Development of a Model for Video-Assisted Postoperative Team Debriefing.

BACKGROUND: Video-assisted debriefing may be a powerful tool to improve surgical team performance. Nevertheless, a true operating team debriefing culture is lacking to date. This study aimed to find evidence on how to debrief the surgical team and develop a model suitable for debriefing using a video and medical data recorder (MDR) in the operating room (OR). METHODS: A review of the PubMed and Embase databases and Cochrane Library was performed. The identified literature was studied and combined with a conceptual framework to develop a model for postoperative video-assisted team debriefing. Thirty-five surgical cases were recorded with an MDR and debriefed with the operating team using the proposed debrief model and a standardized video-assisted performance report. A questionnaire was used to assess the participants' satisfaction with this debrief model. RESULTS: Debrief models and methods are extensively described in the current medical literature. An overview was provided. The OR team needs a structured debrief model, minimizing resource, effort, and motivational constraints. A structured six-step team debrief model suitable for video-assisted OR team debriefing was developed. The model was tested in 35 multidisciplinary MDR-assisted debriefing sessions and the debriefing sessions were overall rated with a mean of 7.8 (standard deviation 1.4, 10-point Likert scale) by participants. CONCLUSIONS: Debriefing surgical teams using a video and MDR in the OR requires a model on how to use such recordings optimally. To date, no such model existed. The proposed debrief model was tested using a multisource MDR and may be used to facilitate OR debriefing across various settings.

Evaluating the Psychopathological Profile of Women Undergoing Reduction Mammaplasty With the Symptom Checklist-90-Revised.

BACKGROUND: Patients who desire reduction mammaplasty (RM) also may seek relief from social and emotional challenges that accompany their physical condition, including low self-confidence and impaired body image. Reduction mammaplasty is known to improve patients' physical and psychological well-being. It may be speculated that patients who undergo RM are motivated by psychological problems and have psychopathologies. Health care insurers reluctant to cover the expense of this surgery may cite mental health as a reason to deny coverage. OBJECTIVES: The authors assessed the psychopathological profile of patients who presented for RM, utilizing a validated instrument, and compared scores with standard norm values. METHODS: Preoperatively, 67 women were assessed with the Symptom Checklist-90-Revised (SCL-90-R), a validated instrument for evaluating a broad range of psychopathological problems and symptoms. The SCL-90-R provides a general psychoneurosis score, as well as scores for 8 symptom subscales. RESULTS: The mean patient age was 36 ± 11.2 years. The mean (SD) total score on the SCL-90-R was 130 (38.7), which was not significantly higher than the norm score of 123. Only the subscores for somatization and sleep disturbance were significantly higher than the norm scores for these subscales. Compared with the norm score for women who presented with chronic pain, the total score for our study population was significantly lower. CONCLUSIONS: Patients who undergo RM have normal scores for psychoneurosis according to the SCL-90-R. Health care insurance coverage for RM should not be denied on the basis that the motivation for surgery relates to psychopathology. Additionally, psychological testing is not recommended for most patients who desire breast reduction surgery; rather, clinical judgment based on common sense should be applied. LEVEL OF EVIDENCE: 3.

Improving teamwork and communication in the operating room by introducing the theatre cap challenge.

OBJECTIVE: One of the steps of the Surgical Safety Checklist is for the team members to introduce themselves. The objective of this study was to implement a tool to help remember and use each other's names and roles in the operating theatre. METHODS: This study was part of a pilot study in which a video and medical data recorder was implemented in one operating theatre and used as a tool for postoperative multidisciplinary debriefings. During these debriefings, name recall was evaluated. Following the implementation of the medical data recorder, this study was started by introducing the theatre cap challenge, meaning the use of name (including role) stickers on the surgical cap in the operating theatre. FINDINGS: In total, 41% (n = 40 out of 98) of the operating theatre members were able to recall all the names of their team at the team briefings. On average 44.8% (n = 103) was wearing the name sticker. CONCLUSIONS: The time-out stage of the Surgical Safety Checklist might be inadequate for correctly remembering and using your operating theatre team members' names. For this, the theatre cap challenge may help.

[Revised Dutch GP guideline 'Depression': diagnosis not as simple as it appears]. / De nieuwe NHG-standaard 'Depressie': diagnostiek niet zo simpel als het lijkt.

The revised Dutch guideline on depression in primary care is excellent. However, there is potential for misinterpretation when counting symptoms - an essential part of diagnosis. In the DSM-IV twenty-one symptoms are classified into 9 clusters. When using this guideline, it is possible to read 'decreased energy or tiredness', not 'and', so the 'or' leads to counting 2 symptoms instead of 1. Symptoms important for diagnosis include a period of at least 2 consecutive weeks during which mood is either depressed or there is loss of interest or pleasure in activities which persists for most of the day, nearly every day. This indicates low reactivity. If these decision rules are not properly understood too many diagnoses of depression may be made. The guideline pays no attention to personality problems, enabling patients to attribute their symptoms to problems of life and thus rule out their own behaviour. To make them responsible for their own actions in as far as this is possible, will be difficult.

Presentation of the Multidisciplinary Guideline Medically Unexplained Physical Symptoms (MUPS) and Somatoform Disorder in the Netherlands: disease management according to risk profiles.

OBJECTIVE: January 2011, the Dutch Multidisciplinary Guideline for Medically Unexplained Symptoms (MUPS) and Somatoform Disorder (SD) was published. The aim was to set a standard for multidisciplinary prevention, diagnosis and treatment of MUPS and SD. METHODS: First, the Multidisciplinary Guideline group defined a conceptual approach for the guideline. After this, a systematic literature review, followed by consensus meetings in the Multidisciplinary working group, aimed to answer the following questions: 1) What evidence exists for preventive interventions, including the patient-doctor communication in MUPS and SD? 2) How can the diagnosis of MUPS be established? 3) What effective treatments of MUPS are available? 4) Which types of treatment are most effective for which patients? RESULTS: As conceptual approach for the guideline, based on existing literature, in this guideline MUPS are considered a category of symptoms that have many common aspects and are best approached by one, generic approach. 1) Research for preventive interventions and the patient-doctor relationship in MUPS and SD is scanty. 2) To establish the diagnosis of MUPS or SD, the GP should follow a parallel somatic-psychosocial diagnostic step plan. 3) A Systematic Review identified Cognitive Behavioral Treatment (CBT), treatment of comorbid depressive and anxiety disorder, psychiatric consultation with a Consultation Letter to General Practitioners (GPs) and stepped care as evidence based interventions for MUPS and SD. 4) In order to apply the best fitting treatment to patients, patient risk profiles were formulated to guide stepped-care treatment that should start at an appropriate level and treatment setting. Three levels are discerned: Low risk patients need reassurement by the GP. Moderate risk patients suffer from comorbidity. They need case-management and generally can be treated by the GP as well, who can be supported by psychiatric consultation. High risk patients often have long term SD and a perturbed patient-doctor relationship with their GP. For this group, specialist mental health treatment is needed. CONCLUSION: Disease-managament based on risk profiles, providing stepped care and case management by the GP, supported by psychiatric consultation with a consultation letter, and mental health in-patient multidisciplinary treatment for severe cases, is the recommended strategy of the Dutch Multidisciplinary Guideline for MUPS and SD.

[The Dutch multidisciplinary guideline entitled 'Medically unexplained physical symptoms and somatoform disorder']. / De Nederlandse multidisciplinaire richtlijn 'Somatisch onvoldoende verklaarde lichamelijke klachten en somatoforme stoornissen'

The Dutch multidisciplinary guideline called 'Medically unexplained physical symptoms (MUPS) and somatoform disorder' presents a disease-management approach based on three pillars: (a) maintaining patient profiles estimating the risk of iatrogenic harm as well as chronicity, (b) stepped-care treatment starting at a level appropriate for the patient's profile, and (c) the introduction of the family physician as case manager (in serious cases: the medical specialist or psychiatrist) whose task is to channel use of the health care system. Patients with a 'minor risk' profile require psycho-education and two-track treatment by the family physician. The 'moderate risk' profile is complicated by co-morbid depression, anxiety disorder or a somatic disorder; the prognosis is favourable when this co-morbidity is treated. The 'serious risk' profile is assigned to patients with long-term somatoform disorders and a history of surgery for MUPS in addition to disturbed patient-doctor relationships. Limiting iatrogenic harm is of highest priority in these patients. Implementation should focus on providing access to care as described in the guideline.

[Knowing better--does pride lead to persisting with superfluous procedures?]. / Beter weten dan de wetenschap--leidt hoogmoed tot het volharden in onnodige handelingen?

Hubris, or pride, is one of the seven cardinal sins, which can manifest itself in over-confidence, incorrect heuristics and biased reasoning. If a tendency to 'know better' leads to performing superfluous procedures, it is an expression of Hubris. Superfluous procedures can be defined as "generally accepted procedures the effectiveness of which can be invalidated on the basis of scientific knowledge". If such superfluous procedures are carried out as a result of pride they can lead to a waste of money, time and resources and may even harm the patient. Superfluous procedures cover the entire spectrum of medical screening, diagnosis and treatment. Carrying out superfluous procedures such as unnecessary referrals or requesting unnecessary diagnostic tests simply to placate the patient is unwarranted. A return to economically viable and worthwhile healthcare can be brought about by thinking in terms of surplus value for the patient and by recognising, admitting and combating Hubris.

Adjuvant occupational therapy for work-related major depression works: randomized trial including economic evaluation.

BACKGROUND: Major depression has far-reaching consequences for work functioning and absenteeism. In most cases depression is treated by medication and clinical management. The addition of occupational therapy (OT) might improve outcome. We determined the cost-effectiveness of the addition of OT to treatment as usual (TAU). METHOD: Sixty-two adults with major depression and a mean absenteeism of 242 days were randomized to TAU (out-patient psychiatric treatment) or TAU+OT [6 months, including (i) diagnostic phase with occupational history and work reintegration plan, and (ii) therapeutic phase with individual sessions and group sessions]. Main outcome domains were depression, work resumption, work stress and costs. Assessments were at baseline and at 3, 6, 12 and 42 months. RESULTS: The addition of OT to TAU: (i) did not improve depression outcome, (ii) resulted in a reduction in work-loss days during the first 18 months, (iii) did not increase work stress, and (iv) had a 75.5% probability of being more cost-effective than TAU alone. CONCLUSION: Addition of OT to good clinical practice does not improve depression outcome, improves productivity without increasing work stress and is superior to TAU in terms of cost-effectiveness.

Switching antidepressants after a first selective serotonin reuptake inhibitor in major depressive disorder: a systematic review.

OBJECTIVE: Selective serotonin reuptake inhibitors (SSRIs) are frequently used as a first antidepressant for major depressive disorder but have response rates of 50% to 60% in daily practice. For patients with insufficient response to SSRIs, switching is often applied. This article aims to systematically review the evidence for switching pharmacotherapy after a first SSRI. DATA SOURCES: A systematic literature search (updated until Feb. 10, 2005) in MEDLINE, EMBASE, CINAHL, and PsychINFO (all indexed years) identified randomized, controlled trials (RCTs) and open studies investigating switching strategies. In the absence of specific keywords for switching, we performed "sensitive" searches using free text words with wildcards ($): "switch$" or ("alternat$" adj5 "treat$") or ("alternat$" adj5 "therap$") in combination with the Cochrane Collaboration search filter for RCTs, the Cochrane Collaboration Depression Anxiety and Neurosis Group search filter for major depressive disorder, and MeSH terms for antidepressants (in combination with additional text words for all antidepressive agents). Additionally, we included 4 recent Sequenced Treatment Alternatives to Relieve Depression publications. We limited searches to adults and humans but did not apply language restrictions. STUDY SELECTION: Relevant articles were retrieved and critically appraised. The methodology of the studies, the results on efficacy and dropouts due to side effects, and remarks were summarized in an evidence table. Three studies comparing a switch to venlafaxine or SSRIs were pooled. DATA SYNTHESIS: Eight RCTs and 23 open studies were identified, studying populations with different levels of treatment resistance. Definitions of response and remission rates varied between studies. Observed response rates after switching to any of the classes of antidepressants varied between 12% and 86%. Remission rates varied between 7% and 82%. The number of previous treatments with antidepressants was negatively correlated with treatment outcome. Rates of dropout due to side effects varied considerably across agents (5%-39%). Switching to venlafaxine showed a modest and clinically equivocal benefit over SSRIs (number needed to treat = 13 [95% CI = 9.1 to 25.0]). CONCLUSIONS: After a first SSRI, any switch within or between classes of antidepressants appears legitimate (second SSRI, novel dual-acting antidepressants, selective norepinephrine or nor-adrenergic/dopaminergic agents, or tricyclic anti-depressant or mianserin). No unequivocal evidence is available to prove an advantage of a between-class switch. More guidance by randomized empirical studies is needed. Clinical implications and methodological considerations for future studies are discussed.

Dose escalation for insufficient response to standard-dose selective serotonin reuptake inhibitors in major depressive disorder: systematic review.

BACKGROUND: Although selective serotonin reuptake inhibitors (SSRIs) are frequently used for major depressive disorder, only 50-60% of patients respond to a standard dose. For non-responders, dose escalation is often applied. AIM: To systematically review the evidence for dose escalation of SSRIs. METHOD: A systematic literature search in MEDLINE, EMBASE, CINAHL and PsycInfo was performed. Randomised controlled trials and meta-analyses investigating dose escalation of SSRIs were identified. Relevant articles were retrieved and critically appraised. Results were summarised in an evidence table. Pooling was not justified because of heterogeneity of the identified studies. RESULTS: Eight true dose-escalation studies and three meta-analyses were identified. The available data provided no unequivocal base for dose escalation. Dose escalation before 4 weeks of treatment at a standard dose appeared to be ineffective. CONCLUSIONS: Dose escalation of SSRIs is equivocally supported by evidence of randomised controlled trials; methodological difficulties in the studies may account for this lack of evidence.