses) and 925 (preceptors) were recruited in six Third-class different hospitals from July to August 2019. RESULTS: The transition shock is negatively correlated with the clinical teaching behaviour in northwest and northeast China, while the transition shock in the northwest is higher than that in the northeast for the behindhand economy and natural limit. CONCLUSION: The transition process of newly graduated nurses in northeast China with ethnic minorities and the behindhand economy is more difficult. For newly graduated nurses, personal health and a supportive environment need further improvement. Teaching strategies for preceptors need to be enhanced. Two-way feedback is more useful for both the newly graduated nurses and preceptors to improve quality care, and holistic care.

A thematic analysis of the effects of compassion rounds on clinicians and the families of NICU patients.

The correlation between spiritual wellness and clinical outcomes is widely established in the literature. This thematic analysis illuminates the experiences of clinicians, chaplains, and parents of Neo-natal Intensive Care Unit (NICU) patients who participated in Compassion Rounds, spiritual care interventions that focus solely on emotional and spiritual well-being, rather than physical diagnoses. Clinicians and families participated in semi-structured interviews and focus groups. The results showed that Compassion Rounds had positive effects on spiritual wellness for NICU parents and their health care providers, while also allowing chaplains to model and provide spiritual care for physicians. Compassion Rounds enabled physicians to learn from chaplains and deliver effective spiritual wellness interventions within their limited available time. Compassion Rounds had a restorative effect on caregivers and have the potential to prevent or overcome burnout, return meaning to the work of clinicians, and create trust within multidisciplinary care teams.

Who Speaks First? Promoting Senior Resident Autonomy on Family-Centered Rounds: A QI Initiative.

BACKGROUND AND OBJECTIVES: Graduated autonomy is fundamental as trainees transition to independent practice. Family-centered rounds (FCR), the leading model of inpatient rounding in pediatrics, is an opportunity for trainees to demonstrate their competence in leading a health care team, which is an entrustable professional activity for all pediatric residents. At our institution, senior residents (SRs) at baseline performed at a novice level on the basis of the Senior Resident Empowerment Actions 21 (SREA-21), a validated tool that is used to assess SR autonomy during FCR. Our objective for this study was to increase the median percentage of SREA-21 domains in which SRs perform at a competent level from 38% to 75% within 6 months. METHODS: Researchers observed 4 FCR encounters weekly and calculated SREA-21 scores after 2 weeks on the basis of actions promoting SR autonomy performed by the SR-hospitalist dyad. The primary outcome measure was the percentage of SREA-21 domains in which the SR achieved a competent score on the SREA-21. We used the model for improvement to identify key drivers and test proposed interventions using serial plan-do-study-act cycles. Interventions included creation of unified inpatient SR expectations, introduction of a SR-hospitalist pre-FCR huddle, auditing of FCR interruptions, and direct feedback to the SR-hospitalist dyad after FCR. Run charts were used to track SR and hospitalist scores on the SREA-21. RESULTS: After multiple plan-do-study-act cycles, there was special cause improvement with a desirable shift upward in the centerline to 100%, which correlated with the project's interventions and surpassed our goal. CONCLUSIONS: Using quality improvement methodology, we improved SR autonomy during FCR, as measured by the SREA-21.

Daily Integrated Care Conferences to Reduce Length of Hospital Stay for Patients With Chronic Obstructive Pulmonary Disease.

CONTEXT: Inefficiencies in care coordination-specifically, the lack of an effective method of communication among multiple health care professionals-often leads to an unnecessary increase in length of hospital stay. OBJECTIVE: To determine whether daily integrated care conferences (ICCs) would significantly reduce the length of stay for patients with chronic obstructive pulmonary disease (COPD) exacerbation. METHOD: Patients with COPD exacerbation were selected for the study using electronic medical records from 2 osteopathic community hospitals located in northeastern Ohio. One hospital used daily ICCs and the other hospital did not use daily ICCs. The average length of stay for patients at each hospital was retrospectively investigated. RESULTS: A total of 1683 patients with COPD exacerbation were selected. The mean (SD) length of stay in the hospital with daily ICCs was 3.37 (2.89) days compared with 5.55 (3.99) days in the hospital without daily ICCs (P<.0001). At the hospital with daily ICCs, patients aged 40 to 69 years had a 67% shorter hospital stay and patients aged 70 to 99 years or older had a 36% shorter length of stay compared with patients at the hospital without daily ICCs. CONCLUSION: Daily integrated care conferences significantly reduced the length of stay for patients with COPD exacerbation at an osteopathic community-based hospital. Implementing daily ICCs may make current health care services and coordinated care more efficient, resulting in decreased costs and length of stay for patients with COPD exacerbation.

The positive effect of student-oriented clinical clerkship rounds employing role-play and peer review on the clinical performance and professionalism of clerkship students.

Background: Role-play (RP) and peer review (PR) are occasionally used in training and evaluating communication skills in clinical clerkship (CC). Thus, we evaluated the effect of combining RP and PR during student-oriented CC rounds.Methods: Clerkship students conducted medical interviews with and performed physical examinations on their patients, which were reviewed by five peer students who observed their performance while role-playing as senior physicians or patients' families. The peer reviewers then provided feedback to the students. The performance of the students was evaluated based on a mini-clinical evaluation exercise (Mini-CEX) and a professionalism mini-evaluation exercise (P-MEX) before and after the rounds by two attending physicians. After the CC, the students responded to questionnaires about the rounds.Results: Seventy-five students completed the rounds, and the duration of each round was 41.7 ± 7.1 min. Their communication skills and professionalism abilities on Mini-CEX and P-MEX showed significant improvement after the rounds. Improvements in medical interviewing and physical examinations were also noted. Additionally, the students recognized the importance of multiple viewpoints in patient care through experiences of the rounds.Conclusions: Combining RP and PR with CC rounds improves the students' clinical performance and professionalism and promotes their awareness of the importance of multiple viewpoints in patient care.

Effectiveness of nursing rounds in the Intensive Care Unit on workplace learning.

OBJECTIVES: To evaluate the implementation of a regular Nursing Round as an educational strategy for workplace learning in an intensive care unit with a single room environment. RESEARCH DESIGN: A multiple methods design was used. Fifty-four Nursing Rounds were observed and nurses (n = 40) completed bespoke evaluative surveys. Structured observational data and open-ended survey responses were submitted to content analysis and descriptive statistics were used to analyse survey findings. RESULTS: Nursing Rounds involved a diverse range of participants, most frequently nurses. The content most frequently discussed included empirical clinical issues where nurses decided on nursing care actions to address these issues. The most frequently observed outcome of Nursing Rounds was knowledge translation. Nursing Rounds were perceived to positively influence application of evidence in practise, identification of areas for practise improvement and ability to communicate clinical information. Two categories emerged from analysis of open-ended survey questions; (1) 'Positive learning environment', where nurses described Nursing Rounds as a social learning experience; and (2) 'Impediments to Nursing Rounds', including difficulty attending Nursing Rounds due to competing priorities. CONCLUSION: Nursing Rounds enabled evidence-based learning that enhanced inter-disciplinary collaboration. Further investigation may be required to understand how to enable nurses to attend more frequently, and generate a more holistic, evidence-based discussion.

Communication about patients during ward rounds and verbal handovers: A gender perspective.

This article investigates gender patterns on how two interprofessional teams communicate about patients in their absence. Thirteen ward rounds and 17 verbal handovers were audio-recorded and analyzed through a qualitative content analysis. The ward rounds consisted of 1 physician and 2-4 nurses. The verbal handovers consisted of 2-3 nurses and as many assistant nurses. The data were collected at a cardiac clinic at a hospital in southern Sweden. The results indicate that when patients acted according to socially-accepted gender norms, the communication among the interprofessional teams was characterized as 'professional', including communication primarily about the medical situation of the patient and statements of a non-judgmental nature. When patients did not act according to socially-accepted gender norms, the communication among the interprofessional teams switched to become more 'informal', including non-medical oriented statements of a negative nature. When the healthcare workers take the patient's psycho-social condition into account, as advocated by concepts like 'holistic care' and 'patient-centered care', the risk for speculation and arbitrariness may increase, especially within interprofessional teams who hold a nursing responsibility for patients. Establishing more defined guidelines of how non-medical aspects should be dealt with are thus of importance to the development of an equitable provision and delivery of healthcare.

Evaluating the Feasibility of Incorporating In-Person Interpreters on Family-Centered Rounds: A QI Initiative.

OBJECTIVES: No best practice has been defined for incorporating in-person interpreters into family-centered rounds (FCRs) for patients with limited English proficiency (LEP). We hypothesized that addressing barriers to scheduling in-person interpreters would make FCR encounters more likely, and thus ensure more equitable care for LEP patients. METHODS: A quality improvement initiative was conducted from October 2014 to March 2016 to arrange in-person interpreters for LEP patients during FCRs on the inpatient pediatric service of a large, urban, tertiary care center in Boston. Main interventions included establishing a protocol for scheduling interpreters for rounds and the implementation of a form to track process adherence. Our primary outcome was the percentage of FCR encounters with LEP patients with an interpreter present. Our balancing measures were patient satisfaction, which was assessed using validated surveys administered weekly by nonphysician team members through convenience sampling of families present on the wards, and rounds duration. RESULTS: There were 614 encounters with LEP patients during the intervention, 367 of which included in-person interpreters. The percentage of encounters with LEP patients involving interpreters increased from 0% to 63%. Form completion, our primary process measure, reached 87% in the most recent phase. English-proficient and LEP patients reported similar satisfaction with their rounding experience amid a modest increase in rounds duration (preintervention, 105 minutes; postintervention, 130 minutes; P = .056). CONCLUSIONS: Using quality improvement as a framework to address key barriers, we successfully implemented a process that increased the participation of in-person interpreters on FCRs on a busy pediatric service.

Physician-Mentored Patient Rounds to Observe and Assess Entrustable Professional Activities 1 and 2 in Preclinical Medical Students.

CONTEXT: Thirteen entrustable professional activities (EPAs) for entering residency were created to aid medical educators as they prepare preclinical students for their residency and to assess student readiness for residency. The A.T. Still University Kirksville College of Osteopathic Medicine (ATSU-KCOM) developed a program called physician-mentored patient rounds (PMPR), which focuses on EPA 1 and EPA 2. OBJECTIVE: To determine whether PMPRs could be used to assess expected behaviors of EPA 1 (gather a history and perform a physical examination) and EPA 2 (prioritize a differential diagnosis after a clinical encounter). METHODS: The PMPR sessions at ATSU-KCOM take place over several weeks (30-minute sessions per week), during which students gather a patient's history (sessions 1 and 2), observe a physical examination by the physician mentor (session 2), analyze diagnostic test results (session 3), and formulate a treatment plan (session 4). The PMPRs in this study used a real patient with confirmed chronic obstructive pulmonary disease (COPD). This study did not include the session-4 treatment plan. Between sessions, students completed an assignment to further demonstrate their behaviors as expected in the EPAs. Student responses were analyzed and summarized for physician feedback in the subsequent PMPR session. Students' diagnostic accuracy was measured at the conclusion of each session. RESULTS: A total of 516 students were included in the study. The PMPR weekly attendance was high (453-475). Although history gathering in the large-group setting was disorderly, diagnostic accuracy over the 3-session period improved. After history taking, 411 students (86.5%) included COPD in the differential diagnosis. A smaller number, 235 students (49.5%), listed COPD as the most likely diagnosis. After the physical examination, 439 included COPD in the differential diagnosis, and 385 listed COPD as the most likely diagnosis. After analysis of diagnostic test results, 468 students listed COPD as the most likely diagnosis. CONCLUSION: Physician-mentored patient rounds seem to be an effective means to assess preclinical students' expected behaviors as described in EPA 1 and EPA 2.

[Application of classic Chinese medicine theory in acupuncture CBL teaching rounds].

Teaching rounds is an important part of clinical teaching. It bright the theory guide to clinical practice. The classical Chinese medicine theory plays an essential role in teaching and clinical practice. During the CBL (case-based learning) teaching rounds of acupuncture and moxibustion, by selecting typical cases, in combination with directional problem settings, the classical Chinese medicine theory is run through the whole process to motivate students' initiative, improve teaching quality and promote inheritance and development of TCM.

A Model of Collaborative Spiritual and Psychiatric Care of Oncology Patients.

BACKGROUND: Many oncology patients see both chaplains and consultation-liaison (C-L) psychiatrists during medical hospitalizations. Studies show that spirituality and mental health influence one another, and that patients often prefer that physicians understand their spirituality. Though models of inpatient chaplaincy-psychiatry collaboration likely exist, none are apparent in the literature. In this study, we present one model of chaplaincy-psychiatry collaboration, hypothesizing that both specialties would find the intervention helpful. METHODS: From April through December 2015, the C-L psychiatry service at Brigham & Women's Hospital piloted 13 sessions of interdisciplinary rounds, where chaplains and C-L psychiatrists discussed common oncology patients. Participants completed questionnaires including quantitative and qualitative prompts before the intervention, after each session, and at the study's conclusion. RESULTS: Eighteen individuals completed baseline questionnaires. Between baseline and final surveys, the proportion of participants describing themselves as "very satisfied" with the 2 services' integration rose from 0-36%. The proportion of participants feeling "not comfortable" addressing issues in the other discipline declined from 17-0%. The most frequently chosen options on how discussions had been helpful were that they had enhanced understanding of both patient needs (83.3%) and the other discipline (78.6%). Qualitative data yielded similar themes. At conclusion, all respondents expressed preference that interdisciplinary rounds continue. CONCLUSION: This study describes a model of enhancing collaboration between chaplains and C-L psychiatrists, an intervention not previously studied to our knowledge. A pilot intervention of the model was perceived by both specialties to enhance both patient care and understanding of the other discipline.

RECALMIN: The association between management of Spanish National Health Service Internal Medical Units and health outcomes.

OBJECTIVE: To investigate the association between management of Internal Medical Units (IMUs) with outcomes (mortality and length of stay) within the Spanish National Health Service. DESIGN: Data on management were obtained from a descriptive transversal study performed among IMUs of the acute hospitals. Outcome indicators were taken from an administrative database of all hospital discharges from the IMUs. SETTING: Spanish National Health Service. PARTICIPANTS: One hundred and twenty-four acute general hospitals with available data of management and outcomes (401 424 discharges). MAIN OUTCOME MEASURES: IMU risk standardized mortality rates were calculated using a multilevel model adjusted by Charlson Index. Risk standardized myocardial infarction and heart failure mortality rates were calculated using specific multilevel models. Length of stay was adjusted by complexity. RESULTS: Greater hospital complexity was associated with longer average length of stays (r: 0.42; P < 0.001). Crude in-hospital mortality rates were higher at larger hospitals, but no significant differences were found when mortality was risk adjusted. There was an association between nurse workload with mortality rate for selected conditions (r: 0.25; P = 0.009). Safety committee and multidisciplinary ward rounds were also associated with outcomes. CONCLUSIONS: We have not found any association between complexity and intra-hospital mortality. There is an association between some management indicators with intra-hospital mortality and the length of stay. Better disease-specific outcomes adjustments and a larger number of IMUs in the sample may provide more insights about the association between management of IMUs with healthcare outcomes.

Factors associated with multidisciplinary case conference outcomes in children admitted to a regional hospital in Hong Kong with suspected child abuse: a retrospective case series with internal comparison.

INTRODUCTION: In all cases of suspected child abuse, accurate risk assessment is vital to guide further management. This study examined the relationship between risk factors in a risk assessment matrix and child abuse case conference outcomes. METHODS: Records of all children hospitalised at United Christian Hospital in Hong Kong for suspected child abuse from January 2012 to December 2014 were reviewed. Outcomes of the hospital abuse work-up as concluded in the Multi-Disciplinary Case Conference were categorised as 'established', 'high risk', or 'not established'. All cases of 'established' and 'high risk' were included in the positive case conference outcome group and all cases of 'not established' formed the comparison group. On the other hand, using the Risk Assessment Matrix developed by the California State University, Fresno in 1990, each case was allotted a matrix score of low, intermediate, or high risk in each of 15 matrix domains, and an aggregate matrix score was derived. The effect of individual matrix domain on case conference outcome was analysed. Receiver operating characteristic curve analysis was used to examine the relationship between case conference outcome and aggregate matrix score. RESULTS: In this study, 265 children suspected of being abused were included, with 198 in the positive case conference outcome group and 67 in the comparison group. Three matrix domains (severity and frequency of abuse, location of injuries, and strength of family support systems) were significantly associated with case conference outcome. An aggregate cut-off score of 23 yielded a sensitivity of 91.4% and specificity of 38.2% in relation to outcome of abuse categorisation. CONCLUSIONS: Risk assessment should be performed when handling suspected child abuse cases. A high aggregate score should arouse suspicion in all disciplines managing child abuse cases.

Interprofessional Clinical Rounding: Effects on Processes and Outcomes of Care.

BACKGROUND AND PURPOSE: Communication breakdown is viewed as a significant contributor to preventable patient harm. Interprofessional rounding (IPR) is one method of communication supporting the evidenced-based care delivery. The purpose of this paper is to explore the benefits of IPR for patients, clinicians, and the healthcare system. REVIEW OF THE LITERATURE: Interprofessional rounding supports collaboration, discussion, and timely intervention to prevent miscommunication leading to adverse patient events. Adherence to evidence-based care suggests a positive impact on patient, process, and financial outcomes. Statistically significant IPR-related improvements are seen in reducing mortality, lengths of stay, medication errors, and hospitalization costs as well as improved staff and patient satisfaction. EVIDENCE-BASED STRATEGIES: One IPR-related gap in the literature is integrative care delivery, a strategy that provides a unified plan to meet the complex needs of patients and produce optimal outcomes. Activation and standardization with active participation in IPR support a collaborative integration of care. CONCLUSION AND IMPLICATIONS: Embracing IPR and advocating for collaboration across the care continuum is a crucial process in preventing adverse events. Integrated care delivery through IPR provides a unified plan to meet the complex needs of patients, prevent harm, and produce best possible outcomes.

The Value of a Brief Thought for the Day Reflection on an Academic Consult Service.

BACKGROUND: Work in hospice and palliative medicine can be stressful. A variety of methods have been used to mitigate workplace stress including mindfulness mediation, reflective writing, and physical activity. An intervention implemented at our institution is a "Thought for the Day," a short reflection on a piece of poetry, music, or religious writing. Although this practice may be commonplace in the field of hospice and palliative medicine, no literature has been published about its perceived utility by team members with various competing demands on their time. OBJECTIVE: This study's objective was to obtain a better understanding about the perception and utility of a Thought for the Day held by clinicians rounding on an academic palliative medicine consult service. METHODS: A survey, containing qualitative and quantitative elements was sent to faculty, staff, and learners who participated in a Thought for the Day over the 18 months between March 2013 and October 2014. Twenty-eight responses were returned and analyzed. RESULTS: Most participants (23 of the 28) felt that the Thought for the Day was an important use of their time on the academic consult service. Differences were seen by gender and team role. Additionally, it was reported that the Thought for the Day improved the participants' perception of teamwork. CONCLUSION: The use of a Thought for the Day reflection may be beneficial and constructive even for a busy academic consult service.