"Nobody told me": Communication Issues Affecting Australian Cardiothoracic Surgery Patients

Comparison of two audit and feedback approaches: descriptive analysis of personal and contextual dynamics

INTRODUCTION

Audit and feedback (A&F) is a systematic intervention that can be used to improve the quality of health care. The EASY-NET Network Project proposes an innovative A&F model.

AIM

This study aimed to describe the newly proposed A&F model. An analysis was conducted, examining the participants' attitudes and their individual and interpersonal mechanisms to understand how they influence the work context and vice versa.

METHODS

Two A&F models were compared, involving emergency and rehabilitation health workers, who were divided into two groups. The classic A&F model was compared with a new model, using a desk audit followed by interactive feedback. Communication training was provided to the audit team by psychologists before commencement of the project. The experimental group underwent psychological screening using two standardized tools (COPE-NVI and ProQoL) to evaluate personal and relational dynamics using the context-mechanism-outcome (CMO) paradigm.

RESULTS

The exchange of ideas among health professionals is more effective when using face-to-face feedback than written feedback. The COPE-NVI and ProQoL questionnaires highlighted the difficulties experienced by health care professionals in implementing effective coping strategies to deal with stressful events.

CONCLUSIONS

Identifying signs of stress in health care workers is essential for improvement strategies to be implemented and for establishing new, optimal conditions. Remote feedback makes it possible to overcome logistical barriers and, in the future, this method can be used for inter-organizational collaboration.

SPANISH ABSTRACT

http://links.lww.com/IJEBH/A203.

Patient perspectives and overall satisfaction after liver resection for benign disease

BACKGROUND

Management of benign liver lesions (BLLs) is still an object of discussion. Frequently, patients receive multiple opinions about their diagnosis and treatment from physicians specialized in different areas, which can be opposite and controversial. This study aimed to understand patients' decision-making process in electing surgery and assess their satisfaction after resection for BLLs.

METHODS

A 104-question survey was administered to 98 patients who had a resection for BLLs in 4 different hepatopancreatobiliary and transplant centers in Argentina. The first section included 64 questions regarding the initial discovery of the BLL, the decision-making process, and the understanding of the patient's feelings after surgery. The second section, 42 queries, referred to the quality of life. The patient's final diagnosis and outcome were correlated with the survey results using univariate analysis.

RESULTS

Among 97 patients who had undergone liver resection for BLLs, 69 (70%) completed the survey. The median age was 51.71 years (range, 18-75), and 63% of the patients were females. Moreover, 21% of patients received conflicting information from different healthcare providers. Surgeons were the best to describe the BLL to the patient (63%), and 30% of patients obtained opinions from multiple surgeons. The respondents were quite or fully satisfied with their decision to have surgery (90%) and the decision-making process (91%). Only 59% of patients considered their lifestyle better after surgery, and 89% of patients would have retaken the same decision.

CONCLUSION

Patients with resected BLLs are delighted with the decision to have surgery, regardless of the final diagnosis and outcome. The role of surgeons is crucial in the decision-making process.

Sensorineural hearing loss after cardiac surgery: a systematic review

BACKGROUND

Sensorineural hearing loss (SNHL) may occur following cardiac surgery. Although preventing post-operative complications is vitally important in cardiac surgery, there are few guidelines regarding this issue. This review aimed to characterize SNHL after cardiac surgery.

METHOD

This systematic review was registered on PROSPERO and conducted in accordance with PRISMA guidelines. A systematic search of the PubMed, Embase and Cochrane Library were conducted from inception. Eligibility determination, data extraction and methodological quality analysis were conducted in duplicate.

RESULTS

There were 23 studies included in the review. In the adult population, there were six cohort studies, which included 36 cases of hearing loss in a total of 7135 patients (5.05 cases per 1000 operations). In seven cohort studies including paediatric patients, there were 88 cases of hearing loss in a total of 1342 operations. The majority of cases of hearing loss were mild in the adult population (56.6%). In the paediatric population 59.2% of hearing loss cases had moderate or worse hearing loss. The hearing loss most often affected the higher frequencies, over 6000 Hz. There have been studies indicating an association between hearing loss and extracorporeal circulation, but cases have also occurred without this intervention.

CONCLUSION

SNHL is a rare but potentially serious complication after cardiac surgery. This hearing loss affects both paediatric and adult populations and may have significant long-term impacts. Further research is required, particularly with respect to the consideration of screening for SNHL in children after cardiac surgery.

Potentially avoidable mortality after endoscopic retrograde cholangiopancreatography in Australia: an 8-year qualitative analysis

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is a commonly performed procedure worldwide. The aim of this study was to examine cases of mortality after ERCP to identify clinical incidents that are potentially preventable, to improve patient safety.

METHODS

The Australian and New Zealand Audit of Surgical Mortality provides an independent and externally peer-reviewed audit of surgical mortality pertaining to potentially avoidable issues. A retrospective review of prospectively collected data within this database was performed for the 8-year audit period from 1 January 2009 to 31 December 2016. Clinical incidents were identified by assessors through first- or second-line review, and thematically coded into periprocedural stages. These themes were then qualitatively analysed.

RESULTS

There were 58 potentially avoidable deaths following ERCP, with 85 clinical incidents. Preprocedural incidents were most common (n = 37), followed by postprocedural (n = 32) and then intraprocedural (n = 8). Communication issues occurred across the periprocedural period (n = 8). Preprocedural incidents included delay to procedure, inadequate resuscitative management, decision to perform procedure and inadequate assessment. Intraprocedural incidents comprised technical factors and inadequate support. Postprocedural incidents involved inappropriate treatment, delay in definitive surgical treatment or in recognizing complications, inappropriate second-line intervention and inadequate assessment. Communication incidents comprised inadequate documentation, failure to escalate care and poor inter-clinician communication.

CONCLUSION

Causes of mortality following ERCP are wide-ranging, and reviewing clinical incidents associated with potentially avoidable mortality can serve to inform and educate practitioners. In collating a subset of cases in which procedure-related mortality was deemed avoidable, a series of cautionary tales about ERCP is presented that may provide cues to practitioners on improving patient safety and inform future surgical practice.

Lost in Translation: The Impact of Language Barriers on the Outcomes of Patients Receiving Coronary Artery Revascularization

INTRODUCTION

Clear and effective communication is vital in discussions regarding coronary revascularization. Language barriers may limit communication in healthcare settings. Previous studies on the influence of language barriers on the outcomes of patients receiving coronary revascularization have produced conflicting results. The aim of this systematic review was to evaluate and synthesise the existing evidence regarding the effects of language barrier on the outcomes of patients receiving coronary revascularization.

METHODS

A systematic review was conducted, including a search of the PubMed, EMBASE, Cochrane, and Google Scholar databases on 01/10/2022. The review was conducted in accordance with PRISMA guidelines. This review was also prospectively registered on PROSPERO.

RESULTS

Searches identified 3983 articles of which a total 12 studies were included in the review. Most studies describe that language barriers result in delayed presentation, but not delays in treatment following hospital arrival with respect to coronary revascularization. The findings with respect to the likelihood of receiving revascularization have varied significantly; however, some studies have indicated that those with language barriers may be less likely to receive revascularization. There have been some conflicting results with respect to the association between language barrier and mortality. However, most studies suggest that there is no association with increased mortality. In studies that evaluated length of stay variable results have been reported based on geographical location. Namely Australian studies have suggested no association between language barrier and length of stay, but Canadian studies support an association. Language barriers may also be associated with readmissions following discharge, and major adverse cardiovascular and cerebrovascular events (MACCE).

CONCLUSION

This study demonstrates that patients with language barriers may have poorer outcomes from coronary revascularization. Future interventional studies will be required to consider the sociocultural context of patients with language barriers, and may be targeted at timepoints including prior to, during, or after hospitalisation for coronary revascularization. Further examination of the adverse health outcomes of those with language barriers in fields outside of coronary revascularization are required in view of the stark inequities identified in this field.

Auditing the Audits: A Systematic Review on Different Procedures in Telemedicine

Telemedicine is a process of delivering health care using information and communication technologies. Audit and feedback (A&F) constitute a systematic intervention that is aimed at collecting data, which are subsequently compared with reference standards and then returned to health care operators through feedback meetings. The aim of this review is to analyse different audit procedures on and by mean of telemedicine services and to identify a practice that is more effective than the others. Systematic searches were performed in three databases evaluating studies focusing on clinical audits performed on and by means of telemedicine systems. Twenty-five studies were included in the review. Most of them focused on telecounselling services with an audit and a maximum duration of one year. Recipients of the audit were telemedicine systems and service users (general practitioners, referring doctors, and patients). Data resulting from the audit were inherent to the telemedicine service. The overall data collected concerned the number of teleconsultations, service activity, reasons for referral, response times, follow-up, reasons why treatment was not completed, technical issues, and other information specific to each telemedicine service. Only two of the considered studies dealt with organizational aspects, and of these, only one analysed communicative aspects. The complexity and heterogeneity of the treatments and services provided meant that no index of uniformity could be identified. Certainly, some audits were performed in an overlapping manner in the different studies, and these show that although attention is often paid to workers' opinions, needs, and issues, little interest was shown in communicative/organizational and team dynamics. Given the importance and influence that communication has in teamwork and care settings, an audit protocol that takes into account intra- and extra-team communication processes could be essential to improving the well-being of operators and the quality of the service provided.

Communication Training: Significance and Effects of a Preliminary Psychological Intervention upon an Audit Team

Communication constitutes an essential aspect of teamwork. This is especially true for audit teams, where communication takes place not only within the work group but also with the audit recipients. For this reason, given the poor evidence in the literature, communication training was carried out on an audit team. Training was divided into 10 meetings of two hours each, with the meetings taking place over 2 months. Questionnaires were administered to identify the characteristics and styles of communication, to assess the sense of perceived self-efficacy in general and at work, and to evaluate the knowledge inherent in the communication. This battery was administered before and after the training to evaluate its effectiveness and its effects on self-efficacy, communication style, and knowledge. Furthermore, a communication audit was performed on the feedback provided by the team, to highlight satisfaction, strengths, and any critical issues that emerged during the feedback phase. The results obtained suggest that training has an effect not only on individual knowledge but also on personological aspects. Communication among colleagues and general self-efficacy appear to be improved by the process. Self-efficacy also specifically improves in the work environment, with subjects feeling more able to manage relationships and collaborations with colleagues and supervisors. Moreover, the audit team members were satisfied with the training received, perceiving an improvement in their own communication skills during the feedback phases.

Geographical distribution of authorship for leading cardiothoracic surgery journals

BACKGROUND

Evolution of surgical practice is influenced by publications in the leading journals of that field. If the authorship of a publication lacks geographical diversity, this could create bias and limit generalizability of the evidence. Accordingly, we conducted a geographical analysis of the leading Cardiothoracic Surgery journals worldwide.

METHODS

Using 2020 Impact Factor, we searched the leading Cardiothoracic Surgery journals over the past decade. Only original articles were included. Data regarding first, second and last authors were extracted from every article. From this, we analysed country of affiliation, highest academic degree obtained and author location by metropolitan or rural setting.

RESULTS

A total of 12,706 original articles were published in the top 5 ranked Cardiothoracic journals between 2011 and 2020. Authors originated from 69 countries, with the majority being from North America and Western Europe. The United States was the most common country of affiliation (42.8%) in all five journals, with New York City the most prominent city. A total of  63.7% of the authorship originated from large metropolitan areas (estimated as population greater than 500,000 residents), and the most common degrees obtained by authors were MD and PhD.

CONCLUSION

The prominent Cardiothoracic authorship is predominantly located in Western countries, most commonly large metropolitan centers in the United States. This raises questions as to whether the literature adequately reflects populations in other geographical areas such as the continents of South America and Africa and rural settings. Leading journals should consider policies which encourage publication by authors from geographical locations that are underrepresented globally.

Endovascular thrombectomy for large vessel occlusion acute ischemic stroke after cardiac surgery

INTRODUCTION

Acute ischemic stroke (AIS) can be a catastrophic complication of cardiac surgery previously without effective treatment. Endovascular thrombectomy (EVT) is a potentially life-saving intervention. We examined patients at our institution who had EVT to treat AIS post cardiac surgery.

METHODS

We retrospectively reviewed a stroke database from January 1, 2016 to October 31, 2021 to identify patients who had undergone EVT to treat AIS following cardiac surgery. Demographic data, operation type, stroke severity, imaging features, management and outcomes (mortality and modified Rankin Score (mRS)) were assessed.

RESULTS

Of 5022 consecutive patients with AIS, 870 underwent EVT. Seven patients (0.8%) had EVT following cardiac surgery. Operations varied: two coronary artery bypass grafting (CABG), two transcatheter AVR, one redo surgical aortic valve replacement (AVR), one mitral valve repair and one patient with combined aortic and mitral valve replacements and CABG. Meantime postsurgery to stroke symptoms onset was 3 days (range 0-9 days). Median NIHSS was 26 (range 10-32). Five patients had middle cerebral artery occlusion and two internal carotid artery (n = 2). Median time between onset of symptoms and recanalization was 157 min (range 97-263). Two patients received Intra-arterial Thrombolysis. All patients survived and were discharged to another hospital (n = 3), home (n = 2), or rehabilitation facility (n = 2). Median 3-month mRS was 3 (range 0-6).

CONCLUSION

We report the largest case series of EVT after cardiac surgery. EVT can be associated with excellent outcomes in these patients. Close neurological monitoring postoperatively to identify patients who may benefit from intervention is key.

Paradigm shift: Beyond the COVID-19 era, is YouTube the future of education for CABG patients?

INTRODUCTION

Patients commonly use YouTube for education, and this may have increased due to COVID-19 related restrictions on access to healthcare professionals. However, YouTube videos lack peer review and regulation. To assess patient education in the COVID-19 era, we analyzed the quality of YouTube videos on coronary artery bypass graft (CABG) surgery.

METHODS

We searched YouTube using the phrase "coronary artery bypass graft." Two authors individually used the Journal of the American Medical Association (JAMA), DISCERN, and Health on the Net (HON) systems, to rate the first 50 videos retrieved. Data collected for each video included; number of views, duration since upload, percentage positivity (proportion of likes relative to total likes plus dislikes), number of comments, and video author. Interobserver reliability was assessed using an intraclass correlation coefficient (ICC). Associations between video characteristics and quality were tested using linear regression or t-tests.

RESULTS

The average number of views was 575,571. Average quality was poor, with mean scores of 1.93/4 (ICC 0.54) for JAMA criteria, 2.52/5 (ICC 0.78) for DISCERN criteria, and 4.04/8 (ICC 0.66) for HON criteria. Videos uploaded by surgeons scored highest overall (p < .05). No other factors demonstrated significant association with video quality.

CONCLUSION

YouTube videos on CABG surgery are of poor quality and may be inadequate for patient education. Given the complexity of the procedure and that beyond the COVID-19 era, patients are more likely to seek education from digital sources, treating surgeons should advise of YouTube's limitations and direct patients to reliable sources of information.

Cardiac surgery on patients with COVID-19: a systematic review and meta-analysis

Introduction

The COVID‐19 pandemic has had a significant impact on global surgery. In particular, deleterious effects of SARS‐CoV‐2 infection on the heart and cardiovascular system have been described. To inform surgical patients, we performed a systematic review and meta‐analysis aiming to characterize outcomes of COVID‐19 positive patients undergoing cardiac surgery.

Methods

The study protocol was registered with PROSPERO (CRD42021228533) and conformed with PRISMA 2020 and MOOSE guidelines. PubMed, Ovid MEDLINE and Web of Science were searched between 1 January 2019 to 24 February 2022 for studies reporting outcomes on COVID‐19 positive patients undergoing cardiac surgery. Study screening, data extraction and risk of bias assessment were conducted in duplicate. Meta‐analysis was conducted using a random‐effects model where at least two studies had sufficient data for that variable.

Results

Searches identified 4223 articles of which 18 studies were included with a total 44 patients undergoing cardiac surgery. Within these studies, 12 (66.7%) reported populations undergoing coronary artery bypass graft (CABG) surgery, three (16.7%) aortic valve replacements (AVR) and three (16.7%) aortic dissection repairs. Overall mean postoperative length of ICU stay was 3.39 (95% confidence interval (CI): 0.38, 6.39) and mean postoperative length of hospital stay was 17.88 (95% CI: 14.57, 21.19).

Conclusion

This systematic review and meta‐analysis investigated studies of limited quality which characterized cardiac surgery in COVID‐19 positive patients and demonstrates that these patients have poor outcomes. Further issues to be explored are effects of COVID‐19 on decision‐making in cardiac surgery, and effects of COVID‐19 on the cardiovascular system at a cellular level.

Validação de checklist para utilização em cirurgia cardíaca segura

RESUMO Objetivo Construir e validar um instrumento no formato checklist para utilização em cirurgia cardíaca segura. Método Pesquisa metodológica realizada nas seguintes etapas: revisão da literatura; construção dos itens e validação de conteúdo por especialistas em duas etapas, a nível regional com 9 e nacional com 14 juízes. Para análise dos dados, aplicou-se a taxa de concordância por item construído. Resultados A construção da versão 1 resultou em 49 itens, a versão 2 apresentou 46 itens, e a versão final 41 itens distribuídos em Sign in (1 a 27), Time out (28 a 32) e Sign out (33 a 41). Na versão final, todos os itens foram validados com concordância superior a 80%. Conclusão O checklist foi construído e validado quanto ao conteúdo, composto por 41 itens,e poderá ser utilizado na área de cirurgia cardíaca para a implementação de assistência segura aos pacientes submetidos a esses procedimentos.

Checklist validation for use in safe heart surgery

ABSTRACT Objective Build and validate an instrument in checklist format for use in safe cardiac surgery. Method Methodological research carried out in the following stages: literature review; national construction of items and content validation by experts in two stages, at regional level 9 and with 41 judges. For data analysis, the agreement rate per constructed item was determined. Results The construction of version 1 resulted in 49 items, version 2 presented 46 items, and the final version 41 items distributed in Sign in (1 to 27), Time out (28 to 32) and Sign out (33 to 41). All items obtained agreement greater than 80%, considering validated. Conclusion The checklist was built and validated in terms of content, consisting of 41 items, and can be used in the area of cardiac surgery for the implementation of safe care for patients undergoing these procedures.