Evaluation of postoperative recovery: past, present and future.

Postoperative recovery, as a window to observe perioperative treatment effect and patient prognosis, is a common outcome indicator in clinical research and has attracted more and more attention of surgeons and anaesthesiologists. Postoperative recovery is a subjective, multidimensional, long-term, complex process, so it is unreasonable to only use objective indicators to explain it. Currently, with the widespread use of patient-reported outcomes, various scales become the primary tools for assessing postoperative recovery. Through systematic search, we found 14 universal recovery scales, which have different structures, contents and measurement properties, as well as their own strengths and weaknesses. We also found that it is urgently necessary to perform further researches and develop a scale that can serve as the gold universal standard to evaluate postoperative recovery. In addition, with the rapid development of intelligent equipment, the establishment and validation of electronic scales is also an interesting direction.

Grit: what is it and why does it matter in medicine?

Grit refers to the combination of passion and perseverance for long-term goals. Grit has emerged as a recent topic of interest within the medical community. With ever-increasing rates of burnout and psychological distress, increasing attention has been directed towards modulatory or protective factors for these deleterious outcomes. Grit has been studied in regard to a variety of outcomes and variables in medicine. This article reviews the current literature on grit in medicine and summarises the current research on grit and performance metrics, personality characteristics, longitudinal progression, psychological well-being, diversity, equity and inclusion, burnout and residency attrition. While there is inconclusive evidence on the influence of grit on performance metrics in medicine, research consistently demonstrates a positive correlation between grit and psychological well-being and a negative correlation between grit and burnout. After discussing some of the inherent limitations of this type of research, this article suggests some possible implications and future areas for research and their potential role in cultivating psychologically healthy physicians and promoting successful careers in medicine.

Grit: what is it and why does it matter in medicine?

Grit refers to the combination of passion and perseverance for long-term goals. Grit has emerged as a recent topic of interest within the medical community. With ever-increasing rates of burnout and psychological distress, increasing attention has been directed towards modulatory or protective factors for these deleterious outcomes. Grit has been studied in regard to a variety of outcomes and variables in medicine. This article reviews the current literature on grit in medicine and summarises the current research on grit and performance metrics, personality characteristics, longitudinal progression, psychological well-being, diversity, equity and inclusion, burnout and residency attrition. While there is inconclusive evidence on the influence of grit on performance metrics in medicine, research consistently demonstrates a positive correlation between grit and psychological well-being and a negative correlation between grit and burnout. After discussing some of the inherent limitations of this type of research, this article suggests some possible implications and future areas for research and their potential role in cultivating psychologically healthy physicians and promoting successful careers in medicine.

A survey exploring the practices of smoking cessation support among hospital-based healthcare providers.

BACKGROUND: Hospital visits constitute a 'window of opportunity' for initiating smoking cessation attempts, and healthcare providers (HCPs) play an important role in supporting patients to stop smoking. Yet, the current practices of supporting smoking cessation in the hospital setting are largely unexplored. The aim of this study was to explore practices of smoking cessation support among hospital-based HCPs. METHODS: HCPs working in a large hospital in the secondary care sector completed an online, cross-sectional survey, including sociodemographic and work-related factors as well as 21 questions assessing practices of smoking cessation support based on the "five As" framework. Descriptive statistics were computed, and predictors of HCPs giving patients advice to stop smoking were explored using logistic regression analysis. RESULTS: All employees (N = 3998) in the hospital received a survey link; 1645 (41.1%) HCPs with daily patient contact completed the survey. Smoking cessation support in the hospital setting was limited with regard to assessment of smoking; providing information and advice; planning and referral for further support; and follow-up on smoking cessation attempts. Almost half (44.8%) of participating HCPs with daily patient contact never or rarely advise their patients to stop smoking. Physicians were more likely than nurses to advice patients to stop smoking, and HCPs in outpatient clinics were more likely to give advice than inpatient clinic HCPs. CONCLUSION: Smoking cessation support is very limited in the hospital-based healthcare setting. This is problematic, as hospital visits can be windows of opportunity to help patients change their health behaviour. An intensified focus on the implementation of hospital-based smoking cessation support is needed.

Impact of a rapid access chest pain clinic in Singapore to improve evaluation of new-onset chest pain.

BACKGROUND: Chest pain (CP) accounts for 5% of emergency department (ED) visits, unplanned hospitalisations and costly admissions. Conversely, outpatient evaluation requires multiple hospital visits and longer time to complete testing. Rapid access chest pain clinics (RACPCS) are established in the UK for timely, cost-effective CP assessment. This study aims to evaluate the feasibility, safety, clinical and economic benefits of a nurse-led RACPC in a multiethnic Asian country. METHODS: Consecutive CP patients referred from a polyclinic to the local general hospital were recruited. Referring physicians were left to their discretion to refer patients to the ED, RACPC (launched in April 2019) or outpatients. Patient demographics, diagnostic journey, clinical outcomes, costs, HEART (History, ECG, Age, Risk Factors, Troponin) scores and 1-year overall mortality were recorded. RESULTS: 577 CP patients (median HEAR score of 2.0) were referred; 237 before the launch of RACPC. Post RACPC, fewer patients were referred to the ED (46.5% vs 73.9%, p < 0.01), decreased adjusted bed days for CP, more non-invasive tests (46.8 vs 39.2 per 100 referrals, p = 0.07) and fewer invasive coronary angiograms (5.6 vs 12.2 per 100 referrals, p < 0.01) were performed. Time from referral to diagnosis was shortened by 90%, while requiring 66% less visits (p < 0.01). System cost to evaluate CP was reduced by 20.7% and all RACPC patients were alive at 12 months. CONCLUSIONS: An Asian nurse-led RACPC expedited specialist evaluation of CP with less visits, reduced ED attendances and invasive testing whilst saving costs. Wider implementation across Asia would significantly improve CP evaluation.

The importance of embedding an inclusive culture within healthcare teamwork education; an evaluation of implementation methods.

Teamworking is a fundamental concept within most organisations and healthcare is no different. It is at the core of everything we do as professionals and has a multitude of impacts including on patient safety, the quality of care that we provide, and staff morale. This paper looks at why we should prioritize advancing teamwork education; argues the advantages of developing an all-encompassing, inclusive team training approach; and summarizes the different methods of how to implement teamwork education within your organisation. Key messages Good teamworking processes have significant effects on patient safety and staff well-being. Inclusive training has wide-reaching benefits for staff morale, fostering colleague relationships and breaking down hierarchies. Teamwork education should be embedded within all healthcare organisations with the method used depending on organisational culture, hierarchy gradient and learners' starting knowledge.

Development and implementation of a postgraduate medical education-wide initiative in quality improvement and patient safety.

BACKGROUND: Quality improvement and patient safety (QIPS) have been assigned a higher profile in CanMEDS 2015, CanMEDS-Family Medicine 2017 and new accreditation standards, prompting an initiative at Dalhousie University to create a vision for integrating QIPS into postgraduate medical education. OBJECTIVE: The purpose of this study is to describe the implementation of a QIPS strategy across residency education at Dalhousie University. METHODS: A QIPS task force was formed, and a literature review and needs assessment survey were completed. A needs assessment survey was distributed to all Dalhousie residency programme directors. 12 programme directors were interviewed individually to collect additional feedback. The results were used to develop a 'road map' of recommendations with a graduated timeline. RESULTS: A task force report was released in February 2018. 46 recommendations were developed with a timeframe and responsible party identified for each. Implementation of the QIPS strategy is underway, and evaluation and challenges faced will be described. CONCLUSIONS: We have developed a multiyear strategy that is available to provide guidance and support to all programmes in QIPS. The development and implementation of this QIPS framework may serve as a template for other institutions who seek to integrate these competencies into residency training.

The use of predictive fall models for older adults receiving aged care, using routinely collected electronic health record data: a systematic review.

BACKGROUND: Falls in older adults remain a pressing health concern. With advancements in data analytics and increasing uptake of electronic health records, developing comprehensive predictive models for fall risk is now possible. We aimed to systematically identify studies involving the development and implementation of predictive falls models which used routinely collected electronic health record data in home-based, community and residential aged care settings. METHODS: A systematic search of entries in Cochrane Library, CINAHL, MEDLINE, Scopus, and Web of Science was conducted in July 2020 using search terms relevant to aged care, prediction, and falls. Selection criteria included English-language studies, published in peer-reviewed journals, had an outcome of falls, and involved fall risk modelling using routinely collected electronic health record data. Screening, data extraction and quality appraisal using the Critical Appraisal Skills Program for Clinical Prediction Rule Studies were conducted. Study content was synthesised and reported narratively. RESULTS: From 7,329 unique entries, four relevant studies were identified. All predictive models were built using different statistical techniques. Predictors across seven categories were used: demographics, assessments of care, fall history, medication use, health conditions, physical abilities, and environmental factors. Only one of the four studies had been validated externally. Three studies reported on the performance of the models. CONCLUSIONS: Adopting predictive modelling in aged care services for adverse events, such as falls, is in its infancy. The increased availability of electronic health record data and the potential of predictive modelling to document fall risk and inform appropriate interventions is making use of such models achievable. Having a dynamic prediction model that reflects the changing status of an aged care client is key to this moving forward for fall prevention interventions.

Pandemic and the human factor.

As the staffing crisis in the UK deepens, it is time for the policy-makers and professional bodies to rethink the approach to the most vital and yet most fragile component of the healthcare system-the human beings. The austerity measures, combined with pandemic and more recently the vision of a backlog with attached unrealistic expectations of tackling it, have brought the NHS and many other healthcare systems to the brink of a crisis. It is a human factors approach, which emphasises clinician's well-being as the core aspect of optimising performance that should become our goal. Delivery of healthcare under circumstances of physical, legal or moral threat cannot be optimal and is not sustainable. The pandemic served to highlight this quite clearly. Also, an injured, tired or burn-out healthcare professional cannot be expected to repair the system that has precipitated his or her condition. The approach to changing the culture of medicine may be multifaceted, but ultimately, we should rethink professionalism and the definition of duty of care putting emphasis on the well-being of those delivering the care as the way to assure best possible care.

Trends and outcomes of ruptured ovarian cysts.

BACKGROUND: Ruptured ovarian cysts are common gynaecological presentation to health institutions with abdominal pain. While this phenomenon is generally self-limiting, surgery may be necessary in cases of haemodynamic compromise or association with torsion. The aim of this audit is to identify the trend of hospital presentations, as well as the review the management of modern gynaecology practice. METHODS: A retrospective audit of all women who presented to the emergency department with an imaging diagnosis of ruptured ovarian cysts was conducted over a 5-year period at St Vincent's Hospital, Sydney. RESULTS: During the study period, 408 women were identified. There was a trend towards conservative management, as observed in 84.7% of women, while the remaining 15.4% underwent surgery. Haemorrhagic or ruptured corpus luteum was the most common diagnoses. As expected, women who had surgical intervention were more likely to have larger cysts (20 vs 50%; p<0.05), and larger free fluid findings on imaging (1.4 vs 23.8%; p<0.05) compared with those managed conservatively. There were no statistically significant differences in location of ovarian cysts (right or left) or antecedent to hospital presentation (vaginal intercourse or trauma). CONCLUSION: Ruptured ovarian cysts of both functional and non-functional types remained a common clinical presentation of acute pain for women to the emergency department. Majority of women were managed conservatively in our cohort, and indications for surgery were large ovarian cysts and large free fluid seen on imaging findings. Surgery was largely feasible with minimal complications.

Enhancing communication between foundation doctors and radiologists: a quality improvement project.

Facilitating radiological imaging for patients is an essential task for foundation year (FY) doctors. Achieving competence in this task can significantly enhance patient management. We evaluated the confidence and skills of FY doctors in facilitating radiological imaging before and after introduction of formal training. Twenty surgical FYs working at a large teaching hospital were surveyed to evaluate their baseline level of competence in booking and discussing imaging with radiology colleagues. Parameters were measured on a Likert scale, including confidence in discussing requests and satisfaction of their own performance following discussions with radiologists. Eight radiology consultants were surveyed to evaluate their opinions on FYs' communication and established areas for improvement. A teaching session was then delivered to improve communication skills. Furthermore, Previous investigation results, Answer you need from the scan, Clinical status and story, Crucial: how urgent is the scan, Safety (PACCSS) poster was introduced to remind the FYs of the salient information required when discussing imaging. One month after the intervention, the initial participants were resurveyed. Based on a 10-point Likert scale, the FYs demonstrated a mean improvement in self-reported confidence (2.1±1.1, p<0.01), and in satisfaction of own performance after a discussion (1.7±1.1, p<0.01). We identified deficiencies in surgical FY doctors' confidence and skills in facilitating radiological imaging. There was a demonstrable benefit with focused training in improving these skills. This could potentially provide significant benefits in patient care and management. Interspecialty communication should be introduced into undergraduate and postgraduate educational curriculum.

A minimalist electronic health record-based intervention to reduce standing lab utilisation.

BACKGROUND: Repetitive laboratory testing in stable patients is low-value care. Electronic health record (EHR)-based interventions are easy to disseminate but can be restrictive. OBJECTIVE: To evaluate the effect of a minimally restrictive EHR-based intervention on utilisation. SETTING: One year before and after intervention at a 600-bed tertiary care hospital. 18 000 patients admitted to General Medicine, General Surgery and the Intensive Care Unit (ICU). INTERVENTION: Providers were required to specify the number of times each test should occur instead of being able to order them indefinitely. MEASUREMENTS: For eight tests, utilisation (number of labs performed per patient day) and number of associated orders were measured. RESULTS: Utilisation decreased for some tests on all services. Notably, complete blood count with differential decreased 9% (p<0.001) on General Medicine and 21% (p<0.001) in the ICU. CONCLUSIONS: Requiring providers to specify the number of occurrences of labs changes significantly reduces utilisation in some cases.

Application of Failure Mode and Effect Analysis (FMEA) to improve medication safety: a systematic review.

Medication safety is a phenomenon of interest in most healthcare settings worldwide. Failure Mode and Effect Analysis (FMEA) is a prospective method to identify failures. We systematically reviewed the application of FMEA in improving medication safety in the medication use process. Electronic databases were searched using keywords ((failure mode and effect analysis) AND (pharmacy OR hospital)). Articles that fulfilled prespecified inclusion criteria were selected and were then screened independently by two researchers. Studies fulfilling the inclusion criteria and cited in articles selected for the study were also included. Selected articles were then analysed according to specified objectives. Among 27€706 articles obtained initially, only 29 matched the inclusion criteria. After adding four cited articles, a total of 33 articles were analysed. FMEA was used to analyse both existing systems and new policies before implementing. All participants of FMEA reported that this process was an effective group activity to identify errors in the system, although time-consuming and subjective.

Clinical Audit Platform for Students (CAPS): a pilot study.

BACKGROUND: A clinical audit measures specific clinical outcomes or processes against a predefined standard. However, many clinicians are unable to carry out audits given their time constraints. Alternatively, medical students may often wish to complete audits early in their career to strengthen their portfolios. As such, the student clinical audit platform was designed to connect willing supervisors and these medical students. METHODS: Project supervisors were members of a regional trainee-led network. Interested students were familiarised with the various aspects of an audit and allocated to supervisors with similar interests. There was regular communication to track progress and anonymised feedback forms were distributed to all students and supervisors after a year. RESULTS: A total of 17 responses were received from the 19 students who were involved in a project. Based on a 5-point Likert scale, students displayed a mean improvement in their understanding of a clinical audit (1.18±1.07, p<0.001), the confidence to approach a supervisor (1.29±1.21, p<0.001) and the ability to conduct an audit by themselves in the future (1.77±1.15, p<0.001). Of the seven affiliated supervisors, five provided feedback with 80% indicating they had projects which remained inactive and all happy with the quality of work produced by their students. CONCLUSION: Despite limitations to this programme, the platform produced projects which were disseminated both locally and nationally, demonstrating positive collaboration between medical students and clinicians. We present our findings and evaluations to encourage similar audit platforms to be adopted at other locations.

Rapid response team integration at a quaternary care academic centre: new paradigm for critical care organistions.

BACKGROUND: Decompensating patients require expeditious and focused care at the bedside. This can be particularly challenging when there are multiple layers of providers, each with differing specialisation, experience and autonomy. We examined the impact of our intensivist-driven hospital-wide rapid response team (RRT) at our 1171-bed quaternary care centre. DESIGN: Single-centre retrospective cohort study. METHODS: RRT service was implemented to assess, manage and triage acutely ill patients outside the intensive care unit (ICU). Criteria for consultation and workflow were established. The 24/7 team was led by an intensivist and included nurse practitioners and respiratory therapists. Over 3 years, we reviewed the impact of the RRT on patient outcomes and critical care support beyond the ICU. RESULTS: Over 3 years, the RRT received 31 392 consults for 12 122 individual patients averaging 30 consults over 24 hours. 58.9% of the calls received were for sepsis alerts/risk of decompensation and 41.1% of the consults were for reasons of acute decompensation. Among patients that were seen by the RRT, over the course of their hospital stay, 14% were upgraded to a step-down unit, 18% were upgraded to the ICU and 68% completed care without requiring any escalation. The average mortality rate for patients seen by the RRT service during their hospital stay was 11.3% with an average 30-day readmission rate of 16.5% and average hospital length of stay 16 days without significant variation between the 3 years. CONCLUSIONS: Intensivist-led RRT ensured consistent high value care. Early intervention and consistent supervision enabled timely and efficient delivery of critical care services.

Discrete choice experiment on educating value-based healthcare.

INTRODUCTION: Identifying costs and values in healthcare interventions as well as the ability to measure and consider costs relative to value for patients are pivotal in clinical decision-making and medical education. This study explores residents' preferences in educating value-based healthcare (VBHC) during postgraduate medical education. Exploring residents' preferences in VBHC education, in order to understand what shapes their choices, might contribute to improved medical residency education and healthcare as a whole. METHODS: A discrete choice experiment (DCE) examined which conditions for educating VBHC are preferred by residents. DCE gives more insight into the trade-off's residents make when choosing alternatives, and which conditions for educating VBHC have the most influence on residents' preference. RESULTS: This DCE shows that residents prefer knowledge on both medical practice as well as the process of care-to be educated by an expert on VBHC together with a clinician. They prefer limited protected time to conduct VBHC initiatives (thus while at work) and desire the inclusion of VBHC in formal educational plans. CONCLUSION: When optimising graduate and postgraduate medical education curricula, these preferences should be considered to create necessary conditions for the facilitation and participation of residents in VBHC education and the set-up of VBHC initiatives.

Validation of phlebotomy performance metrics developed as part of a proficiency-based progression initiative to mitigate wrong blood in tube.

AIMS: The purpose of this study was to (1) characterise the procedure of phlebotomy, deconstruct it into its constituent parts and develop a performance metric for the purpose of training healthcare professionals in a large teaching hospital and to (2) evaluate the construct validity of the phlebotomy metric and establish a proficiency benchmark. METHOD: By engaging with a multidisciplinary team with a wide range of experience of preanalytical errors in phlebotomy and observing video recordings of the procedure performed in the actual working environment, we defined a performance metric. This was brought to a modified Delphi meeting, where consensus was reached by an expert panel. To demonstrate construct validity, we used the metric to objectively assess the performance of novices and expert practitioners. RESULTS: A phlebotomy metric consisting of 11 phases and 77 steps was developed. The mean inter-rater reliability was 0.91 (min 0.83, max 0.95). The expert group completed more steps of the procedure (72 vs 69), made fewer errors (19 vs 13, p=0.014) and fewer critical errors (1 Vs 4, p=0.002) than the novice group. CONCLUSIONS: The metrics demonstrated construct validity and the proficiency benchmark was established with a minimum observation of 69 steps, with no critical errors and no more than 13 errors in total.

Characteristics and predictors of burnout among healthcare professionals: a cross-sectional study in two tertiary hospitals.

BACKGROUND: The pattern and impact of burnout among the medical staff are not yet well defined. However, the consequences of burnout are not limited to the healthcare providers but also may affect their family, colleagues and patients in a negative manner. We aimed to assess the characteristics and predictors of burnout among health professionals at two large tertiary hospitals. METHODS: We conducted a cross-sectional study during the period from July 2018 to 31 December 2018. Data, via Maslach Burnout Inventory survey, were collected from physicians and other healthcare workers in two hospitals. RESULTS: A total of 624 responses to questionnaires were analysed. Half of the respondents were physicians, and men constituted the majority. About 10% (95% CI, 7.8 to 12.5) of the respondents satisfied the criteria of burnout. Emotional exhaustion (EE) was observed in 45.7%, depersonalisation (DP) in 26.9% and personal accomplishment (PA) in 41.2% of the respondents. There was a positive correlation between EE and DP (r=0.627, p=0.001), and a weak negative correlation between DP and PA (r=-0.195, p=0.001). Young age, less experience, trauma surgery, lack of habits and getting depressed ≥1 time/week were predictors of burnout. CONCLUSIONS: Burnout affects one-tenth of the health professionals in the tertiary hospitals in Qatar. Physicians are more likely to have higher DP and lower PA, whereas nurses prone to have higher EE. In this study, no gender discrepancy is appreciated and the junior medical staff is at a higher risk of burnout.

Pharmacists in general practice: a qualitative process evaluation of the General Practice Pharmacist (GPP) study.

BACKGROUND: There is some evidence to suggest that pharmacists integrated into primary care improves patient outcomes and prescribing quality. Despite this growing evidence, there is a lack of detail about the context of the role. OBJECTIVE: To explore the implementation of The General Practice Pharmacist (GPP) intervention (pharmacists integrating into general practice within a non-randomized pilot study in Ireland), the experiences of study participants and lessons for future implementation. DESIGN AND SETTING: Process evaluation with a descriptive qualitative approach conducted in four purposively selected GP practices. METHODS: A process evaluation with a descriptive qualitative approach was conducted in four purposively selected GP practices. Semi-structured interviews were conducted, transcribed verbatim and analysed using a thematic analysis. RESULTS: Twenty-three participants (three pharmacists, four GPs, four patients, four practice nurses, four practice managers and four practice administrators) were interviewed. Themes reported include day-to-day practicalities (incorporating location and space, systems and procedures and pharmacists' tasks), relationships and communication (incorporating GP/pharmacist mode of communication, mutual trust and respect, relationship with other practice staff and with patients) and role perception (incorporating shared goals, professional rewards, scope of practice and logistics). CONCLUSIONS: Pharmacists working within the general practice team have potential to improve prescribing quality. This process evaluation found that a pharmacist joining the general practice team was well accepted by the GP and practice staff and effective interprofessional relationships were described. Patients were less clear of the overall benefits. Important barriers (such as funding, infrastructure and workload) and facilitators (such as teamwork and integration) to the intervention were identified which will be incorporated into a pilot cluster randomized controlled trial.

Simple budget-neutral tool to improve intraoperative communication.

BACKGROUND: Communication failure is a common cause of medical errors and adverse events. Within the operating room (OR), there are many barriers to good communication, which can adversely affect patient outcome. OBJECTIVE: Implementing a simple, cost-neutral tool aimed at improving intraoperative communication and engagement. METHODS: Three anaesthesiology residents collected data using a data sheet and tailored surveys distributed to OR staff. Data were collected over a 2-week period in 2019, with 1 week each of preintervention and postintervention data collection. The intervention consisted of wearing OR caps displaying the first name and role of the anaesthesia resident clearly on the front. RESULTS: A total of 20 data sheets and 48 preintervention and postintervention surveys were collected for a response rate of 57%. There was a statistically significant increase in OR staff knowledge of the anaesthesia resident's name (66% vs 100%, p=<0.001), an increase in the mean number of times the surgical providers addressed the anaesthesia residents (3.6 vs 7.8, p=0.0074) and an increase in the mean number of times the surgical providers addressed them by their first name (0.7 vs 4, p=0.0067). Comments received during the intervention were positive with overwhelming support. CONCLUSIONS: This study demonstrated that a simple, cost-effective intervention can result in dramatic improvement in intraoperative communication and engagement between teams.