The Buddy Study: Local reach, adoption and implementation following a randomised controlled trial of conservative management of fifth metacarpal neck fractures.

OBJECTIVE: To understand the reach, adoption and implementation of the evidence that buddy strapping for uncomplicated fifth metacarpal neck fractures is non-inferior to plaster casting. METHODS: Mixed-method study using clinical audit of the years before and after the original randomised controlled study was published (2019) and staff questionnaires/semi-structured interviews. RESULTS: Sixty-nine percent of questionnaire respondents were aware of the original study findings (i.e. reach) and 57% had adopted the research findings. The proportion of patients receiving buddy strapping was 6% in 2014-2016 and 28% in 2019-2021 (implementation). Qualitative data provided insight into ongoing barriers to adoption and implementation including fear of reprisal, the need for permission, opinions of senior decision makers, perceptions about patient preferences, and an overall tendency to 'play it safe'. CONCLUSIONS: Even in a department where primary research is conducted, implementation requires ongoing attention to factors impacting reach and adoption.

Symbols and rituals are alive and well in clinical practice in Australia: Perspectives from a longitudinal qualitative professional identity study.

PURPOSE: Many factors impact an individual's professional identity on their journey to becoming a doctor, including their experiences, the learning environment, role models, and symbols and rituals. Rituals and symbols associated with the medical profession have historically included wearing a white coat (now rare) and the stethoscope. This study explored two medical students' perspectives of symbolic identifiers in a six-year longitudinal study in Australia (2012-2017). METHODOLOGY: A 2012 qualitative cross-sectional qualitative professional identity study in an Australian five-year undergraduate medical programme was extended to a longitudinal study with annual interviews. A conversation about the symbolism of the stethoscope and other identifiers began in Year 1 and concluded when the students were junior doctors. FINDINGS: Symbols and rituals remain part of the 'becoming' and 'being' a doctor. In the context of Australian hospitals, the stethoscope appears to no longer be exclusively associated with the medical profession, with 'professional attire' distinguishing medical students and doctors from other team members (uniform). The study identified lanyard colour and design as a symbol and language as a ritual. CONCLUSIONS: Although symbols and rituals may change over time and across cultural contexts, some forms of treasured material possessions and rituals will persist in medical practice.[Box: see text].

The impact of antibiotics on clinical response over time in uncomplicated cellulitis: a systematic review and meta-analysis.

PURPOSE: Antibiotic treatment of uncomplicated cellulitis is highly variable with respect to agent, dose, and route of administration. As there is uncertainty about optimal/appropriate time to reassess, we aimed to assess time to clinical response. METHODS: We conducted a systematic review of randomized controlled trials reporting clinical response of uncomplicated cellulitis to antibiotic treatment over multiple timepoints. PubMed, Embase, CENTRAL, WHO ICTRP, and clinicaltrials.gov were searched from inception to June 2021 without language restrictions. The primary outcome was time to clinical response. Other outcomes were components of clinical response (pain, severity score, redness, edema measured at ≥ 2 timepoints) and the proportion of patients with treatment failure. We performed a pooled estimate of the average time to clinical response together with 95% confidence intervals using a random effects model. RESULTS: We included 32 randomized controlled trials (n = 13,576 participants). The mean time to clinical response was 1.68 days (95%CI 1.48-1.88; I2 = 76%). The response to treatment for specific components was as follows: ~ 50% reduction of pain and severity score by day 5, a ~ 33% reduction in area of redness by day 2-3, and a 30-50% reduction of proportion of patients with edema by day 2-4. Treatment failure was variably defined with an overall failure rate of 12% (95%CI 9-16%). CONCLUSION: The best available data suggest the optimal time to clinical reassessment is between 2 and 4 days, but this must be interpreted with caution due to considerable heterogeneity and small number of included studies.

The revised Approved Instructional Resources score: An improved quality evaluation tool for online educational resources.

BACKGROUND: Free Open-Access Medical education (FOAM) use among residents continues to rise. However, it often lacks quality assurance processes and residents receive little guidance on quality assessment. The Academic Life in Emergency Medicine Approved Instructional Resources tool (AAT) was created for FOAM appraisal by and for expert educators and has demonstrated validity in this context. It has yet to be evaluated in other populations. OBJECTIVES: We assessed the AAT's usability in a diverse population of practicing emergency medicine (EM) physicians, residents, and medical students; solicited feedback; and developed a revised tool. METHODS: As part of the Medical Education Translational Resources: Impact and Quality (METRIQ) study, we recruited medical students, EM residents, and EM attendings to evaluate five FOAM posts with the AAT and provide quantitative and qualitative feedback via an online survey. Two independent analysts performed a qualitative thematic analysis with discrepancies resolved through discussion and negotiated consensus. This analysis informed development of an initial revised AAT, which was then further refined after pilot testing among the author group. The final tool was reassessed for reliability. RESULTS: Of 330 recruited international participants, 309 completed all ratings. The Best Evidence in Emergency Medicine (BEEM) score was the component most frequently reported as difficult to use. Several themes emerged from the qualitative analysis: for ease of use-understandable, logically structured, concise, and aligned with educational value. Limitations include deviation from questionnaire best practices, validity concerns, and challenges assessing evidence-based medicine. Themes supporting its use include evaluative utility and usability. The author group pilot tested the initial revised AAT, revealing a total score average measure intraclass correlation coefficient (ICC) of moderate reliability (ICC = 0.68, 95% confidence interval [CI] = 0 to 0.962). The final AAT's average measure ICC was 0.88 (95% CI = 0.77 to 0.95). CONCLUSIONS: We developed the final revised AAT from usability feedback. The new score has significantly increased usability, but will need to be reassessed for reliability in a broad population.

High Prevalence of Buprenorphine in Prenatal Drug Screens in an Appalachian City.

OBJECTIVES: To define the magnitude of buprenorphine presence in the urine drug screens of pregnant women and to assess the presence of illicit buprenorphine use versus the presence of prescribed buprenorphine use. METHODS: Initial prenatal drug screen results for all pregnant patients in our practice for a 1-year period were analyzed and tabulated. RESULTS: Buprenorphine was found in the urine drug screens of 16% of pregnant patients. The presence of buprenorphine was by far the highest for any substance associated with neonatal abstinence syndrome (NAS). We estimate that the exposure to buprenorphine of approximately one-third of individuals in our population is associated with illicit buprenorphine use. CONCLUSIONS: The high rate of NAS in our region is primarily associated with both illicit and prescribed buprenorphine rather than other substances. Buprenorphine usage at the time that prenatal care is initiated, rather than opiate use at the onset of prenatal care, is the underlying factor that must be addressed if our region is to successfully combat our high rates of NAS.

Doing our work better, together: a relationship-based approach to defining the quality improvement agenda in trauma care.

BACKGROUND: Trauma care represents a complex patient journey, requiring multidisciplinary coordinated care. Team members are human, and as such, how they feel about their colleagues and their work affects performance. The challenge for health service leaders is enabling culture that supports high levels of collaboration, co-operation and coordination across diverse groups. We aimed to define and improve relational aspects of trauma care at Gold Coast University Hospital. METHODS: We conducted a mixed-methods collaborative ethnography using the relational coordination survey-an established tool to analyse the relational dimensions of multidisciplinary teamwork-participant observation, interviews and narrative surveys. Findings were presented to clinicians in working groups for further interpretation and to facilitate co-creation of targeted interventions designed to improve team relationships and performance. FINDINGS: We engaged a complex multidisciplinary network of ~500 care providers dispersed across seven core interdependent clinical disciplines. Initial findings highlighted the importance of relationships in trauma care and opportunities to improve. Narrative survey and ethnographic findings further highlighted the centrality of a translational simulation programme in contributing positively to team culture and relational ties. A range of 16 interventions-focusing on structural, process and relational dimensions-were co-created with participants and are now being implemented and evaluated by various trauma care providers. CONCLUSIONS: Through engagement of clinicians spanning organisational boundaries, relational aspects of care can be measured and directly targeted in a collaborative quality improvement process. We encourage healthcare leaders to consider relationship-based quality improvement strategies, including translational simulation and relational coordination processes, in their efforts to improve care for patients with complex, interdependent journeys.

Improving the relational aspects of trauma care through translational simulation.

BACKGROUND: Major trauma care is complex and requires individuals and teams to perform together in time critical, high-stakes situations. Scenario-based simulation is well established as a strategy for trauma teamwork improvement, but its role in the relational and cultural aspects of trauma care is less well understood. Relational coordination theory offers a framework through which we aimed to understand the impact of an established trauma simulation programme. METHODS: We studied simulation activities using a narrative survey of trauma providers from anaesthesia, emergency medicine, medical imaging, surgery, trauma service, intensive care, and pre-hospital providers at Gold Coast University Hospital, in conjunction with data from an ethnography. Data analysis was performed using a recursive approach-a simultaneous deductive approach using the relational coordination framework and an inductive analysis. RESULTS: Ninety-five of 480 (19.8%) staff completed free-text survey questions on simulation. Deductive analysis of data from these narrative survey results using the RC framework domains identified examples of shared goals, shared knowledge, communication and mutual respect. Two major themes from the inductive analysis-"Behaviour, process and system change" and "Culture and relationships"-aligned closely with findings from the RC analysis, with additional themes of "Personal and team learning" and the "Impact of the simulation experience" identified. CONCLUSIONS: Our findings suggest that an established trauma simulation programme can have a profound impact on the relational aspects of care and the development of a collaborative culture, with perceived tangible impacts on teamwork behaviours and institutional systems and processes. The RC framework-shared knowledge, shared goals and mutual respect in the context of communication that is timely, accurate, frequent and problem-solving based-can provide a common language for simulation educators to design and debrief simulation exercises that aim to have a translational impact.

Identifying and Transmitting the Culture of Emergency Medicine Through Simulation.

BACKGROUND: Simulation is commonly used in medical education. It offers the opportunity for participants to apply theoretical knowledge and practice nontechnical skills. We aimed to examine how simulation may also help to identify emergency medicine culture and serve as a tool to transmit values, beliefs, and practices to medical learners. METHODS: We undertook a focused ethnography of a simulated emergency department exercise delivered to 98 third-year medical students. This ethnography included participant observation, informal interviews, and document review. Analysis was performed using a recursive method, a simultaneous deductive and inductive approach to data interpretation. RESULTS: All 20 staff (100%) and 92 of 98 medical students (94%) participated in the study. We identified seven core values-identifying and treating dangerous pathology, managing uncertainty, patients and families at the center of care, balancing needs and resources at the system level, value of the team approach, education as integral, and emergency medicine as part of self-identity-and 27 related beliefs that characterized emergency medicine culture. We observed that culture was transmitted during the simulation exercise. CONCLUSION: This study contributes to the characterization of the culture of emergency medicine by identifying core values and beliefs that are foundational to the specialty. Simulation facilitated cultural compression, which allowed for ready identification of values, beliefs, and practices and also facilitated transmission of culture to learners. This study expands understanding of the culture of emergency medicine and the role of simulation in the process of cultural exchange.

Development and Psychometric Testing of an Electronic Patient-Reported Outcome Tool for Vulval Disorders (ePAQ-Vulva).

OBJECTIVE: Development of an electronic patient-reported outcome measure (PROM) specifically designed for vulval disorders. Psychometric testing of the components of the questionnaire, which assess vulval symptoms, sexual function, and quality of life (QoL). MATERIALS AND METHOD: Development and programming of the instrument (ePAQ-Vulva) was informed by national guidelines for the assessment of vulval disorders, an expert panel, and a survey of 61 vulval clinic patients. The PROM assesses frequency and impact of vulval symptoms, sexual function, and QoL. It also records conditions and behaviors related to vulval disorders and patient concerns/goals.Scale generation and psychometric testing were undertaken for the vulval symptoms, sexual function, and QoL components of the PROM with 91 participants; descriptive statistics, factor analysis and internal reliability of identified domains, and agreement between free-text and multiple-choice items to assess convergent validity and interrater reliability of picture items were assessed. RESULTS: Descriptive statistics showed high floor effects for seven questionnaire items. Factor analysis identified 5 principal components. These were reviewed and amended to provide a putative domain structure of 6 domains. Internal reliability of these domains was assessed using Cronbach α, producing values of 0.715 to 0.917. Interrater reliability of the picture items produced a κ statistic of 0.405. Spearman rank showed moderate correlation between multiple-choice answers and free-text concerns (r = 0.364-0.462) in 3 of the 6 domains (pain, sex, and dyspareunia). CONCLUSIONS: ePAQ-Vulva offers the first patient-reported outcome tool, specifically designed for vulval disorders. The instrument requires further validation and testing, including evaluation of the stability, responsiveness, and reliability.

Bariatric Surgery and the Pregnancy Complicated by Gestational Diabetes.

Gestational diabetes mellitus (GDM) is an increasingly common obstetrical problem. Due to the global escalation in the prevalence of obesity, as many as 15 % of pregnant women may soon be classified as having GDM. While often not diagnosed until late gestation, GDM is now recognized as a disorder of glucose and lipid metabolism, systemic inflammation, and insulin resistance that begins early in pregnancy. Recent large randomized trials have clarified the risk of maternal and neonatal complications caused by GDM, as well as the potential to ameliorate these risks. There is significant interest in the potential to reduce the risk for developing GDM in obese women through the performance of bariatric surgery (BS) before pregnancy. BS significantly reduces the risk for GDM, preeclampsia, and large neonates. However, it seems that the risk for small neonates and preterm delivery is increased. No significant differences are observed in regard to cesarean section, postpartum hemorrhage, or perinatal mortality. In this article, we address the effects of GDM on the mother and child, and explore the risks and benefits of BS in the obstetrical population.