Planejamento da assistência ao paciente hospitalizado na unidade de terapia intensiva oncológica na perspectiva dos cuidados paliativos / Patient care planning hospitalized in the intensive care unit Oncology palliative care perspective

A pessoa com câncer avançado pode necessitar de hospitalização e em muitas situações, influenciadas pelas incertezas no momento de sua entrada nos serviços é indicada à terapia intensiva. Nestes casos, o planejamento da assistência pode ser conflitante e desafiador e resultar em investimentos obstinados terapeuticamente para oferecer ao paciente uma condição de sobrevivência não mais que vegetativa. Assim, objetivou-se: analisar o entendimento dos profissionais da equipe de saúde multidisciplinar acerca da assistência ao paciente sem possibilidades terapêuticas para a cura no contexto da unidade de terapia intensiva (UTI) oncológica e discutir os objetivos que os profissionais da equipe de saúde buscam alcançar ao planejar esta assistência, na perspectiva dos cuidados paliativos. Estudo descritivo, qualitativo, realizado com profissionais da equipe de saúde multidisciplinar, a saber: enfermeiros, médicos, fisioterapeutas e nutricionistas, que atuam na UTI adulto do Hospital do Câncer I, Instituto Nacional de Câncer, localizado no município do Rio de Janeiro, Brasil. Os dados foram coletados no período entre dezembro de 2015 e maio de 2016. A técnica de coleta de dados utilizada foi a entrevista semiestruturada e os dados foram analisados seguindo referencial metodológico da análise temática, resultando em seis principais núcleos temáticos. Os profissionais descreveram o perfil da clientela adulta em cuidados intensivos na oncologia como peculiar, com predomínio de pacientes para cuidados de fim de vida. Apesar disso, evidenciou-se ausência de um planejamento assistencial estratégico para os pacientes em situação de terminalidade da vida na UTI oncológica, bem como o reconhecimento dos desafios, principalmente éticos, dos processos relacionados com a sua complexidade. No entanto, sinaliza-se uma consciência por parte desses profissionais da importância de se garantir aos pacientes em cuidados intensivos condições terapêuticas menos danosas e sofridas, com vistas a respeitar a dignidade humana no processo de morrer. Contudo, dificuldades foram apontadas na adoção de melhores práticas assistenciais, dentre elas a falta de conhecimento específico, comunicação ineficaz, deficiências relacionadas ao processo de formação profissional sobre cuidados paliativos, necessidade de conscientização de todas as pessoas envolvidas no processo, déficit de recursos humanos, acúmulo de funções, falta de protocolos que norteiem tal assistência e a complexidade no processo de gestão (triagem e alocação) da clientela diante da atual estrutura hospitalar. Desponta como principal estratégia para viabilizar uma prática assistencial humanizada na perspectiva dos cuidados paliativos a necessidade de capacitação da equipe com investimento maciço na educação dos profissionais acerca dos preceitos paliativos, assim como a implementação de estratégias que minimizem o déficit de comunicação entre as equipes, visando favorecer a qualidade da assistência prestada na UTI oncológica. Para integração entre os cuidados curativos e paliativos na UTI oncológica sugere-se o modelo interconsultivo, uma vez que a instituição possui capital humano detentor deste conhecimento específico.(AU)

Interviewers' and interviewees' perceptions of the changes in recruitment of orthodontic specialty registrars.

AIM: To assess interviewers' and interviewees' perceptions of the National Recruitment for Orthodontic Specialty Registrars in 2012. DESIGN: Cross-sectional survey. METHODS: Interviewers and interviewees completed an anonymous questionnaire comprising of 25 and 16 questions, respectively. Statistical analysis included descriptive statistics and frequency distributions. RESULTS: All interviewees (83/83) and 88% (36/41) of interviewers completed the questionnaires. Of the interviewees, 61% were female; their mean age was 28·9 years (95% CI: 28·2-29·6). The mean time since bachelor of dental science (BDS) was 5·6 years (95% CI: 4·9-6·3) with 78% qualifying from a UK university. The interviewees preferred the multi-station interview (MSI) format, considered the questions easy to understand and thought that MSI was fairer than traditional interviews. Of the interviewers, 56% were male; their mean age was 45·5 years (95% CI: 43·0-48·0). The mean time that they had been a consultant was 11·4 years (95% CI: 8·7-13·1). The interviewers thought that the interviews were fair, tested an appropriate range of competences, selected the best candidates to be appointed and would appoint the same people if repeated. CONCLUSIONS: Interviewees were very positive about the organization and perceived fairness of the MSI format. Interviewers were positive about the selection of candidates, fairness and conduct of the MSI format.

An evaluation of senior house officer training in oral and maxillofacial surgery.

UNLABELLED: The senior house officer (SHO) is a training post but there is concern over whether service commitments are impinging on this. The European Working Time Directive (EWTD) and Foundation Programme have recently been introduced to try and improve working lives and training quality respectively. AIM: To examine the current perceptions of SHO training in relation to the recommended standards in the UK, and to compare the level of training with data sets from the survey in 2002 (Keith and Durham 2002). METHOD: A questionnaire using Likert, dichotomous and free text responses was posted to all SHOs in oral and maxillofacial surgery (OMFS) in the UK. The questionnaire was almost identical to that used in a previous national survey (Keith and Durham 2002). The data set from the previous survey was available thereby allowing statistical comparisons to be made. RESULTS: An estimated response rate of 56% was achieved (n = 228). Forty-eight percent of respondents felt undergraduate BDS training was inadequate for their job, and the longer individuals had been qualified the less they felt out of their depth (r = 0.452, p <0.0001). These findings were consistent with the previous survey. Formal training in medical examination of patients had been provided to 58%, which was slightly less than previously (64%). Over half of those responding had regular supervised local anaesthetic minor oral surgery sessions (55%), and outpatient clinics with a designated trainer (54%). A minority of trainees had not had any appraisal (27%). The majority of respondents (79%) stated their rota was EWTD-compliant. CONCLUSION: Improvements have been made but the introduction of a national structured programme could help standardise training.

Reducing postoperative pain by changing the process.

Untreated postoperative pain is an important ethical and financial issue that can lead to unnecessary suffering and prolonged stays in hospital. Despite the availability of effective analgesics and a growing body of published material that supports their use, postoperative pain remains a problem worldwide. To reduce acute postoperative pain, we introduced an intervention combining evidence-based analgesic protocols with the education of staff and patients on a surgical ward. The experiences of 68 patients before and 80 patients after the intervention were compared (worst pain scores, duration of pain, and satisfaction). Inadequately controlled pain was significantly reduced after the intervention, which suggests that the introduction of analgesic protocols supported by the education of staff and patients can be beneficial. Despite this, severe pain remained relatively common, indicating room for improvement. Duration of pain and patient satisfaction were not affected by the intervention, and patient satisfaction remained high throughout the study.

An assessment of the competence and experience of dentists with the management of medical emergencies in a Nigerian teaching hospital.

BACKGROUND: Previous reports show that medical emergency events have ocurred in Teaching Hospital Dental centres, with attendant mortality and morbidity. OBJECTIVES: (1) To study the pattern of medical emergencies encountered by clinical dental staff of Lagos University Teaching Hospital (2) To evaluate their training, perception of their training and competence as undergraduates and postgraduates to manage such events. METHODS: All the clinical staff viz: Dental surgeons of different cadres--consultants, registrars, house surgeons and dental nurses of Lagos University Teaching Hospital. A structured questionnaire requesting to know demographic data, respondents attendance of life support training viz: Basic life support (BLS), advanced trauma life support (ATLS), intensive care support (ICS). A self rating in the competence of management of medical emergencies and previous personal encounter with medical emergencies with success/failure in the management with/or without medical colleage assistance were sought. In addition adequacy of their dental clinic/centres for drugs, equipments and their perceived readiness to deal with emergencies were enquired. RESULTS: Among the dental surgeons, 20 (26.6%) were consultants, 40 (53.3%) were registrars and 35 (46.6%) were house-officers. Thirty five (43.7%) had previous knowledge of basic life support (BLS) training, while 45 (56.2%) denied such knowledge. The figures for other trainings such as advanced trauma life Support (ATLS) was 8 (10%) and intensive care support (ICS) 2 (2.5% 73.3% of the respondents felt inadequate in the management of cardiovascular emergencies, while only 15.4% felt adequately prepared. Similar ratings for respiratory emergencies are 63.1% inadequacy, 16.9% adequacy, and only 3.3% felt very adequate. The availability of oxygen extension tubing and ambu bag was nil in all departments. Emergency drugs were claimed to be present by 28.5% oral surgery respondents and, 34.7% Child Dental Health respondents. Most of the respondents felt their clinics are not adequately prepared to deal with medical emergencies. CONCLUSION: The study showed that syncope is the commonest medical emergency event in dental surgery practice in our teaching hospital, others are bleeding, seizure disorders and asthmatic attacks. The constitution of hospital emergency team (consisting of cardiologists, anaesthetists) as done in advanced countries is advocated and dentists should ensure that the departmental staff are adequately trained to provide basic life support.

A unique role for dental school faculty: telephone triage training and integration into a health departments' emergency response planning.

OBJECTIVE: Dental professionals with proper training and integration into existing protocols for mobilization can be one additional resource during catastrophic events. A pilot project on training of dental school faculty in telephone triage in the event of an avian flu pandemic is described. A partnership was established with a grant from the Department of Justice/Department of Homeland Security, between the New York City Department of Health and Mental Hygiene, and New York University to initiate a pilot program to increase the manpower resources available to the health agency should an overwhelming public health event be present in the New York City area. METHODS: Eight faculties from New York University College of Dentistry were selected to receive telephone triage training consisting of 15 hours of formal presentations. This training was specifically designed to give participants a background in "outbreak investigations," and included a mock influenza outbreak. Also, a "phone triaging" training during a surge event was practiced. RESULTS: The training resulted in enabling alternative healthcare providers as capable personnel and one alternative source for a surge manpower pool. This was the innovative use of dental school faculty to bolster critically understaffed and overwhelmed areas in the NYCDOHMH infrastructure, such as call centers and for telephone triage, in their disaster scenarios, particularly in their response to avian flu. CONCLUSIONS: The established public health systems and medical community must understand the need to preplan for medical surge events and accept that a potential source of additional manpower could be the dental profession or other nontraditional healthcare personnel.

How we do it: training in airway management for a head and neck unit.

Experience and confidence in the management of the airway is highly variable among junior surgical trainees, who are usually the first on scene when problems arise, particularly out of hours. Juniors must possess the skills required to recognise and institute appropriate management in an airway emergency. We describe a local training programme, an airway equipment trolley, and a protocol for recognition, stabilisation, and management, in case of an airway emergency.

A comparison of knowledge of local analgesia, pulp therapy and restoration of primary molar teeth amongst dental students, dentists and dental therapists within a dental hospital setting.

AIM: To gain an overview of knowledge of local analgesia, pulpal therapy and restorative procedures in the primary dentition amongst dental undergraduate students (DS), dental therapy students (DTS), recently-qualified dentists (QD) and dental therapists (DT), working within a Dental Hospital setting. STUDY DESIGN: A survey undertaken at Dundee Dental Hospital and School, NHS Tayside, United Kingdom to determine current knowledge regarding the use of local analgesia, pulp anatomy and pulp therapy techniques in addition to restoration of primary teeth. RESULTS: Data were available for 24 individuals (DS: 5; QD: 6; DTS: 8; DT: 5). Deficiencies in knowledge regarding the maximum safe dose for local analgesia, pulp canal anatomy, pulp therapy medicaments and the preparation required prior to placement of a pre-formed metal crown were noted in both student and staff groups. CONCLUSIONS: The knowledge of basic dental procedures for children amongst a group of dental students, student dental therapists and recently qualified dentists and dental therapists, was found to be imperfect. These findings indicate that more research is needed on the educational procedures used in the transfer of such knowledge and skills. Deficiencies in knowledge were identified in all areas assessed. Courses should be designed at both the pre- and postgraduate level to address and avoid such gaps in knowledge.

Anaesthetists and the standard of preoperative assessment by dentally-qualified hospital staff.

Our aims were to seek the opinion of consultant anaesthetists about the competence of maxillofacial SHOs to make preoperative assessments, and to compare the competence of maxillofacial SHOs with that of medically-trained SHOs in preoperative assessment as assessed by consultant anaesthetists. We concluded that most of the consultant anaesthetists who replied to our questionnaire were satisfied with the standard of preoperative assessment by maxillofacial SHOs.

Proposed educational objectives for hospital-based dentists during catastrophic events and disaster response.

The purpose of this project was to define education and training requirements for hospital-based dentists to efficiently and meaningfully participate in a hospital disaster response. Eight dental faculty with hospital-based training and/or military command and CBRNE (chemical, biological, radiological, nuclear, and explosive) expertise were recruited as an expert panel. A consensus set of recommended educational objectives for hospital-based dentists was established using the following process: 1) identify assumptions supported by all expert panelists, 2) determine current advanced dental educational training requirements, and 3) conduct additional training and literature review by various panelists and discussions with other content and systems experts. Using this three-step process, educational objectives that the development group believed necessary for hospital-based dentists to be effective in treatment or management roles in times of a catastrophic event were established. These educational objectives are categorized into five thematic areas: 1) disaster systems, 2) triage/medical assessment, 3) blast and burn injuries, 4) chemical agents, and 5) biological agents. Creation of training programs to help dentists acquire these educational objectives would benefit hospital-based dental training programs and strengthen hospital surge manpower needs. The proposed educational objectives are designed to stimulate discussion and debate among dental, medical, and public health professionals about the roles of dentists in meeting hospital surge manpower needs.

Teaching of the assessment of head and brain injury in UK dental schools--The Headway Survey.

Under the auspices of Headway--the brain injury association, the charity supplies information on head/brain injury and runs a telephone advice line: (0115 924 0800). Questionnaires regarding the undergraduate teaching related to head/brain injuries were sent to, and returned by, all 12 UK dental schools. The replies suggest that undergraduate teaching of this subject is patchy and inadequately prepares dentists to recognise and cope with patients who may have had head, and consequently brain, injuries. It is recommended that dental schools review their teaching of this subject and ensure that it is consistent with the current guidelines issued by the National Institute of Clinical Excellence (NICE) on the recognition of head injury and that the findings are brought to the attention of the General Dental Council in the context of the GDC's "The first five years" report.

Current products and practices: curriculum development in orthodontic specialist registrar training: can orthodontics achieve constructive alignment?

This paper aims to encourage a debate on the learning outcomes that have been developed for orthodontic specialist education. In outcome-based education the learning outcomes are clearly defined. They determine curriculum content and its organization, the teaching and learning approaches, the assessment techniques and hope to focus the minds of the students on ensuring all the learning outcomes are met. In Orthodontic Specialist Registrar training, whether constructive alignment can be achieved depends on the relationship between these aspects of the education process and the various bodies responsible for their delivery in the UK.

Bridging the gap--vocational trainee to senior house officer: a new induction course.

OBJECTIVES: The objectives of this course were: to develop an induction course for vocational trainees taking up first SHO posts; to enable new dental SHOs to have enhanced skills from the beginning of the post; to create safe practitioners capable of performing SHO duties; and to assess whether such a course is perceived to be beneficial by the SHOs, their educational supervisors and professional colleagues from medicine, dentistry and nursing. DESIGN: A 5-day intensive, interactive course was developed and directed by a consultant maxillofacial surgeon, with contributions from a range of professional colleagues to teach appropriate knowledge, skills and attitudes. SUBJECTS: Trainees completing the VT programme; due to commence SHO posts in the Yorkshire Region. EVALUATION METHOD: Detailed daily and end of course questionnaires were completed. A post course; in-work evaluation was sought from the trainees, educational supervisors and a range of professional colleagues about the validity of the course. RESULTS: Daily and end of course evaluations were positive about the perceived importance and relevance of the course. After 6 weeks in post the SHOs continued to place high value on the course as a preparation for hospital practice. Feedback from the supervisors and colleagues indicated that the SHOs were performing well, but the influence of the course on performance could not be determined in this study. CONCLUSION: It was possible to design and deliver an appropriate induction course, which appeared to meet most of the needs of new dental SHOs. Feedback indicated the need for modification of some aspects of the course.

A survey of the medical and dental consultants' management skills in University College Hospital, Ibadan, Nigeria.

Good management/administration is vital in the realisation of any business objective whether in a private or public establishment. The aims of this study were to assess the level of knowledge and ability on management/administrative skills by Medical/Dental consultants as perceived by themselves; to stimulate more interest in management/administrative skills acquisition, and to suggest possible ways in achieving such skills by doctors. A self-evaluation questionnaire was distributed to the doctors and 88 of them completed and returned their forms. They consisted of 55 (62.5%) males and 33 (37.5%) females cutting across all the specialities in medicine and dentistry in the University College Hospital, Ibadan, Nigeria. In all, 42 (47.7%) of the respondents reported that they had good ability of management/administration while 46 (52.3%) were below average. Of the 55 males, 28 (31.8%) had good ability while 27 (30.7%) were below average. Fourteen (15.9%) of the females had good ability while (21.6%) were below average. Good knowledge was assumed by 41 (46.6%) of the respondents while 47 (53.4%) were below average. Twenty-seven (30.7%) of the males showed good knowledge as against 14 (15.9%) of the females. Twenty-eight (31.8%) of the males were below average as against 19 (21.6%) of the female respondents. The sex differences were not statistically significant (P>0.05). The surgeons significantly (P<0.05) claimed better knowledge of management/administrative skills than physicians though their claim of ability to perform was higher too but significant (P>0.05). The percentage of the consultants with good knowledge and ability was found to increase with increasing age except for those under 40 years of age. The differences were not significant (P>0.05). A strong positive correlation (r=0.948; P<0.001) was found between ability and knowledge. Knowledge of the respondents was found to be good predictor of the ability using the regression equation: Ability = 11.151 + 0.835 (Knowledge). Suggestions on possible way forward were made. It was concluded that improving the knowledge of the doctors while in training on management/administrative skills will positively affect their performance abilities.