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1.
J Gen Intern Med ; 36(7): 2111-2114, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-33506393

RESUMO

Personality is the description of an individual's tendencies when acting or reacting to others. Clinicians spontaneously form impressions of a patient's apparent personality yet such unstructured impressions might lead to snap judgments or unhelpful labels. Here we review the evidence-based five-factor model from psychology science for understanding personalities (OCEAN taxonomy). Openness to experience is defined as the general appreciation for a variety of experiences. Conscientiousness is the tendency to exhibit self-discipline. Extraversion is the degree of engagement with the external world. Agreeableness is the general concern for social harmony. Neuroticism is the tendency to experience negative emotions. An awareness of these five dimensions might help clinicians avoid faulty judgments from casual contact. Expert assessment of personality requires extensive training and data, thereby suggesting that clinicians should take a humble view of their own unsophisticated impressions of a patient's personality.


Assuntos
Extroversão Psicológica , Personalidade , Humanos , Inventário de Personalidade
2.
JAMA ; 321(24): 2448-2457, 2019 06 25.
Artigo em Inglês | MEDLINE | ID: mdl-31237649

RESUMO

Importance: Syncope can result from a reduction in cardiac output from serious cardiac conditions, such as arrhythmias or structural heart disease (cardiac syncope), or other causes, such as vasovagal syncope or orthostatic hypotension. Objective: To perform a systematic review of studies of the accuracy of the clinical examination for identifying patients with cardiac syncope. Study Selection: Studies of adults presenting to primary care, emergency departments, or referred to specialty clinics. Data Extraction and Synthesis: Relevant data were abstracted from articles in databases through April 9, 2019, and methodologic quality was assessed. Included studies had an independent comparison to a reference standard. Main Outcomes and Measures: Sensitivity, specificity, and likelihood ratios (LRs). Results: Eleven studies of cardiac syncope (N = 4317) were included. Age at first syncope of at least 35 years was associated with greater likelihood of cardiac syncope (n = 323; sensitivity, 91% [95% CI, 85%-97%]; specificity, 72% [95% CI, 66%-78%]; LR, 3.3 [95% CI, 2.6-4.1]), while age younger than 35 years was associated with a lower likelihood (LR, 0.13 [95% CI, 0.06-0.25]). A history of atrial fibrillation or flutter (n = 323; sensitivity, 13% [95% CI, 6%-20%]; specificity, 98% [95% CI, 96%-100%]; LR, 7.3 [95% CI, 2.4-22]), or known severe structural heart disease (n = 222; range of sensitivity, 35%-51%, range of specificity, 84%-93%; range of LR, 3.3-4.8; 2 studies) were associated with greater likelihood of cardiac syncope. Symptoms prior to syncope that were associated with lower likelihood of cardiac syncope were mood change or prodromal preoccupation with details (n = 323; sensitivity, 2% [95% CI, 0%-5%]; specificity, 76% [95% CI, 71%-81%]; LR, 0.09 [95% CI, 0.02-0.38]), feeling cold (n = 412; sensitivity, 2% [95% CI, 0%-5%]; specificity, 89% [95% CI, 85%-93%]; LR, 0.16 [95% CI, 0.06-0.64]), or headache (n = 323; sensitivity, 3% [95% CI, 0%-7%]; specificity, 80% [95% CI, 75%-85%]; LR, 0.17 [95% CI, 0.06-0.55]). Cyanosis witnessed during the episode was associated with higher likelihood of cardiac syncope (n = 323; sensitivity, 8% [95% CI, 2%-14%]; specificity, 99% [95% CI, 98%-100%]; LR, 6.2 [95% CI, 1.6-24]). Mood changes after syncope (n = 323; sensitivity, 3% [95% CI, 0%-7%]; specificity, 83% [95% CI, 78%-88%]; LR, 0.21 [95% CI, 0.06-0.65]) and inability to remember behavior prior to syncope (n = 323; sensitivity, 5% [95% CI, 0%-9%]; specificity, 82% [95% CI, 77%-87%]; LR, 0.25, [95% CI, 0.09-0.69]) were associated with lower likelihood of cardiac syncope. Two studies prospectively validated the accuracy of the multivariable Evaluation of Guidelines in Syncope Study (EGSYS) score, which is based on 6 clinical variables. An EGSYS score of less than 3 was associated with lower likelihood of cardiac syncope (n = 456; range of sensitivity, 89%-91%, range of specificity, 69%-73%; range of LR, 0.12-0.17; 2 studies). Cardiac biomarkers show promising diagnostic accuracy for cardiac syncope, but diagnostic thresholds require validation. Conclusions and Relevance: The clinical examination, including the electrocardiogram as part of multivariable scores, can accurately identify patients with and without cardiac syncope.


Assuntos
Cardiopatias/complicações , Síncope/etiologia , Fatores Etários , Idoso , Biomarcadores/análise , Diagnóstico Diferencial , Eletrocardiografia , Feminino , Cardiopatias/diagnóstico , Humanos , Fatores de Risco , Sensibilidade e Especificidade
3.
CMAJ ; 194(33): E1133-E1134, 2022 08 29.
Artigo em Inglês | MEDLINE | ID: mdl-36302105
4.
CMAJ ; 187(5): 321-9, 2015 Mar 17.
Artigo em Inglês | MEDLINE | ID: mdl-25667258

RESUMO

BACKGROUND: Shorter resident duty periods are increasingly mandated to improve patient safety and physician well-being. However, increases in continuity-related errors may counteract the purported benefits of reducing fatigue. We evaluated the effects of 3 resident schedules in the intensive care unit (ICU) on patient safety, resident well-being and continuity of care. METHODS: Residents in 2 university-affiliated ICUs were randomly assigned (in 2-month rotation-blocks from January to June 2009) to in-house overnight schedules of 24, 16 or 12 hours. The primary patient outcome was adverse events. The primary resident outcome was sleepiness, measured by the 7-point Stanford Sleepiness Scale. Secondary outcomes were patient deaths, preventable adverse events, and residents' physical symptoms and burnout. Continuity of care and perceptions of ICU staff were also assessed. RESULTS: We evaluated 47 (96%) of 49 residents, all 971 admissions, 5894 patient-days and 452 staff surveys. We found no effect of schedule (24-, 16- or 12-h shifts) on adverse events (81.3, 76.3 and 78.2 events per 1000 patient-days, respectively; p = 0.7) or on residents' sleepiness in the daytime (mean rating 2.33, 2.61 and 2.30, respectively; p = 0.3) or at night (mean rating 3.06, 2.73 and 2.42, respectively; p = 0.2). Seven of 8 preventable adverse events occurred with the 12-hour schedule (p = 0.1). Mortality rates were similar for the 3 schedules. Residents' somatic symptoms were more severe and more frequent with the 24-hour schedule (p = 0.04); however, burnout was similar across the groups. ICU staff rated residents' knowledge and decision-making worst with the 16-hour schedule. INTERPRETATION: Our findings do not support the purported advantages of shorter duty schedules. They also highlight the trade-offs between residents' symptoms and multiple secondary measures of patient safety. Further delineation of this emerging signal is required before widespread system change. TRIAL REGISTRATION: ClinicalTrials.gov, no. NCT00679809.


Assuntos
Continuidade da Assistência ao Paciente/estatística & dados numéricos , Unidades de Terapia Intensiva/organização & administração , Internato e Residência/organização & administração , Erros Médicos/estatística & dados numéricos , Segurança do Paciente/estatística & dados numéricos , Admissão e Escalonamento de Pessoal/organização & administração , Médicos/psicologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Atitude do Pessoal de Saúde , Continuidade da Assistência ao Paciente/organização & administração , Fadiga , Feminino , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Erros Médicos/prevenção & controle , Pessoa de Meia-Idade , Ontário , Avaliação de Processos e Resultados em Cuidados de Saúde , Tolerância ao Trabalho Programado , Carga de Trabalho
5.
Ann Intern Med ; 171(9): SS1, 2019 Nov 05.
Artigo em Inglês | MEDLINE | ID: mdl-31683300
7.
Kidney Int ; 83(5): 901-8, 2013 May.
Artigo em Inglês | MEDLINE | ID: mdl-23325077

RESUMO

Survivors of severe acute kidney injury remain at high risk of death well after apparent recovery from the initial insult. Here we determine whether early nephrology follow-up after a hospitalization complicated by severe acute kidney injury associates with patient survival. This consisted of a cohort study of all hospitalized adults in Ontario from 1996 to 2008 with acute kidney injury who received temporary inpatient dialysis and survived for 90 days following discharge independent from dialysis. Propensity scores were used to match individuals with early nephrology follow-up, defined as a visit with a nephrologist within 90 days of discharge, to those without. The outcome was time to all-cause mortality of 3877 patients who met the eligibility criteria within a maximum follow-up of 2 years. A total of 1583 patients had early nephrology follow-up of whom 1184 were successfully matched 1:1 to those not receiving early follow-up. The incidence of all-cause mortality was lower in those patients with early nephrology follow-up compared with those without (8.4 compared with 10.6 per 100-patient years, hazard ratio 0.76 (95% CI: 0.62-0.93)). Thus, early nephrology follow-up after hospitalization with acute kidney injury and temporary dialysis was associated with improved survival. This finding requires definitive testing in a randomized controlled trial.


Assuntos
Injúria Renal Aguda/mortalidade , Nefrologia , Encaminhamento e Consulta , Sobreviventes/estatística & dados numéricos , Injúria Renal Aguda/diagnóstico , Injúria Renal Aguda/terapia , Idoso , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Ontário , Alta do Paciente , Prognóstico , Pontuação de Propensão , Modelos de Riscos Proporcionais , Diálise Renal , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença , Fatores de Tempo
9.
Adv Health Sci Educ Theory Pract ; 18(1): 141-56, 2013 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-22167577

RESUMO

Public and professional concern about health care quality, safety and efficiency is growing. Continuing education, knowledge translation, patient safety and quality improvement have made concerted efforts to address these issues. However, a coordinated and integrated effort across these domains is lacking. This article explores and discusses the similarities and differences amongst the four domains in relation to their missions, stakeholders, methods, and limitations. This paper highlights the potential for a more integrated and collaborative partnership to promote networking and information sharing amongst the four domains. This potential rests on the premise that an integrated approach may result in the development and implementation of more holistic and effective interdisciplinary interventions. In conclusion, an outline of current research that is informed by the preliminary findings in this paper is also briefly discussed. The research concerns a comprehensive mapping of the relationships between the domains to gain an understanding of potential dissonances between how the domains represent themselves, their work and the work of their 'partner' domains.


Assuntos
Educação Médica Continuada , Segurança do Paciente , Melhoria de Qualidade , Pesquisa Translacional Biomédica , Comportamento Cooperativo , Humanos , Disseminação de Informação
10.
BMC Health Serv Res ; 13: 230, 2013 Jun 25.
Artigo em Inglês | MEDLINE | ID: mdl-23800355

RESUMO

BACKGROUND: Unresolved medication discrepancies during hospitalization can contribute to adverse drug events, resulting in patient harm. Discrepancies can be reduced by performing medication reconciliation; however, effective implementation of medication reconciliation has proven to be challenging. The goals of the Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS) are to operationalize best practices for inpatient medication reconciliation, test their effect on potentially harmful unintentional medication discrepancies, and understand barriers and facilitators of successful implementation. METHODS: Six U.S. hospitals are participating in this quality improvement mentored implementation study. Each hospital has collected baseline data on the primary outcome: the number of potentially harmful unintentional medication discrepancies per patient, as determined by a trained on-site pharmacist taking a "gold standard" medication history. With the guidance of their mentors, each site has also begun to implement one or more of 11 best practices to improve medication reconciliation. To understand the effect of the implemented interventions on hospital staff and culture, we are performing mixed methods program evaluation including surveys, interviews, and focus groups of front line staff and hospital leaders. DISCUSSION: At baseline the number of unintentional medication discrepancies in admission and discharge orders per patient varies by site from 2.35 to 4.67 (mean=3.35). Most discrepancies are due to history errors (mean 2.12 per patient) as opposed to reconciliation errors (mean 1.23 per patient). Potentially harmful medication discrepancies averages 0.45 per patient and varies by site from 0.13 to 0.82 per patient. We discuss several barriers to implementation encountered thus far. In the end, we anticipate that MARQUIS tools and lessons learned have the potential to decrease medication discrepancies and improve patient outcomes. TRIAL REGISTRATION: Clinicaltrials.gov identifier NCT01337063.


Assuntos
Reconciliação de Medicamentos , Melhoria de Qualidade , Benchmarking , Humanos , Capacitação em Serviço , Corpo Clínico Hospitalar/normas , Erros de Medicação/prevenção & controle , Erros de Medicação/estatística & dados numéricos , Reconciliação de Medicamentos/organização & administração , Cultura Organizacional , Farmacêuticos/normas , Avaliação de Processos em Cuidados de Saúde/métodos , Avaliação de Processos em Cuidados de Saúde/normas , Projetos de Pesquisa , Gestão da Segurança , Fatores de Tempo , Estados Unidos
11.
CMAJ Open ; 11(1): E201-E207, 2023.
Artigo em Inglês | MEDLINE | ID: mdl-36854457

RESUMO

BACKGROUND: Identifying potentially avoidable admissions to Canadian hospitals is an important health system goal. With general internal medicine (GIM) accounting for 40% of hospital admissions, we sought to develop a method to identify potentially avoidable admissions and characterize patient, provider and health system factors. METHODS: We conducted an observational study of GIM admissions at our institution from August 2019 to February 2020. We defined potentially avoidable admissions as admissions that could be managed in an appropriate and safe manner in the emergency department or ambulatory setting and asked staff physicians to screen admissions daily and flag candidates as potentially avoidable admissions. For each candidate, we prepared a case review and debriefed with members of the admitting team. We then reviewed each candidate with our research team, assigned an avoidability score (1 [low] to 4 [high]) and identified contributing factors for those with scores of 3 or more. RESULTS: We screened 601 total admissions and staff physicians flagged 117 (19.5%) of these as candidate potential avoidable admissions. Consensus review identified 67 candidates as potentially avoidable admissions (11.1%, 95% confidence interval 8.8%-13.9%); these patients were younger (mean age 65 yr v. 72 yr), had fewer comorbidities (Canadian Institute for Health Information Case Mix Group+ 0.42 v. 1.14), had lower resource-intensity weighting scores (0.72 v. 1.50) and shorter hospital lengths of stay (29 h v. 105 h) (p < 0.01). Common factors included diagnostic and therapeutic uncertainty, perceived need for short-term monitoring, government directive of a 4-hour limit for admission decision-making and subspecialist request to admit. INTERPRETATION: Our prospective method of screening, flagging and case review showed that 1 in 9 GIM admissions were potentially avoidable. Other institutions could consider adapting this methodology to ascertain their rate of potentially avoidable admissions and to understand contributing factors to inform improvement endeavours.


Assuntos
Hospitalização , Hospitais de Ensino , Humanos , Idoso , Canadá/epidemiologia , Academias e Institutos , Medicina Interna
12.
Med Educ ; 46(8): 795-806, 2012 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-22803757

RESUMO

CONTEXT: Many academic medical centres (AMCs) have introduced institutional policies, changed processes of care and implemented new technologies to improve health care quality. The impact of such changes on medical education has received little attention. We examine the impact of computerised provider order entry (CPOE) on the educational experiences of medical trainees who work and train in AMCs. METHODS: We conducted semi-structured interviews of postgraduate trainees and attending physicians in internal medicine at five AMCs (two with CPOE, three without CPOE). Trainees routinely rotate from CPOE to non-CPOE AMCs, whereas some attending physicians work at both types of AMC and are therefore well positioned to reflect on differences between CPOE and non-CPOE learning environments. Data collection and analysis used grounded theory methods. We sampled purposively until we achieved theoretical saturation. RESULTS: Our study included 11 residents and six attending physicians. Computerised provider order entry had both positive and negative impacts on five aspects of postgraduate training: (i) learning (better for medication interactions and availability of learning resources; worse for learning medication doses); (ii) teaching (more medication information available to enhance case discussions; fewer face-to-face teaching opportunities); (iii) feedback (improved ability to observe medication ordering behaviours to inform feedback; less provision of direct feedback); (iv) clinical supervision (facilitates efficient and safe supervision from a distance; may impede trainee independence), and (v) trainee assessment (increased opportunity to assess clinical decision-making and organisational skills). CONCLUSIONS: We identify five key educational themes that are positively and negatively impacted by CPOE. These themes form a conceptual framework that could be applied to define the educational impact of other health care quality and patient safety practices. This will help educators to identify educational opportunities and protect the safety of the training experience of residents in AMCs.


Assuntos
Educação de Pós-Graduação em Medicina/métodos , Internato e Residência , Sistemas de Registro de Ordens Médicas/organização & administração , Corpo Clínico Hospitalar/psicologia , Médicos/psicologia , Estudantes de Medicina/psicologia , Centros Médicos Acadêmicos , Canadá , Educação de Pós-Graduação em Medicina/normas , Humanos , Sistemas de Registro de Ordens Médicas/normas , Corpo Clínico Hospitalar/educação
13.
Can J Surg ; 54(3): 173-8, 2011 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-21443835

RESUMO

BACKGROUND: Prior studies show significant gaps in the informed decision-making process, a central goal of surgical care. These studies have been limited by their focus on low-risk decisions, single visits rather than entire consultations, or both. Our objectives were, first, to rate informed decision-making for major elective vascular surgery based on audiotapes of actual physician-patient conversations and, second, to compare ratings of informed decision-making for first visits to ratings for multiple visits by the same patient over time. METHODS: We prospectively enrolled patients for whom vascular surgical treatment was a potential option at a tertiary care outpatient vascular surgery clinic. We audio-taped all surgeon-patient conversations, including multiple visits when necessary, until a decision was made. Using an existing method, we evaluated the transcripts for elements of decision-making, including basic elements (e.g., an explanation of the clinical condition), intermediate elements (e.g., risks and benefits) and complex elements (e.g., uncertainty around the decision). RESULTS: We analyzed 145 surgeon-patient consultations. Overall, 45% of consultations contained complex elements, whereas 23% did not contain the basic elements of decision-making. For the 67 consultations that involved multiple visits, ratings were significantly higher when evaluating all visits (50% complex elements) compared with evaluating only the first visit (33% complex elements, p < 0.001.) CONCLUSION: We found that 45% of consultations contained complex elements, which is higher than prior studies with similar methods. Analyzing decision-making over multiple visits yielded different results than analyzing decision-making for single visits.


Assuntos
Comunicação , Tomada de Decisões , Consentimento Livre e Esclarecido , Visita a Consultório Médico , Participação do Paciente , Relações Médico-Paciente , Gravação em Fita , Procedimentos Cirúrgicos Vasculares , Adulto , Idoso , Idoso de 80 Anos ou mais , Aneurisma Aórtico/cirurgia , Estenose das Carótidas/cirurgia , Fatores de Confusão Epidemiológicos , Procedimentos Cirúrgicos Eletivos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Ontário , Doença Arterial Periférica/cirurgia , Estudos Prospectivos , Fatores de Risco , Incerteza , Varizes/cirurgia
14.
Acad Emerg Med ; 28(5): 502-510, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-33382159

RESUMO

OBJECTIVES: Emergency department (ED) patients with unexplained syncope are at risk of experiencing an adverse event within 30 days. Our objective was to systematically review the accuracy of multivariate risk stratification scores for identifying adult syncope patients at high and low risk of an adverse event over the next 30 days. METHODS: We conducted a systematic review of electronic databases (MEDLINE, Cochrane, Embase, and CINAHL) from database creation until May 2020. We sought studies evaluating prediction scores of adults presenting to an ED with syncope. We included studies that followed patients for up to 30 days to identify adverse events such as death, myocardial infarction, stroke, or cardiac surgery. We only included studies with a blinded comparison between baseline clinical features and adverse events. We calculated likelihood ratios and confidence intervals (CIs). RESULTS: We screened 13,788 abstracts. We included 17 studies evaluating nine risk stratification scores on 24,234 patient visits, where 7.5% (95% CI = 5.3% to 10%) experienced an adverse event. A Canadian Syncope Risk Score (CSRS) of 4 or more was associated with a high likelihood of an adverse event (LRscore≥4  = 11, 95% CI = 8.9 to 14). A CSRS of 0 or less (LRscore≤0  = 0.10, 95% CI = 0.07 to 0.20) was associated with a low likelihood of an adverse event. Other risk scores were not validated on an independent sample, had low positive likelihood ratios for identifying patients at high risk, or had high negative likelihood ratios for identifying patients at low risk. CONCLUSION: Many risk stratification scores are not validated or not sufficiently accurate for clinical use. The CSRS is an accurate validated prediction score for ED patients with unexplained syncope. Its impact on clinical decision making, admission rates, cost, or outcomes of care is not known.


Assuntos
Serviço Hospitalar de Emergência , Síncope , Adulto , Canadá , Humanos , Medição de Risco , Fatores de Risco , Síncope/diagnóstico , Síncope/epidemiologia , Síncope/etiologia
15.
CMAJ ; 182(6): 551-7, 2010 Apr 06.
Artigo em Inglês | MEDLINE | ID: mdl-20194559

RESUMO

BACKGROUND: Readmissions to hospital are common, costly and often preventable. An easy-to-use index to quantify the risk of readmission or death after discharge from hospital would help clinicians identify patients who might benefit from more intensive post-discharge care. We sought to derive and validate an index to predict the risk of death or unplanned readmission within 30 days after discharge from hospital to the community. METHODS: In a prospective cohort study, 48 patient-level and admission-level variables were collected for 4812 medical and surgical patients who were discharged to the community from 11 hospitals in Ontario. We used a split-sample design to derive and validate an index to predict the risk of death or nonelective readmission within 30 days after discharge. This index was externally validated using administrative data in a random selection of 1,000,000 Ontarians discharged from hospital between 2004 and 2008. RESULTS: Of the 4812 participating patients, 385 (8.0%) died or were readmitted on an unplanned basis within 30 days after discharge. Variables independently associated with this outcome (from which we derived the mnemonic "LACE") included length of stay ("L"); acuity of the admission ("A"); comorbidity of the patient (measured with the Charlson comorbidity index score) ("C"); and emergency department use (measured as the number of visits in the six months before admission) ("E"). Scores using the LACE index ranged from 0 (2.0% expected risk of death or urgent readmission within 30 days) to 19 (43.7% expected risk). The LACE index was discriminative (C statistic 0.684) and very accurate (Hosmer-Lemeshow goodness-of-fit statistic 14.1, p=0.59) at predicting outcome risk. INTERPRETATION: The LACE index can be used to quantify risk of death or unplanned readmission within 30 days after discharge from hospital. This index can be used with both primary and administrative data. Further research is required to determine whether such quantification changes patient care or outcomes.


Assuntos
Indicadores Básicos de Saúde , Readmissão do Paciente , Adulto , Idoso , Comorbidade , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Previsões , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Alta do Paciente , Prognóstico
16.
Med Educ ; 44(6): 559-69, 2010 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-20604852

RESUMO

OBJECTIVES In keeping with the current emphasis on quality improvement and patient safety, a Canadian division of general internal medicine began holding weekly morbidity and mortality rounds (M&MRs) with postgraduate trainees. Grounded in the medical education and social sciences literatures about such rounds, we sought to explore the teaching and learning processes that occur in M&MRs in order to understand their role in, and contribution to, the current medical education context. METHODS We conducted an ethnography of these M&MRs. We observed the rounds, conducted interviews with both staff doctors and residents and triangulated the resultant data. Concurrent, iterative data collection and analysis enabled sampling to saturation. RESULTS Staff doctors had differing understandings of the role of M&MRs and valued different kinds of teaching. They did not think they were teaching medical content knowledge at these rounds, but rather that they were role-modelling six skills, attitudes and behaviours, including 'identifying and addressing process and systems issues affecting care'. Residents primarily wanted to learn content knowledge and tried to extract such knowledge out of the rounds. They did recognise and value that they were learning about process and systems issues. They also agreed that staff doctors were role-modelling other things, but had varying perceptions of what those were; most did not value this role-modelled learning as much as they valued the acquisition of content knowledge. CONCLUSIONS These M&MRs were effective forums for addressing patient safety and quality improvement competencies. They carried none of the negative functions attributed to such rounds in the sociology literature, focusing neither on absolving responsibility nor on learning socially acceptable ways to discuss death in public. However, this study revealed a marked disjunction between the teaching valued by staff doctors and the learning valued by their trainees.


Assuntos
Competência Clínica/normas , Educação de Pós-Graduação em Medicina/métodos , Corpo Clínico Hospitalar , Estudantes de Medicina , Visitas de Preceptoria/métodos , Humanos , Morbidade , Mortalidade , Relações Médico-Paciente , Visitas de Preceptoria/normas
17.
JMIR Res Protoc ; 9(1): e15753, 2020 Jan 22.
Artigo em Inglês | MEDLINE | ID: mdl-32012116

RESUMO

BACKGROUND: Patients with heart failure (HF) are at the highest risk for hospital readmissions during the first few weeks after discharge when patients are transitioning from hospital to home. Telemonitoring (TM) for HF management has been found to reduce mortality risk and hospital readmissions if implemented appropriately; however, the impact of TM targeted for patients recently discharged from hospital, for whom TM might have the biggest benefit, is still unknown. Medly, a mobile phone-based TM system that is currently being used as a standard of care for HF at a large Canadian hospital, may be an effective tool for the management of HF in patients recently discharged from hospital. OBJECTIVE: The objective of the Medly-After an Incidence of acute Decompensation (Medly-AID) trial is to determine the effect of Medly on the self-care and quality of life of patients with HF who have been recently discharged from hospital after an HF-related decompensation. METHODS: A multisite multimethod randomized controlled trial (RCT) will be conducted at 2 academic hospitals and at least one community hospital to evaluate the impact of Medly-enabled HF management on the outcomes of patients with HF who had been hospitalized for HF-related decompensation and discharged during the 2 weeks before recruitment. The trial will include 144 participants with HF (74 in each control and intervention groups). Control patients will receive standard of care, whereas patients in the intervention group will receive standard of care and Medly. Specifically, patients in the intervention group will record daily weight, blood pressure, and heart rate and answer symptom-related questions via the Medly app. Medly will generate automated patient self-care messages such as to adjust diuretic medications, based on the rules-based algorithm personalized to the individual patient, and send real-time alerts to their health care providers as necessary. All patients will be followed for 3 months. Primary outcome measures are self-care and quality of life as measured through the validated questionnaires Self-Care of Heart Failure Index, EQ-5D-5L, and the Kansas City Cardiomyopathy Questionnaire-12. Secondary outcome measures for this study include cost of health care services used and health outcomes. RESULTS: Patient recruitment began in November 2018 at the Sunnybrook Health Sciences Centre, with a total of 35 participants recruited by July 30, 2019 (17 in the intervention group and 18 in the control group). The final analysis is expected to occur in the fall of 2020. CONCLUSIONS: This RCT will be the first to assess the effectiveness of the Medly TM system for use following discharge from hospital after a HF-related decompensation. TRIAL REGISTRATION: ClinicalTrials.gov NCT03358303; https://clinicaltrials.gov/ct2/show/NCT03358303. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/15753.

18.
Circulation ; 117(23): 2969-76, 2008 Jun 10.
Artigo em Inglês | MEDLINE | ID: mdl-18541752

RESUMO

BACKGROUND: The goal of this study was to determine the relationship between all-cause, risk-adjusted, in-hospital mortality after coronary artery bypass graft surgery and the proportion of preventable in-hospital deaths as a measure of quality of care at an institution level. METHODS AND RESULTS: We conducted a retrospective analysis of 347 randomly selected in-hospital deaths after isolated coronary artery bypass graft surgery at 9 institutions in Ontario over the period of 1998 to 2003. Nurse-abstracted chart summaries were reviewed by 2 experienced cardiac surgeons who were blinded to patient, surgeon, and hospital and used a standardized implicit tool to identify preventable death. A third reviewer reassessed all cases in which the first 2 reviewers disagreed. Rates of preventable deaths were estimated for each hospital and compared with all-cause mortality rates. A structured adverse event audit completed by each surgeon-reviewer was used to identify quality improvement opportunities for the preventable deaths. A total of 111 of 347 deaths (32%) were judged preventable despite a low risk-adjusted mortality range (1.3% to 3.1%) across hospitals. No significant correlation was found between all-cause, risk-adjusted in-hospital mortality rates and the proportion of preventable deaths at the hospital level (Spearman coefficient, -0.42; P=0.26). A large proportion of preventable deaths were related to problems in the operating room (86%) and intensive care unit (61%). Many deaths were associated with deviations in perioperative care (32% based on concurrence of 2 reviewers, and another 42% in cases in which 1 reviewer reached that opinion). CONCLUSIONS: Approximately one third of in-hospital coronary artery bypass graft deaths were judged preventable by surgeon reviewers. All-cause risk-adjusted mortality rates are convenient measures of institutional quality of care but were not correlated with preventable mortality in our jurisdiction. Providers should conduct detailed adverse event audits to drive meaningful improvements in quality.


Assuntos
Ponte de Artéria Coronária/mortalidade , Ponte de Artéria Coronária/normas , Doença da Artéria Coronariana/mortalidade , Doença da Artéria Coronariana/cirurgia , Mortalidade Hospitalar , Adulto , Ponte de Artéria Coronária/efeitos adversos , Humanos , Modelos Logísticos , Auditoria Médica , Ontário/epidemiologia , Política Organizacional , Qualidade da Assistência à Saúde , Estudos Retrospectivos , Fatores de Risco
19.
Can J Anaesth ; 56(12): 901-7, 2009 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-19816751

RESUMO

PURPOSE: The operating room (OR) has been identified by hemovigilance systems as a hospital area at high risk for transfusion errors. Where it was confirmed that transfusion products were being administered to the intended patient, we sought to determine the frequency that surgical patients' identification (ID) bands were inaccessible, the procedures used to identify patients when ID bands were inaccessible, and the effect on pre-transfusion bedside checks when ID bands were inaccessible. METHODS: We tracked the accuracy, location, and accessibility of patient ID bands in the operative phase over three months at a single Canadian Academic Health Sciences Centre. We also evaluated the surgical team's compliance with transfusion policy, focusing on bedside checks. RESULTS: Forty-four percent of the 426 patients who were tracked had accessible ID bands intraoperatively. The ID bands were removed from 6.3% of surgical patients, primarily for the placement of additional vascular lines. Cardiovascular procedures, which have a high frequency of transfusions, had the highest rate of ID band removals (26.9%) and the third-to-lowest ID band accessibility rate (19.2%). General surgery procedures had the lowest percentage of accessible ID bands (14.8%). Sixty-four of the 77 patients observed receiving transfusions in the OR had inaccessible ID bands due to positioning of the patient's arm, interference from equipment, or the surgeon. No patient ID bands were used at bedside checks, and addressograph cards and anesthetic records were used in place of the ID band in 97.4% and 2.6% of transfusions, respectively. CONCLUSION: Due to intraoperative inacessibility, the system of patient ID banding has inherent limitations as a means for providing consistent pre-transfusion checks in surgical patients. A consistently accessible ID source that is continuously affixed to surgical patients should be introduced in the OR.


Assuntos
Transfusão de Sangue/métodos , Erros Médicos/prevenção & controle , Sistemas de Identificação de Pacientes/métodos , Humanos , Cuidados Intraoperatórios/métodos , Cuidados Intraoperatórios/normas , Ontário , Estudos Prospectivos , Centro Cirúrgico Hospitalar/organização & administração , Centro Cirúrgico Hospitalar/normas , Procedimentos Cirúrgicos Operatórios/métodos , Procedimentos Cirúrgicos Operatórios/normas
20.
Healthc Q ; 12 Spec No Patient: 102-9, 2009.
Artigo em Inglês | MEDLINE | ID: mdl-19667786

RESUMO

Admission Medication Reconciliation (Med Rec) is an organizational practice designed to ensure patients' pre-admission medications are ordered correctly upon hospital admission. We describe the implementation of admission Med Rec at two academic health sciences centres, each having designed distinctly different processes. Common challenges encountered included the multi-step, inter-professional nature of Med Rec, staffing resource and workload concerns and frequent medical staff turnover in a teaching environment. Both teams found that participation in a national safety collaborative enabled the pilot initially; however, they later found the outcome measures suggested by the collaborative less useful and switched to internal compliance measures for establishing maintenance and spread. Common themes were identified among the critical success factors, with unique variations at each centre. Both teams acknowledged accreditation standards to be a major accelerator of implementation and spread. Using different measures of implementation success at each centre, the majority of patient admissions on the pilot units are complying with admission Med Rec. However, very high levels of compliance remain elusive. At Sunnybrook Health Sciences Centre's pilot unit, 62-77% of patients are being screened by a pharmacist and 65-75% of high-risk patients identified are undergoing Med Rec by a pharmacist. At The Hospital for Sick Children's pilot unit, 72-88% of patients have a physician's primary medication history documented on a Med Rec form and 57-73% of patients are also undergoing Med Rec by a nurse or pharmacist.


Assuntos
Centros Médicos Acadêmicos , Erros de Medicação/prevenção & controle , Admissão do Paciente , Difusão de Inovações , Humanos , Ontário , Estudos de Casos Organizacionais
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