An analytic observational study on complaints management in the general practice out of hours care setting: who complains, why, and what can we do about it?

BACKGROUND: General Practice Co-Operatives provide most out of hours care in communities in Ireland. Limited data exists on patient complaints. This study reports on complaints at Kildare and West Wicklow Doctors on Call ('K Doc'), a GP Co-Operative in Ireland, examining the impact of a formal risk reduction strategy implemented (2010-2013). The aim of the study was to determine if it was possible to reduce the rate of written complaints per 1000 consultations through a formal approach encompassing evaluation of complaints, improved communication in relation to complaints, and more direct use of insights gained from complaints analysis in continuing professional development at the Co-Operative. METHODS: Initially, complaints submitted over an 18 month period (01.06.08 to 31.12.09) were analysed. Complaint rate (number of complaints per 1000 consultations), complainant demographics, aspects of complaint response at the Co-Operative, and nature of complaint were recorded. Based on analysis, a risk reduction strategy was undertaken, including procedural change, focused training and education. Areas selected for improvement during a second phase of data collection included complaints rate, timeliness of Co-Operative response to complaint, and rate of complaint notification to patient's GP. Further analysis was then carried out over a 45 month period (01.01.10 to 30.09.13). RESULTS: From 2008-2013, 216,716 patient consultations occurred. Complaints were received from 131 individuals, regarding 125 patients. Following introduction of risk reduction strategy, complaints rate reduced by 36 %, from 0.77 to 0.49 per 1000 consultations (p = 0.02) between the two periods of data collection. Timeliness of response from Co-Operative to the complainant improved from 63 % to 75 %. Notification of complaint to the patient's GP improved from 48 % to 96 %. Most complaints were not associated with medically significant events. The largest categories of complaint related to clinical care (55 % n = 69), cost (46 %, n = 58), communication (42 %, n = 53), and process of care (15 %, n = 19). Mothers of affluent paediatric patients were most likely to make formal complaints. CONCLUSIONS: This study reports a statistically significant reduction in complaints rate of 36 % following introduction of risk reduction strategies at a GP Co -Operative. Out of hours consulting is known to be an area of high medical risk. Findings are of interest where number and costs of complaints against GPs are elsewhere reported to be rising, contributing to medical inflation, and to public concern.

The Association Between Borderline Dysnatremia and Perioperative Morbidity and Mortality: Retrospective Cohort Study of the American College of Surgeons National Surgical Quality Improvement Program Database.

BACKGROUND: Hyponatremia and hypernatremia, as conventionally defined (<135 mEq/L and >145 mEq/L, respectively), are associated with increased perioperative morbidity and mortality. However, the effects of subtle deviations in serum sodium concentration within the normal range are not well-characterized. OBJECTIVE: The purpose of this analysis is to determine the association between borderline hyponatremia (135-137 mEq/L) and hypernatremia (143-145 mEq/L) on perioperative morbidity and mortality. METHODS: A retrospective cohort study was performed using data from the American College of Surgeons National Surgical Quality Improvement Program database. This database is a repository of surgical outcome data collected from over 600 hospitals across the United States. The National Surgical Quality Improvement Program database was queried to extract all patients undergoing elective, noncardiac surgery from 2015 to 2019. The primary predictor variable was preoperative serum sodium concentration, measured less than 5 days before the index surgery. The 2 primary outcomes were the odds of morbidity and mortality occurring within 30 days of surgery. The risk of both outcomes in relation to preoperative serum sodium concentration was modeled using weighted generalized additive models to minimize the effect of selection bias while controlling for covariates. RESULTS: In the overall cohort, 1,003,956 of 4,551,726 available patients had a serum sodium concentration drawn within 5 days of their index surgery. The odds of morbidity and mortality across sodium levels of 130-150 mEq/L relative to a sodium level of 140 mEq/L followed a nonnormally distributed U-shaped curve. The mean serum sodium concentration in the study population was 139 mEq/L. All continuous covariates were significantly associated with both morbidity and mortality (P<.001). Preoperative serum sodium concentrations of less than 139 mEq/L and those greater than 144 mEq/L were independently associated with increased morbidity probabilities. Serum sodium concentrations of less than 138 mEq/L and those greater than 142 mEq/L were associated with increased mortality probabilities. Hypernatremia was associated with higher odds of both morbidity and mortality than corresponding degrees of hyponatremia. CONCLUSIONS: Among patients undergoing elective, noncardiac surgery, this retrospective analysis found that preoperative serum sodium levels less than 138 mEq/L and those greater than 142 mEq/L are associated with increased morbidity and mortality, even within currently accepted "normal" ranges. The retrospective nature of this investigation limits the ability to make causal determinations for these findings. Given the U-shaped distribution of risk, past investigations that assume a linear relationship between serum sodium concentration and surgical outcomes may need to be revisited. Likewise, these results question the current definition of perioperative eunatremia, which may require future prospective investigations.

Preeclamptic serous retinal detachment without hypertension: A case report.

Preeclampsia is a disease of pregnancy classically defined by the development of new-onset hypertension and proteinuria. Serous retinal detachment is a rare complication of severe preeclampsia that is associated with a high incidence of morbidity and mortality. We present the case of a 24-year-old primigravida who was diagnosed with preeclamptic serous retinal detachment at 30 weeks of gestation that occurred in the absence of hypertension. The patient was delivered by cesarean section for fetal malpresentation and she had complete recovery of her vision by three months postpartum. Providers should exercise vigilance for preeclampsia in women presenting with new-onset visual symptoms, even in the absence of hypertension.

End-of-life planning with frail patients attending general practice: an exploratory prospective cross-sectional study.

BACKGROUND: End-of-life planning means decision making with patients, formulating and recording decisions regarding their end-of-life care. Although clearly linked with benefits including improved quality of life, reduced hospital admissions, and less aggressive medical care, it is still infrequently undertaken and is regarded as challenging by healthcare professionals. AIM: To ascertain the feasibility of improving the identification of patients at high risk of dying in general practice and the acceptability of providing patients identified with an end-of-life planning tool. DESIGN AND SETTING: Exploratory prospective cross-sectional study in four general practices. METHOD: Patients at high risk of dying were identified during routine consulting by their GP, using the Supportive and Palliative Care Indicators Tool (SPICT). Patients identified were invited to participate, and provided with Think Ahead - an end-of-life planning tool, which has been used previously in general practice. Participants completed telephone surveys, assessing their response to Think Ahead, and the acceptability of the GP raising end-of-life issues during routine consulting. RESULTS: Provision of Think Ahead to a purposive sample of preterminal patients identified by GPs was feasible, acceptable to most patients, and somewhat effective in increasing discussion among families and in practice on end-of-life planning. CONCLUSION: The SPICT and Think Ahead tools were mostly acceptable, effective, and enabling of discussions on end-of-life care in general practice.