Improving Time to Stat Intravenous Antibiotic Administration: An 8-Year Quality Initiative.

BACKGROUND AND OBJECTIVES: Prompt antibiotics have been shown to improve outcomes in pediatric sepsis, which continues to be a leading cause of death in children. We describe the quality improvement (QI) efforts of a single academic children's hospital to improve antibiotic timeliness. METHODS: Using the electronic health record, we report time from order to the administration of stat intravenous (IV) antibiotics from 2012 to 2020 using statistical process control charts. We describe QI interventions initiated over the study period. These include the formation of a Pediatric Sepsis Committee, routine use of automated dispensing machines for stat IV antibiotics, creation of sepsis order sets, manual and automated sepsis screening implementation, participation in national sepsis QI collaboratives, creation of difficult intravenous access guidelines, and an automated notification system for charge nurses. As a balancing measure, we assessed stat IV antibiotic use normalized to total emergency department visits and inpatient days. RESULTS: Multiple quality improvement interventions were initiated and sustained under the direction of the hospital Pediatric Sepsis Committee. We improved our stat IV antibiotics given within 1 hour of order from 33% in 2012 to 77% in 2019 and maintained this through the end of the study period in July 2020. CONCLUSIONS: By using a multipronged quality improvement approach, we demonstrated consistent and sustained improvement in the timely administration of stat IV antibiotics over an 8-year period at our institution. Further study is needed to assess whether this is associated with reduced length of stay or improved survival in children with sepsis.

iValidate: a communication-based clinical intervention in life-limiting illness.

OBJECTIVES: Report the implementation, user evaluation and key outcome measures of an educational intervention-the iValidate educational programme-designed to improve engagement in shared decision-making by health professionals caring for patients with life-limiting illness (LLI). DESIGN: Prospective, descriptive, cohort study. PARTICIPANTS: Health professionals working in acute care settings caring for patients with an LLI. MAIN OUTCOMES MEASURED: Participant evaluation of learning outcomes for communication skills and shared decision-making; demographic data of participants attending education workshops; and documentation of patients with LLI goals of management, including patient values and care decision based on area in acute care and seniority of doctor. RESULTS: The programme was well accepted by participants. Participant evaluations demonstrated self-reported improved confidence in the areas of patient identification, information gathering to ascertain patient values and shared decision-making. There was strong agreement with the course-enhanced knowledge of core communication skills and advanced skills such as discussing mismatched agendas. CONCLUSIONS: We described the educational pedagogy, implementation and key outcome measures of the iValidate education programme, an intervention designed to improve person-centred care for patients with an LLI. A targeted education programme could produce cultural and institutional change for vulnerable populations within a healthcare institution. A concurrent research programme suggests effectiveness within the current service and the potential for transferability.

Interventions for improving medical students' interpersonal communication in medical consultations.

BACKGROUND: Communication is a common element in all medical consultations, affecting a range of outcomes for doctors and patients. The increasing demand for medical students to be trained to communicate effectively has seen the emergence of interpersonal communication skills as core graduate competencies in medical training around the world. Medical schools have adopted a range of approaches to develop and evaluate these competencies. OBJECTIVES: To assess the effects of interventions for medical students that aim to improve interpersonal communication in medical consultations. SEARCH METHODS: We searched five electronic databases: Cochrane Central Register of Controlled Trials, MEDLINE, Embase, PsycINFO, and ERIC (Educational Resource Information Centre) in September 2020, with no language, date, or publication status restrictions. We also screened reference lists of relevant articles and contacted authors of included studies. SELECTION CRITERIA: We included randomised controlled trials (RCTs), cluster-RCTs (C-RCTs), and non-randomised controlled trials (quasi-RCTs) evaluating the effectiveness of interventions delivered to students in undergraduate or graduate-entry medical programmes. We included studies of interventions aiming to improve medical students' interpersonal communication during medical consultations. Included interventions targeted communication skills associated with empathy, relationship building, gathering information, and explanation and planning, as well as specific communication tasks such as listening, appropriate structure, and question style. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. Two review authors independently reviewed all search results, extracted data, assessed the risk of bias of included studies, and rated the quality of evidence using GRADE. MAIN RESULTS: We found 91 publications relating to 76 separate studies (involving 10,124 students): 55 RCTs, 9 quasi-RCTs, 7 C-RCTs, and 5 quasi-C-RCTs. We performed meta-analysis according to comparison and outcome. Among both effectiveness and comparative effectiveness analyses, we separated outcomes reporting on overall communication skills, empathy, rapport or relationship building, patient perceptions/satisfaction, information gathering, and explanation and planning. Overall communication skills and empathy were further divided as examiner- or simulated patient-assessed. The overall quality of evidence ranged from moderate to very low, and there was high, unexplained heterogeneity. Overall, interventions had positive effects on most outcomes, but generally small effect sizes and evidence quality limit the conclusions that can be drawn. Communication skills interventions in comparison to usual curricula or control may improve both overall communication skills (standardised mean difference (SMD) 0.92, 95% confidence interval (CI) 0.53 to 1.31; 18 studies, 1356 participants; I² = 90%; low-quality evidence) and empathy (SMD 0.64, 95% CI 0.23 to 1.05; 6 studies, 831 participants; I² = 86%; low-quality evidence) when assessed by experts, but not by simulated patients. Students' skills in information gathering probably also improve with educational intervention (SMD 1.07, 95% CI 0.61 to 1.54; 5 studies, 405 participants; I² = 78%; moderate-quality evidence), but there may be little to no effect on students' rapport (SMD 0.18, 95% CI -0.15 to 0.51; 9 studies, 834 participants; I² = 81%; low-quality evidence), and effects on information giving skills are uncertain (very low-quality evidence). We are uncertain whether experiential interventions improve overall communication skills in comparison to didactic approaches (SMD 0.08, 95% CI -0.02 to 0.19; 4 studies, 1578 participants; I² = 4%; very low-quality evidence). Electronic learning approaches may have little to no effect on students' empathy scores (SMD -0.13, 95% CI -0.68 to 0.43; 3 studies, 421 participants; I² = 82%; low-quality evidence) or on rapport (SMD 0.02, 95% CI -0.33 to 0.38; 3 studies, 176 participants; I² = 19%; moderate-quality evidence) compared to face-to-face approaches. There may be small negative effects of electronic interventions on information giving skills (low-quality evidence), and effects on information gathering skills are uncertain (very low-quality evidence).  Personalised/specific feedback probably improves overall communication skills to a small degree in comparison to generic or no feedback (SMD 0.58, 95% CI 0.29 to 0.87; 6 studies, 502 participants; I² = 56%; moderate-quality evidence). There may be small positive effects of personalised feedback on empathy and information gathering skills (low quality), but effects on rapport are uncertain (very low quality), and we found no evidence on information giving skills. We are uncertain whether role-play with simulated patients outperforms peer role-play in improving students' overall communication skills (SMD 0.17, 95% CI -0.33 to 0.67; 4 studies, 637 participants; I² = 87%; very low-quality evidence). There may be little to no difference between effects of simulated patient and peer role-play on students' empathy (low-quality evidence) with no evidence on other outcomes for this comparison. Descriptive syntheses of results that could not be included in meta-analyses across outcomes and comparisons were mixed, as were effects of different interventions and comparisons on specific communication skills assessed by the included trials. Quality of evidence was downgraded due to methodological limitations across several risk of bias domains, high unexplained heterogeneity, and imprecision of results. In general, results remain consistent in sensitivity analysis based on risk of bias and adjustment for clustering. No adverse effects were reported.  AUTHORS' CONCLUSIONS: This review represents a substantial body of evidence from which to draw, but further research is needed to strengthen the quality of the evidence base, to consider the long-term effects of interventions on students' behaviour as they progress through training and into practice, and to assess effects of interventions on patient outcomes. Efforts to standardise assessment and evaluation of interpersonal skills will strengthen future research efforts.

Upscaling communication skills training - lessons learned from international initiatives.

OBJECTIVE: To collect experiences and to identify the main facilitators and barriers for the implementation process of large scale communication training programs. METHODS: Using a multiple case study design, data was collected from leaders of the individual programs in Australia, Ireland, Austria and Denmark. The RE-AIM framework was used to evaluate the components: Reach, Effectiveness, Adoption, Implementation, and Maintenance of the programs. RESULTS: The programs, all based on the Calgary-Cambridge Guide, succeeded in reaching the intended target groups corresponding to between 446 and 3000 healthcare workers. New courses are planned and so far the outcome of the intervention has been investigated in two countries. The fact that implementation, including educating trainers, relies on a few individuals was identified as the main challenge. CONCLUSION: Large scale communication training programs based on the Calgary-Cambridge Guide can be implemented and adopted in multiple different healthcare settings across a national health system culture. The importance of standardized trainer education and adaption of the programs to clinical practice was highlighted. PRACTICE IMPLICATIONS: In order to address the sustainability of the programs and to allow the intervention to scale up, it is important to prioritise and allocate resources at the political and organizational level.

Video-triggered professional learning for general practice trainers: using the 'cauldron of practice' to explore teaching and learning.

Many clinicians who take on a formal role of supervising or teaching trainees need to be taught how to teach and then continuously improve as educators. We describe the research-informed design of a novel professional development intervention that may be perceived by clinical educators as challenging, but being based on the key features of effective professional development is likely to lead to changes in their teaching practices. The video-club brings together a small group of clinical educators who have a shared interest in exploring their educator role and their teaching practices. It supports their learning through collective inquiry, using video-recordings of their authentic teaching practices as stimuli for discussion. A pilot has produced findings that are promising in terms of outcomes and impact. Participants responded to the educational design in the way that was envisioned and engaged with the requisite risk-taking and vulnerability that was necessary for their own learning and promoting learning for others.

A Repeated Measures Pilot Comparison of Trajectories of Fluctuating Endogenous Hormones in Young Women with Traumatic Brain Injury, Healthy Controls.

OBJECTIVE: To compare baseline and 72-hour hormone levels in women with traumatic brain injury (TBI) and controls. SETTING: Hospital emergency department. PARTICIPANTS: 21 women ages 18-35 with TBI and 21 controls. DESIGN: Repeated measures. MAIN MEASURES: Serum samples at baseline and 72 hours; immunoassays for estradiol (E2), progesterone (PRO), luteinizing hormone (LH), follicle-stimulating hormone (FSH), and cortisol (CORT); and health history. RESULTS: Women with TBI had lower E2 (p = 0.042) and higher CORT (p = 0.028) levels over time. Lower Glasgow Coma Scale (GSC) and OCs were associated with lower FSH (GCS p = 0.021; OCs p = 0.016) and higher CORT (GCS p = 0.001; OCs p = 0.008). CONCLUSION: Acute TBI may suppress E2 and increase CORT in young women. OCs appeared to independently affect CORT and FSH responses. Future work is needed with a larger sample to characterize TBI effects on women's endogenous hormone response to injury and OC use's effects on post-TBI stress response and gonadal function, as well as secondary injury.

Developing the International Association for Communication in Healthcare (EACH) to address current challenges of health communication.

In 2017, EACH celebrated its change of name from European Association for Communication in Healthcare to EACH: International Association for Communication in Healthcare. This paper aims to present the developments and achievements of EACH over the past five years with a focus on its mission in promoting and advancing the field of communication in healthcare. Specifically, the paper focuses on how EACH, first, promotes research in the field of health communication, second, provides support, resources and sharing for healthcare communication teachers and, third, aims at influencing policy through dissemination of evidence. This paper also explores future challenges and directions for EACH to further strengthen its impact by designing activities in knowledge transfer and knowledge dissemination, engaging with patients and truly benefitting from their expertise, fostering active participation and networking among its members, targeting interventions to the needs of different countries around the world and refining knowledge-sharing and cooperation both within the membership of EACH and outside the association to as wide an audience as possible. Scholars, educators and practitioners active in the field of healthcare communication are invited to comment on this paper and to actively contribute towards the goals of EACH.

An overview of interventional strategies for the management of oncologic pain.

Pain is a ubiquitous part of the cancer experience. Often the presenting symptom of malignancy, pain becomes more prevalent in advanced or metastatic disease and often persists despite curative treatment. Although management of cancer pain improved following publication of the WHO's analgesic ladder, when used in isolation, conservative approaches often fail to control pain and are limited by intolerable side effects. Interventional strategies provide an option for managing cancer pain that remains refractory to pharmacologic therapy. The purpose of this review is to investigate these strategies and discuss the risks and benefits which must be weighed when considering their use. Therapies anticipated to have an increasingly important role in the future of cancer pain management are also discussed.

Rating Communication in GP Consultations: The Association Between Ratings Made by Patients and Trained Clinical Raters.

Patient evaluations of physician communication are widely used, but we know little about how these relate to professionally agreed norms of communication quality. We report an investigation into the association between patient assessments of communication quality and an observer-rated measure of communication competence. Consent was obtained to video record consultations with Family Practitioners in England, following which patients rated the physician's communication skills. A sample of consultation videos was subsequently evaluated by trained clinical raters using an instrument derived from the Calgary-Cambridge guide to the medical interview. Consultations scored highly for communication by clinical raters were also scored highly by patients. However, when clinical raters judged communication to be of lower quality, patient scores ranged from "poor" to "very good." Some patients may be inhibited from rating poor communication negatively. Patient evaluations can be useful for measuring relative performance of physicians' communication skills, but absolute scores should be interpreted with caution.

Peer-review for selection of oral presentations for conferences: Are we reliable?

INTRODUCTION: Although peer-review for journal submission, grant-applications and conference submissions has been called 'a counter- stone of science', and even 'the gold standard for evaluating scientific merit', publications on this topic remain scares. Research that has investigated peer-review reveals several issues and criticisms concerning bias, poor quality review, unreliability and inefficiency. The most important weakness of the peer review process is the inconsistency between reviewers leading to inadequate inter-rater reliability. AIM OF THE PAPER: To report the reliability of ratings for a large international conference and to suggest possible solutions to overcome the problem. METHODS: In 2016 during the International Conference on Communication in Healthcare, organized by EACH: International Association for Communication in Healthcare, a calibration exercise was proposed and feedback was reported back to the participants of the exercise. RESULTS: Most abstracts, as well as most peer-reviewers, receive and give scores around the median. Contrary to the general assumption that there are high and low scorers, in this group only 3 peer-reviewers could be identified with a high mean, while 7 has a low mean score. Only 2 reviewers gave only high ratings (4 and 5). Of the eight abstracts included in this exercise, only one abstract received a high mean score and one a low mean score. Nevertheless, both these abstracts received both low and high scores; all other abstracts received all possible scores. DISCUSSION: Peer-review of submissions for conferences are, in accordance with the literature, unreliable. New and creative methods will be needed to give the participants of a conference what they really deserve: a more reliable selection of the best abstracts. PRACTICE IMPLICATIONS: More raters per abstract improves the inter-rater reliability; training of reviewers could be helpful; providing feedback to reviewers can lead to less inter-rater disagreement; fostering negative peer-review (rejecting the inappropriate submissions) rather than a positive (accepting the best) could be fruitful for selecting abstracts for conferences.

Lost in translation: Cultural divides in communication skills teaching identified in the ICCH 2016 student symposium.

OBJECTIVE: To provide a platform for learners' voices at an international conference on communication in healthcare. METHODS: A group of medical students were invited to explore their experiences with communication skills learning at a symposium at the 2016 International Conference on Communication in Healthcare in Heidelberg, DE. RESULTS: Students from the US, Denmark, Germany, and Russia discussed their experiences with communication skills curriculum at their institutions. We identified divides that have challenged our ability to develop and maintain strong communication skills: 1) valuation of communication skills vs. other topics, 2) curricular theory vs. practice, 3) evaluation vs. feedback, 4) preclinical vs. clinical learning, and 5) the medical student vs. practicing clinician role. CONCLUSION: The points of transition we identified on the road of communication skills teaching highlight opportunities to strengthen the educational experience for students. Without an effort to address these divides, however, our communication skills may be lost in translation. PRACTICE IMPLICATIONS: Students value communication skills teaching during their medical education and there are opportunities to translate this to countries that currently lack robust curricula and to the real-life post-graduate setting. Support is necessary from students, teachers, and administrators, and focus on translation of skills during role transitions is needed.

General principles to consider when designing a clinical communication assessment program.

OBJECTIVES: Assessment of clinical communication helps teachers in healthcare education determine whether their learners have acquired sufficient skills to meet the demands of clinical practice. The aim of this paper is to give input to educators when planning how to incorporate assessment into clinical communication teaching by building on the authors' experience and current literature. METHODS: A summary of the relevant literature within healthcare education is discussed, focusing on what and where to assess, how to implement assessment and how to choose appropriate methodology. RESULTS: Establishing a coherent approach to teaching, training, and assessment, including assessing communication in the clinical context, is discussed. Key features of how to implement assessment are presented including: establishing a system with both formative and summative approaches, providing feedback that enhances learning and establishing a multi-source and longitudinal assessment program. CONCLUSIONS: The implementation of a reliable, valid, credible, feasible assessment method with specific educational relevance is essential for clinical communication teaching. PRACTICE IMPLICATIONS: All assessment methods have strengths and limitations. Since assessment drives learning, assessment should be aligned with the purpose of the teaching program. Combining the use of different assessment formats, multiple observations, and independent measurements in different settings is advised.

The effects of malnutrition on cardiac function in African children.

OBJECTIVE: Cardiac dysfunction may contribute to high mortality in severely malnourished children. Our objective was to assess the effect of malnutrition on cardiac function in hospitalised African children. DESIGN: Prospective cross-sectional study. SETTING: Public referral hospital in Blantyre, Malawi. PATIENTS: We enrolled 272 stable, hospitalised children ages 6-59 months, with and without WHO-defined severe acute malnutrition. MAIN OUTCOME MEASURES: Cardiac index, heart rate, mean arterial pressure, stroke volume index and systemic vascular resistance index were measured by the ultrasound cardiac output monitor (USCOM, New South Wales, Australia). We used linear regression with generalised estimating equations controlling for age, sex and anaemia. RESULTS: Our primary outcome, cardiac index, was similar between those with and without severe malnutrition: difference=0.22 L/min/m(2) (95% CI -0.08 to 0.51). No difference was found in heart rate or stroke volume index. However, mean arterial pressure and systemic vascular resistance index were lower in children with severe malnutrition: difference=-8.6 mm Hg (95% CI -12.7 to -4.6) and difference=-200 dyne s/cm(5)/m(2) (95% CI -320 to -80), respectively. CONCLUSIONS: In this largest study to date, we found no significant difference in cardiac function between hospitalised children with and without severe acute malnutrition. Further study is needed to determine if cardiac function is diminished in unstable malnourished children.

Patient safety and communication: a new assessment for doctors trained in countries where language differs from that of the host country: results of a pilot using a domain-based assessment.

OBJECTIVE: Global migration of healthcare workers places responsibility on employers to comply with legal employment rights whilst ensuring patient safety remains the central goal. We describe the pilot of a communication assessment designed for doctors who trained and communicated with patients and colleagues in a different language from that of the host country. It is unique in assessing clinical communication without assessing knowledge. METHODS: A 14-station OSCE was developed using a domain-based marking scheme, covering professional communication and English language skills (speaking, listening, reading and writing) in routine, acute and emotionally challenging contexts, with patients, carers and healthcare teams. Candidates (n=43), non-UK trained volunteers applying to the UK Foundation Programme, were provided with relevant station information prior to the exam. RESULTS: The criteria for passing the test included achieving the pass score and passing 10 or more of the 14 stations. Of the 43 candidates, nine failed on the station criteria. Two failed the pass score and also the station criteria. The Cronbach's alpha coefficient was 0.866. CONCLUSION: This pilot tested 'proof of concept' of a new domain-based communication assessment for non-UK trained doctors. PRACTICE IMPLICATIONS: The test would enable employers and regulators to verify communication competence and safety in clinical contexts, independent of clinical knowledge, for doctors who trained in a language different from that of the host country.

Assessing communication quality of consultations in primary care: initial reliability of the Global Consultation Rating Scale, based on the Calgary-Cambridge Guide to the Medical Interview.

OBJECTIVES: To investigate initial reliability of the Global Consultation Rating Scale (GCRS: an instrument to assess the effectiveness of communication across an entire doctor-patient consultation, based on the Calgary-Cambridge guide to the medical interview), in simulated patient consultations. DESIGN: Multiple ratings of simulated general practitioner (GP)-patient consultations by trained GP evaluators. SETTING: UK primary care. PARTICIPANTS: 21 GPs and six trained GP evaluators. OUTCOME MEASURES: GCRS score. METHODS: 6 GP raters used GCRS to rate randomly assigned video recordings of GP consultations with simulated patients. Each of the 42 consultations was rated separately by four raters. We considered whether a fixed difference between scores had the same meaning at all levels of performance. We then examined the reliability of GCRS using mixed linear regression models. We augmented our regression model to also examine whether there were systematic biases between the scores given by different raters and to look for possible order effects. RESULTS: Assessing the communication quality of individual consultations, GCRS achieved a reliability of 0.73 (95% CI 0.44 to 0.79) for two raters, 0.80 (0.54 to 0.85) for three and 0.85 (0.61 to 0.88) for four. We found an average difference of 1.65 (on a 0-10 scale) in the scores given by the least and most generous raters: adjusting for this evaluator bias increased reliability to 0.78 (0.53 to 0.83) for two raters; 0.85 (0.63 to 0.88) for three and 0.88 (0.69 to 0.91) for four. There were considerable order effects, with later consultations (after 15-20 ratings) receiving, on average, scores more than one point higher on a 0-10 scale. CONCLUSIONS: GCRS shows good reliability with three raters assessing each consultation. We are currently developing the scale further by assessing a large sample of real-world consultations.

Increase in pediatric magnet-related foreign bodies requiring emergency care.

STUDY OBJECTIVE: We describe magnetic foreign body injuries among children and obtain national estimates of magnetic foreign body injury incidence over time. METHODS: We searched the National Electronic Injury Surveillance System for cases of magnetic foreign bodies in children younger than 21 years in the United States, from 2002 to 2011. Cases were analyzed by location: alimentary or respiratory tract, nasal cavity, ear canal, or genital area. RESULTS: We identified 893 cases of magnetic foreign bodies, corresponding to 22,581 magnetic foreign body cases during a 10-year period (95% confidence interval [CI] 17,694 to 27,469). Most magnetic foreign bodies were ingested (74%) or intranasal (21%). Mean age was 5.2 years for ingested magnetic foreign bodies and 10.1 years for nasal magnetic foreign bodies (difference 4.9; 95% CI 4.1 to 5.6), suggesting different circumstances of injury. The incidence of pediatric magnet ingestions increased from 2002 to 2003 from 0.57 cases per 100,000 children per year (95% CI 0.22 to 0.92) to a peak in 2010 to 2011 of 3.06 cases per 100,000 children per year (95% CI 2.16 to 3.96). Most ingested magnetic foreign bodies (73%) and multiple magnet ingestions (91%) occurred in 2007 or later. Patients were admitted in 15.7% of multiple magnet ingestions versus 2.3% of single magnet ingestions (difference 13.4%; 95% CI 2.8% to 24.0%). CONCLUSION: Magnet-related injuries are an increasing public health problem for young children, as well for older children who may use magnets for play or to imitate piercings. Education and improved magnet safety standards may decrease the risk small magnets pose to children.

Microbiology of urinary tract infections in Gaborone, Botswana.

OBJECTIVE: The microbiology and epidemiology of UTI pathogens are largely unknown in Botswana, a high prevalence HIV setting. Using laboratory data from the largest referral hospital and a private hospital, we describe the major pathogens causing UTI and their antimicrobial resistance patterns. METHODS: This retrospective study examined antimicrobial susceptibility data for urine samples collected at Princess Marina Hospital (PMH), Bokamoso Private Hospital (BPH), or one of their affiliated outpatient clinics. A urine sample was included in our dataset if it demonstrated pure growth of a single organism and accompanying antimicrobial susceptibility and subject demographic data were available. RESULTS: A total of 744 samples were included. Greater than 10% resistance was observed for amoxicillin, co-trimoxazole, amoxicillin-clavulanate, and ciprofloxacin. Resistance of E. coli isolates to ampicillin and co-trimoxazole was greater than 60% in all settings. HIV status did not significantly impact the microbiology of UTIs, but did impact antimicrobial resistance to co-trimoxazole. CONCLUSIONS: Data suggests that antimicrobial resistance has already emerged to most oral antibiotics, making empiric management of outpatient UTIs challenging. Ampicillin, co-trimoxazole, and ciprofloxacin should not be used as empiric treatment for UTI in this context. Nitrofurantoin could be used for simple cystitis; aminoglycosides for uncomplicated UTI in inpatients.