Time needed to resolve patient complaints and factors influencing it: a cohort study.

OBJECTIVE: There has been an increase in the number and complexity of patient complaints against healthcare institutions. An understanding of the resources needed in this area is important for proper planning. DESIGN: Cohort study. SETTING: A 1250-bed tertiary-care teaching hospital. PARTICIPANTS: All patient complaints received between 1 February 2014 and 31 January 2015 were prospectively included in this cohort study. MAIN OUTCOME MEASURES: The amount of time spent on the investigation and liaising with the complainant for each case was recorded. The complainant's personal details and characteristics were recorded anonymously. RESULTS: In total, 908 patient complaints were recorded from 801 individuals during the study period. Longer median person-hours were spent on managing complaints that were brought forward by men (1.48 h), those who were distant relatives of the patients (2.08 h), foreigners (1.58 h) and non-subsidised patients (1.83 h). Patient complaints falling into the categories of clinical domain (3.00 h) and patient rights (2.54 h), quality (3.00 h) and safety (2.83 h) required the longest median time to manage. Multiple logistic regression analysis revealed that the total amount of time spent on the complaints was predicted by the gender of the complainant, the relationship of the complainant with the patient, the subsidy status of the patient, the severity and the domain of the complaint. CONCLUSIONS: This study reported the time required to manage patient complaints in a larger tertiary-care academic medical centre. Predictors of the time spent on resolving patient complaints can be used as parameters for resource planning.

Correction: A knowledge, attitude, and practice survey on mediation among clinicians in a tertiary-care hospital in Singapore.

[This corrects the article DOI: 10.1371/journal.pone.0199885.].

A knowledge, attitude, and practice survey on mediation among clinicians in a tertiary-care hospital in Singapore.

Healthcare delivery is a highly complex, deeply personal and costly endeavour that involves multiple specialties and services. There is an imbalance in knowledge between the healthcare provider and consumer that may contribute to doubts and uncertainty over treatment and outcomes. It is unsurprising that conflict and dispute can develop between healthcare providers and patients and their next-of-kin. The use of mediation in the healthcare setting has recently been promoted in many developed countries, including Singapore. We administered a detailed 32-item survey in a large tertiary-care teaching hospital to improve our understanding of the knowledge, attitude and practice of dispute resolution among clinicians to pave the way for better strategies to improve the adoption of mediation in healthcare setting. Ninety-seven respondents had an average of 62% (SD: 12%) knowledge score. The most common misconceptions held by the respondents about mediation were: (1) mediation was about fact-finding, (2) mediation is limited to only certain types of dispute, (3) mediation proceeds by both parties giving their account of the dispute, then a third party decides a settlement, (4) the average time it takes to resolve a dispute through mediation, (5) the cost of mediation, (5) the venue of mediation, (6) the person determining the outcome of mediation, (7) confidentiality of mediation. In general, the respondents were positive about the use of mediation as a dispute resolution tool. When asked to indicate the relative importance of different outcomes of dispute resolution, financial compensation and waiver of hospital bill attracted mixed responses while understanding facts of dispute, assurance that the same error would not recur, and offering corrective treatment were rated as being important. By contrast, seeking an apology from the complainant was considered neutral to somewhat important and the respondents were least concerned with the publicity of the dispute. Direct negotiation with the complainant was considered the most time- and cost-efficient means of resolving a dispute while the opposite was true for litigation. Mediation was considered the approach where the clinicians are most likely to achieve their desired outcome while litigation was considered least likely to produce a favourable outcome. Approximately half of the respondents reported having personal experience or known of a colleague who had been involved in a medico-legal dispute. A quarter of these cases were resolved by direct negotiations with the complainant while lawyers, the judge and mediation, resolved approximately 15% each, respectively. The knowledge base of the clinicians in this study about mediation was moderate and probably reflected the general lack of direct experience in the resolution of a dispute or training in mediation. This further corroborated with the general response that the uptake of mediation in the healthcare setting is currently poor in Singapore due to the lack of awareness and perceived lack of avenue among the surveyed clinicians. Any further work to be done with clinicians may be in the direction of (1) increasing general understanding of mediation, (2) increasing awareness of avenues for mediation, and (3) becoming better aware of when to propose mediation.

Survival outcomes with the introduction of intravenous epinephrine in the management of out-of-hospital cardiac arrest.

STUDY OBJECTIVE: The benefit of epinephrine in cardiac arrest is controversial and has not been conclusively shown in any human clinical study. We seek to assess the effect of introducing intravenous epinephrine on the survival outcomes of out-of-hospital cardiac arrest patients in an emergency medical services (EMS) system that previously did not use intravenous medications. METHODS: This observational, prospective, before-after clinical study constitutes phase II of the Cardiac Arrest and Resuscitation Epidemiology project. Included were all patients who are older than 8 years, with nontraumatic out-of-hospital cardiac arrest conveyed by the national emergency ambulance service. The comparison between the 2 intervention groups for survival to discharge was made with logistic regression and expressed in terms of the odds ratio (OR) and the corresponding 95% confidence interval (CI). RESULTS: From October 1, 2002, to October 14, 2004, 1,296 patients were enrolled into the study, with 615 in the pre-epinephrine and 681 in the epinephrine phase. Demographic and EMS characteristics were similar in both groups. Forty-four percent of patients received intravenous epinephrine in the epinephrine phase. There was no significant difference in survival to discharge (pre-epinephrine 1.0%; epinephrine 1.6%; OR 1.7 [95% CI 0.6 to 4.5]; adjusted for rhythm OR 2.0 [95% CI 0.7 to 5.5]); return of circulation (pre-epinephrine 17.9%; epinephrine 15.7%; OR 0.9 [95% CI 0.6 to 1.2]), or survival to admission (pre-epinephrine 7.5%; epinephrine 7.5%; OR 1.0 [95% CI 0.7 to 1.5]). There was a minimal increase in scene time in the epinephrine phase (10.3 minutes versus 10.7 minutes; 95% CI of difference 0.02 to 0.94 minutes). CONCLUSION: We were unable to establish a significant survival benefit with the introduction of intravenous epinephrine to an EMS system. More research is needed to determine the effectiveness of drugs such as epinephrine in resuscitation.

Role of peak current in conversion of patients with ventricular fibrillation.

INTRODUCTION: Peak currents are the final arbiter of defibrillation in patients with ventricular fibrillation (VF). However, biphasic defibrillators continue to use energy in joules for electrical conversion in hopes that their impedance compensation properties will address transthoracic impedance (TTI), which must be overcome when a fixed amount of energy is delivered. However, optimal peak currents for conversion of VF remain unclear. We aimed to determine the role of peak current and optimal peak levels for conversion in collapsed VF patients. METHODS: Adult, non-pregnant patients presenting with non-traumatic VF were included in the study. All defibrillations that occurred were included. Impedance values during defibrillation were used to calculate peak current values. The endpoint was return of spontaneous circulation (ROSC). RESULTS: Of the 197 patients analysed, 105 had ROSC. Characteristics of patients with and without ROSC were comparable. Short duration of collapse < 10 minutes correlated positively with ROSC. Generally, patients with average or high TTI converted at lower peak currents. 25% of patients with high TTI converted at 13.3 ± 2.3 A, 22.7% with average TTI at 18.2 ± 2.5 A and 18.6% with low TTI at 27.0 ± 4.7 A (p = 0.729). Highest peak current conversions were at < 15 A and 15-20 A. Of the 44 patients who achieved first-shock ROSC, 33 (75.0%) received < 20 A peak current vs. > 20 A for the remaining 11 (25%) patients (p = 0.002). CONCLUSION: For best effect, priming biphasic defibrillators to deliver specific peak currents should be considered.

A multicenter prospective randomized study comparing the efficacy of escalating higher biphasic versus low biphasic energy defibrillations in patients presenting with cardiac arrest in the in-hospital environment.

BACKGROUND: Biphasic defibrillation has been practiced worldwide for >15 years. Yet, consensus does not exist on the best energy levels for optimal outcomes when used in patients with ventricular fibrillation (VF)/pulseless ventricular tachycardia (VT). METHODS: This prospective, randomized, controlled trial of 235 adult cardiac arrest patients with VF/VT was conducted in the emergency and cardiology departments. One group received low-energy (LE) shocks at 150-150-150 J and the other escalating higher-energy (HE) shocks at 200-300-360 J. If return of spontaneous circulation (ROSC) was not achieved by the third shock, LE patients crossed over to the HE arm and HE patients continued at 360 J. Primary end point was ROSC. Secondary end points were 24-hour, 7-day, and 30-day survival. RESULTS: Both groups were comparable for age, sex, cardiac risk factors, and duration of collapse and VF/VT. Of the 118 patients randomized to the LE group, 48 crossed over to the HE protocol, 24 for persistent VF, and 24 for recurrent VF. First-shock termination rates for HE and LE patients were 66.67% and 64.41%, respectively (P=0.78, confidence interval: 0.65-1.89). First-shock ROSC rates were 25.64% and 29.66%, respectively (P=0.56, confidence interval: 0.46-1.45). The 24-hour, 7-day, and 30-day survival rates were 85.71%, 74.29%, and 62.86% for first-shock ROSC LE patients and 70.00%, 50.00%, and 46.67% for first-shock ROSC HE patients, respectively. Conversion rates for further shocks at 200 J and 300 J were low, but increased to 38.95% at 360 J. CONCLUSION: First-shock termination and ROSC rates were not significantly different between LE and HE biphasic defibrillation for cardiac arrest patients. Patients responded best at 150/200 J and at 360 J energy levels. For patients with VF/pulseless VT, consideration is needed to escalate quickly to HE shocks at 360 J if not successfully defibrillated with 150 or 200 J initially.