Communication in healthcare: a narrative review of the literature and practical recommendations

OBJECTIVES

Effective and efficient communication is crucial in healthcare. Written communication remains the most prevalent form of communication between specialised and primary care. We aimed at reviewing the literature on the quality of written communication, the impact of communication inefficiencies and recommendations to improve written communication in healthcare.

DESIGN

Narrative literature review.

METHODS

A search was carried out on the databases PubMed, Web of Science and The Cochrane Library by means of the (MeSH)terms 'communication', 'primary health care', 'correspondence', 'patient safety', 'patient handoff' and 'continuity of patient care'. Reviewers screened 4609 records and 462 full texts were checked according following inclusion criteria: (1) publication between January 1985 and March 2014, (2) availability as full text in English, (3) categorisation as original research, reviews, meta-analyses or letters to the editor.

RESULTS

A total of 69 articles were included in this review. It was found that poor communication can lead to various negative outcomes: discontinuity of care, compromise of patient safety, patient dissatisfaction and inefficient use of valuable resources, both in unnecessary investigations and physician worktime as well as economic consequences.

CONCLUSION

There is room for improvement of both content and timeliness of written communication. The delineation of ownership of the communication process should be clear. Peer review, process indicators and follow-up tools are required to measure the impact of quality improvement initiatives. Communication between caregivers should feature more prominently in graduate and postgraduate training, to become engraved as an essential skill and quality characteristic of each caregiver.

Drug interactions and adverse drug reactions in the older patients admitted to the emergency department

PURPOSE

The aim of this study was to prospectively evaluate drug interactions and adverse drug reactions (ADRs) in the older patients admitted to the emergency department (ED) and to characterize risk factors.

METHODS

In 80 patients aged 65 years and older medication history and ED drug administration were analysed. Medical records were analysed for ADRs by an expert panel which also evaluated their avoidability and causality. An interaction program was used to search for potential drug interactions followed by assessment for clinical significance. Data were analysed using a logistic regression model. The significance level was set at alpha=0.05.

RESULTS

Eighty seven ADRs were identified in 37 patients; 18 were the result of an interaction (15 patients). Causality was assessed as definite (n=11), probable (n=62) and possible (n=24). The reason for admission was definitely and probably related to an ADR in 6 and 18 patients respectively. Only 17 (20%) of the ADRs were assessed as unavoidable, while 23 (26%) and 47 (54%) were classified as definitely and possibly avoidable, respectively. ADRs were related with female gender (p=0.023) and number of drugs (p=0.004), but not with high age (p=0.151). Clinically relevant interactions were related with older age (p=0.032) and number of drugs (p=0.003), but not with gender (p=0.380). None of the interactions with ED initiated medications were considered unjustified.

CONCLUSIONS

ADRs frequently occur in the older patients admitted to the ED and are an important cause of hospital admissions with a substantial contribution of adverse drug interactions.

Use of out-of-hours services: the patient's point of view on co-payment a mixed methods approach

INTRODUCTION

In many countries out of hours (OOH) care is offered by different health care services. General practitioners (GP) tend to offer services in competition with emergency departments (ED). Patients behaviour depends on a number of factors. In this study, we highlight the knowledge and ideas of patients concerning the co-payment system.

METHODS

We used a mixed methods design, combining quantitative and qualitative research. During two weekends in January 2005, all patients using the ED or the GP OOH service, were invited for an interview with a structured questionnaire. A stratified random sample of patients participated in a semi-structured interview. Both methods add complementary data to answer the research questions.

RESULTS

Most mentioned reasons for seeking help at the ED are: accessibility (15.0%), proximity (6.4%) and competence of the staff (5.6%). Reasons for choosing the GP are: GP is easy to find, minor medical problem or anxiety and confidence in the GP. The odds of not knowing the co-payment system are significantly higher in patients visiting the ED (OR 1.783; 95% CI: 1.493-2.129). Mostly GP users recognize the problem of ED overuse. They suggested especially to provide clear information about the tasks of the different services and about the payment system, to reduce ED overuse.

CONCLUSION AND DISCUSSION

When intending to shift from ED to GP services for minor medical problems, aiming at just one measure is no option. Information campaigns aiming to address the entire population, can clarify the role of each player in out-of-hours care.

An inquiry on pain management in the emergency department of training hospitals

INTRODUCTION

Improving pain management in the ED might be attained by adequate teaching of medical students. We assessed the skills in pain treatment of ED physicians who teach the students.

METHODS

All physicians working in an ED who provide elective training to undergraduate medical students from the Ghent University were asked to complete a questionnaire consisting of vignette patient cases concerning acute pain management of abdominal colic pain, and non-traumatic abdominal pain.

RESULTS

Thirty two physicians completed the cases. In the renal colic case 91% of the respondents proposed a NSAID as first line treatment. Butylhyoscine was still suggested by 18%. After initial failure of analgesia 31% administered a strong opioid. In biliary colic pain NSAIDs and butylhyoscine were proposed as first line analgesics by 59% and 31% respectively. In second line, butylhyoscine would be given by 22%. The patient case with right fossa abdominal pain would initially be treated with acetaminophen by 81%. Thirteen % of the respondents would not give further analgesia if the first line treatment was insufficient.

CONCLUSION

Our results indicate that adherence by teachers to evidence based guidelines of acute pain management is insufficient. Therefore improving knowledge and skills in pain management of the teachers should receive more attention.

Collisions involving mobile intensive care unit vehicles in Flanders, Belgium

In order to evaluate the risk of collision during emergency responses of mobile intensive care units (MICUs) in Flanders, Belgium, a questionnaire was sent to 37 MICU services. The response rate was 84%. During the study period (1992-96) the incident rates for collision, collision with significant physical harm, and collision leading to a wrecked MICU vehicle were 1 per 52,000 km, 1 per 214,000 km and 1 per 250,000 km, respectively. Most collisions occurred during use of 'lights and siren' (66%), and involved other motor vehicles (72%). About 50% occurred during daylight with clear weather conditions and on dry roadways. Drivers had attended a course for safe and defensive driving in only four services (13%). The use of seat belts was imposed by the hospital authorities in 21 services (72%). Vehicles equipped with airbags and an ABS-braking system were used in eight (28%) and 13 (45%) services, respectively. Our data confirm that the collision rate for MICUs is high and that measures to reduce the risk of collisions and resulting injuries and damage are at present not optimal.

When an AED meets an ICD... Automated external defibrillator. Implantable cardioverter defibrillator

The chances of prehospital care providers being confronted with a patient with an implantable cardioverter defibrillator (ICD) are increasing and so care providers must receive proper training. Based on observations made during the resuscitation of a patient with an ICD using an automated external defibrillator (AED) some technical features and possible interactions of ICDs and AEDs are highlighted. Furthermore, we discuss the key points of basic knowledge, safety, and treatment protocols for cardiac arrest and other situations required for practical training in the ICD for prehospital care providers.

ECG changes and plasma concentrations of propafenone and its metabolites in a case of severe poisoning

CASE REPORT

Propafenone is a class IC antiarrhythmic agent metabolized into two major metabolites, 5-hydroxypropafenone and N-depropylpropafenone. The potency of 5-hydroxypropafenone to block fast sodium channels is comparable to that of its parent. We report the positive correlation between plasma concentrations and electrocardiographic changes in a patient with severe oral self-poisoning. Serial ECG changes were measured and plasma concentrations were determined by high-performance liquid chromatography. The initial plasma concentrations of propafenone were in the toxic range and correlated with the widening of the QRS-complex. The slow decline in concentration during this first phase might relate to saturation of the isoenzyme CYP2D6. The half-life of propafenone, calculated from the second phase, was approximately 3 hours, defining the patient as a fast metabolizer. The initial concentrations of the metabolite N-depropylpropafenone were surprisingly higher than those of 5-hydroxypropafenone which may also be due to saturation of CYP2D6.

The effect of semi-automatic external defibrillation by emergency medical technicians on survival after out-of-hospital cardiac arrest: an observational study in urban and rural areas in Belgium

The introduction of semi-automatic external defibrillators (SAEDs) allowed emergency medical technicians (EMTs) to deliver electroshocks in cases of out-of-hospital ventricular fibrillation (VF) or ventricular tachycardia (VT), often many minutes before the arrival of the mobile intensive care unit (MICU) team. In this observational study we report on the results obtained by the EMTs from the fire departments of Gent, Aalter and Brugge. In Gent, an SAED project started in May 1991. By December 1995, the SAED's electrodes had been attached in 367 cardiac arrest patients. The first rhythm detected by the device was asystole or electromechanical dissociation (EMD) in 241 patients (66%): only 5 of these patients survived to hospital discharge (2%). In the remaining 126 VF/VT cases (34%) the survival rate was 21% (26/126). In 14 of these 26 patients the shock(s) delivered by the EMTs restored spontaneous circulation before the arrival of the MICU team, with only venous cannulation and/or intubation being performed by the MICU team. In 4 other VF patients, the shock(s) delivered by EMTs converted the VF, with the MICU team successfully taking care of VF/VT relapses or postcountershock EMD. In the remaining 8 VF/VT cases, only the MICU attempts could resuscitate the patient. The SAED project in Aalter was set up in April 1993. By December 1995, care was taken for only 21 patients. None of the 4 VF/VT patients and the 17 asystole/EMD patients survived. In Brugge, there were 240 cardiac arrest cases treated with SAED between January 1991 and December 1995. Among the 89 VF/VT cases, there were 20 survivors (22%): 8 cases survived thanks to SAED shock(s) delivered by EMTs, in 3 cases survival was due to the combination of SAED shock(s) by EMTs and extensive ALS treatment by the MICU team, and in 9 cases restoration of spontaneous circulation was only obtained after application of ALS techniques by the MICU team. This observational study seems to show a beneficial effect of the introduction of SAED in Gent and Brugge. In Aalter the number of treated cases is tool low to draw conclusions. Anyhow, the global survival rate in the three areas remains low. Therefore, more efforts are needed to strengthen the other links of the chain of survival (early access to the emergency medical services-system, early basic cardiopulmonary resuscitation and early advanced life support.

Hepatotoxicity of N, N-dimethylformamide (DMF) in acute poisoning with the veterinary euthanasia drug T-61

1. We report on a patient who was resuscitated after a suicide attempt with the veterinary euthanasia product T-61 and treated with N-acetylcysteine (NAC) to prevent hepatotoxicity from N,N-dimethylformamide (DMF), the solvent of T-61. 2. Serum concentrations of DMF were high as compared with values published on occupational exposure. 3. The patient showed only a transient increase in liver enzymes with eventually a full recovery. 4. The hepatoprotective effect of NAC was studied in a rat model using the rise in serum sorbitol dehydrogenase (SDH) as a marker for DMF-induced hepatotoxicity. 5. Four series of randomized, controlled and double-blind experiments were carried out and consistently showed a lower increase in SDH in NAC-treated animals in each series. The difference was statistically significant only when the data of the 4 series were pooled. This is probably due to the large interindividual variations in the effect of DMF. 6. We hypothesize that in the rat NAC may have a protective effect. Whether NAC is also protective in patients, in which it is administered after exposure to DMF, cannot be concluded from the present experiments.

Patients with psychiatric emergencies transported by an ambulance in an urban region

This paper studies the use of an ambulance service in the case of psychiatric emergency referrals. A cross-sectional design was used to compare the patients brought in by an ambulance with all other psychiatric emergency referrals. The sociodemographic and clinical characteristics as well as the referral pattern of both groups of patients are compared. Results show that an important proportion of patients brought in by an ambulance can be described as high risk referrals. However, for another group of referrals the ambulance is used for other reasons. The possibility of using alternative social services in these cases are discussed.

The management of non-compliance with referral to out-patient after-care among attempted suicide patients: a controlled intervention study

The failure to comply with referral for out-patient after-care is a well-documented problem among attempted suicide patients. The present study aimed at the investigation of an experimental referral procedure by means of a randomized controlled study. Non-compliant patients in the experimental group were visited in their homes by a community nurse in order to assess reasons for non-compliance and to motivate patients to comply with referral. One year after their suicide attempt patients were visited in their homes in order to assess repetition of suicidal behaviour. Uni- and multi-variate analyses showed a significant beneficial effect of the experimental procedure on compliance with referral. A near-significant effect of the experimental procedure on the rate of repetition of suicidal behaviour was found.

How to evaluate an emergency medical dispatch system: a Belgian perspective

In order to evaluate the local emergency medical dispatch centre, 4601 calls were analysed. Information was obtained from the tape recordings of the dispatch centre and standardized reports from the basic life support (BLS) teams, advanced life support (ALS) teams and the emergency departments of all receiving hospitals in the study area. The need for prehospital ALS care was assessed 'post hoc', based on the clinical findings at the scene and in the emergency department. The accuracy of the medical dispatch was evaluated by comparing the level of care actually sent with the real medical needs of the patient. The 4601 medical problems reported led to 4446 interventions: a BLS team only in 82% (n = 3627), an ALS team and BLS team simultaneously in 14% (n = 623), and a BLS team followed somewhat later by an ALS team in 4% (n = 196). In the 633 cases judged 'post hoc' to require prehospital ALS care, an ALS team was not sent in 260 (41%) or sent with some delay in 112 (18%). Of the 819 interventions of the ALS teams, 446 (54%) dealt with cases not requiring that level of care. With regard to the role of the dispatchers in the mismatches between the medical needs of the patients and the level of care sent, underestimation and overestimation of the severity of the emergency by the dispatchers was found in 31% and 22% cases respectively.

The 'early access' link in the chain of survival for cardiac arrest victims in Ghent, Belgium

Without early access to the emergency medical services (EMS) system, the chances of surviving an out-of-hospital cardiopulmonary arrest (CPA) are poor. The aim of this study was to evaluate this first link in the chain of survival in Ghent. Therefore, we reviewed the data from the registry on all CPA cases treated by our mobile intensive care unit (MICU) and the tape recordings from the local EMS dispatch centre of 100 consecutive non-traumatic CPA cases that occurred after January 1, 1993. Alarm signs before the collapse were recorded in 39 cases. In only 54% (21 out of 39) a pre-arrest call to the EMS system was made. In only four cases (10%) was the MICU at the patient's side when the collapse occurred. The delay between collapse and call in the 79 cases in which no call to the EMS system was made before the collapse was estimated to be 3 min or less for only 49% (39 out of 79). To evaluate the processing of the call in the EMS dispatch centre, we examined all 100 cases with regard to whether or not the first tier (emergency medical technicians) and the second tier (MICU) were dispatched simultaneously upon the first call. We found that in 41 cases the MICU was not sent immediately. The most important reasons were minimal information available for the EMS system (n = 8), underestimation of the emergency of the call by the dispatcher (n = 10) and underestimation of the pre-alarm signs by a general practitioner (n = 7). This analysis shows that all aspects of the first link of the chain of survival need improvement.

Metabolism and hepatotoxicity of N,N-dimethylformamide, N-hydroxymethyl-N-methylformamide, and N-methylformamide in the rat

The metabolism and hepatotoxicity of N,N-dimethylformamide (DMF) and two of its metabolites, N-hydroxymethyl-N-methylformamide (HMMF) and N-methylformamide (NMF) were evaluated over a 4-day period in rats. DMF toxicity was dose dependent and delayed toxicity after the administration of a high DMF dose (13.7 mmol/kg) in comparison to a lower dose (4.1 mmol/kg) was observed. Treatment of rats with 13.7 mmol/kg DMF, HMMF, or NMF showed i) that DMF is more toxic than HMMF or NMF, and ii) that hepatotoxicity occurs later for DMF than for HMMF or NMF. Analysis of serum and urine samples demonstrated that DMF is first metabolized to HMMF, which is then partially converted to NMF. After HMMF administration, NMF was found both in serum and in urine. The time course of DMF and HMMF toxicity in relation to NMF formation fitted the hypothesis that the hepatotoxicity of DMF and HMMF is mediated via NMF. The degree of hepatotoxicity after HMMF and NMF treatment is similar. However, the degree of DMF hepatotoxicity is much higher than in the case of NMF or HMMF. The role of NMF as an obligatory intermediate in DMF and HMMF hepatotoxicity is discussed.

[Resuscitation in heart arrest due to severe hypothermia]

Two patients were resuscitated after cardiopulmonary arrest due to severe hypothermia. The first patient, a 76-year-old man, had ventricular fibrillation resistant to conventional therapy; he was rapidly rewarmed by means of cardiopulmonary bypass. In the second patient, a 77-year-old woman, classical resuscitation led to restoration of spontaneous circulation. The patient was subsequently rapidly rewarmed with hemodialysis with fluid of 40 degrees C. We conclude that rapid rewarming with cardiopulmonary bypass is the treatment of choice in severely hypothermic patients presenting with cardiac arrest that is resistant to conventional therapy. Hemodialysis seems a suitable technique in patients who remain deeply hypothermic after resuscitation. However, it is difficult to assess its value because of the lack of clinical studies comparing this technique with other procedures.

A positron emission tomography study of patients with acute carbon monoxide poisoning treated by hyperbaric oxygen

Seven patients with an acute and severe carbon monoxide intoxication were treated with hyperbaric oxygen and underwent a positron emission tomographic examination 2-5 days after the acute event. Although the final clinical outcome was good in all patients, ischaemic changes were observed. Three patients with temporary sequelae after hyperbaric oxygen treatment showed the most severe changes, mainly in striatum and thalamus. Although positron emission tomographic examination cannot predict the final outcome, it can show the regions at risk for development of late complications following carbon monoxide poisoning.

Should semi-automatic defibrillators be used by emergency medical technicians in Belgium? The Belgian Cerebral Resuscitation Study Group

Early external defibrillation is the single most effective intervention in patients with out-of-hospital cardiac arrest. Literature data indicate that instructing emergency medical technicians (EMTs) to use defibrillators is beneficial, provided the local emergency medical system is well organized. We tried to estimate the potential benefit of early defibrillation in some centres in Belgium by retrospectively analyzing the data from the Belgian Cardio-Pulmonary-Cerebral Resuscitation Registry collected between 1983 and 1987 in Belgian centres with a Mobile Intensive Care Unit (MICU). The data show that 2310 out of 3371 patients (69%) were first attended by the EMTs; on subsequent arrival of the MICU-teams, 584 of these 2310 patients i.e. 17% of the whole study population, presented with ventricular fibrillation. Analysis of estimated time factors in these 2310 patients revealed that the median time interval between collapse and start of resuscitation by EMTs was 8 min; the median time interval between collapse and start of MICU-resuscitation attempts was 16 min. The duration of EMT-resuscitation before MICU-arrival was probably more than 5 min and 10 min in 58% and 23% of the cases respectively. It is concluded that EMTs can be expected to reach a substantial number of ventricular fibrillation victims within a few minutes after the collapse and many minutes before arrival of the MICU. Therefore, training of EMTs in the use of semi-automatic defibrillators seems worthwhile in MICU-served regions in Belgium.

Early prediction of non-survival for patients suffering cardiac arrest--a word of caution. The Belgian Cerebral Resuscitation Study Group

A total of 6178 persons with out-of-hospital (70%) and in hospital (30%) cardiac arrests from the first of January 1982 until the end of 1989 were reviewed retrospectively with respect to 4 variables, contributing to a score for specific prediction of poor prognosis (cut-off point: greater than 3 points). These included age, initial ECG, type of respiratory arrest and bystander resuscitation. Presence of ventricular fibrillation, gasping and bystander resuscitation contributes nothing to the score, while presence of asystole or EMD (electromechanical dissociation), apnoea and absence of bystander resuscitation adds one point to it. Of patients scoring 4 or 5 points 44 were awake 14 days post CPR (Class 3). The positive predictive value of the score was 97% (95% CI 96-98%) for the out-of-hospital group and 92.2% (95% CI 88-95%) for the in-hospital group. The specificity was respectively 92.3% (95% CI 89-95%) and 94.2% (95% CI 91-96%). Although the score can weigh the likelihood of no success against that of success, we cannot recommend it for decision making as far as abandoning or continuing cardiopulmonary resuscitation efforts.

Acute cholinesterase inhibitor poisoning mimicking pulmonary oedema

In patients poisoned with a cholinesterase inhibitor, the diagnosis may initially be missed especially when no history is available from the patient or his relatives. The predominant respiratory symptoms may suggest pulmonary oedema as illustrated by the two case reports presented here. A high degree of suspicion and a careful clinical examination are necessary to make the correct diagnosis, which eventually can be confirmed by measurement of red cell and serum cholinesterase activity.

[Analysis of severely injured patients admitted via an emergency service]

Data about the number and treatment of trauma-patients are, certainly in our country, very rare. In this study we showed that such a registration with grading of the severity of the injuries following the ISS-Score is feasible and useful. Further and more extensive registration seems necessary in order to obtain a better insight in epidemiology and treatment of trauma patients in our country.

Predictive value of Glasgow coma score for awakening after out-of-hospital cardiac arrest. Cerebral Resuscitation Study Group of the Belgian Society for Intensive Care

The Glasgow coma score (GCS) during days 1-6 after cardiac arrest was used to predict neurological outcome in 360 resuscitated victims of out-of-hospital cardiac arrest. A predictive rule based on the best GCS of 216 patients resuscitated in 1983-84 (prediction group) was constructed, and its predictive power was tested on 133 patients treated in 1985 (test group). Neurological outcome was correctly predicted 2 days after cardiac arrest in 80% of the prediction group, with a best GCS of 10 or above and 4 or below as cutoff points. For patients with a best GCS of 5-9, prediction of outcome was possible 6 days after cardiac arrest, with a best GCS of 8 during the first 6 days as the single cutoff point. The rule was then validated in the test group: the sensitivity was 96%; the specificity 86%; the negative predictive value 97%; and the positive predictive value 77%. These data suggest that this simple GCS-based rule can be helpful in predicting outcome in patients resuscitated after out-of-hospital cardiac arrest, but confirmation of these data is required in a prospective study in a larger number of patients.

[Surgical case report: diagnosis of associated abdominal lesions in penetrating injuries of the lower chest]

We discuss the way to diagnose intra-abdominal lesions caused by penetrating objects in the lower thorax. Let us call these wounds penetrating wounds. Two kinds of penetrating wounds are considered: 1. shotwounds; 2. knifewounds. 1. In shotwounds of the lower thorax there is not any non-surgical method available to find the associated intra-abdominal lesions. In these cases the results of: 1. physical examination; 2. local wound exploration; 3. echography of the abdomen and 4. peritoneal lavage cannot be trusted. Only laparotomy can show us if any associated lesion in the abdomen exists. 2. For knifewounds we can make almost the same remarks: 1. physical examination; 2. local exploration of the lesion; 3. echography of the abdomen are not to be considered as good diagnostic tools to find the associated intra-abdominal wounds. However in this situation the results of peritoneal lavage are to be trusted. Without omitting a 24 h observation of the patient the most rational criteria for a positive peritoneal lavage are red blood cell greater than 100.000/mm3; white blood cell greater than 500/mm3.

[Activities of mobile emergency units in Ghent]

We present here the analysis of the activities of the mobile intensive care unit of the university hospital of Ghent in 1984. The call for medical intervention from the unit originated in most cases from the 900 centre. Trauma and cardiac arrest were the most frequent reasons for intervention. The majority of the interventions of the mobile unit were needed for patients at home. These data illustrate the need for orienting the medical emergency care systems towards patients at home.