[Evolution of adherence to hand hygiene in health care professionals in a third level hospital in relation to the SARS-CoV-2 pandemic]

OBJECTIVE

Proper hand hygiene is the main measure in the prevention and control of infection associated with healthcare. It describes how the pandemic period of 2020 has influenced the evolution of the degree of compliance with hand hygiene practices in health professionals at the Hospital Universitario Insular de Gran Canaria with respect to previous years.

METHODS

Descriptive cross-sectional study of direct observation on compliance with the five moments of hand hygiene in the 2018-2020 period. Adherence is described with the frequency distribution of the different moments in which it was indicated.

RESULTS

Total adherence has increased from 42.5% in 2018, to 47.6% in 2019, and 59.2% in 2020 (p <0.05). Total adherence was greater in the moments after contact with the patient (67%) than in the moments before contact (48%). The area with the highest adherence was dialysis (83%). There is a greater adherence in open areas than in hospitalization areas (65% vs 56%). Higher adherence was determined in physicians (73%) and nurses (74%), than in nursing assistants (50%) (p<0.05).

CONCLUSIONS

In 2020 there was an increase in adherence to hand hygiene compared to previous years. A higher percentage of adherence was determined in physicians and nurses than in nursing assistants. We consider that the current SARS-CoV-2 pandemic has played a relevant role in this increase in adherence.

Becoming clinical supervisors: identity learnings from a registrar faculty development program

This article shares our experiences and surprises as we developed, implemented and evaluated a 12-week faculty development program for registrars as clinical supervisors over three cohorts. The program has consistently been rated highly by participants. Yet, following a comprehensive curriculum review, we were surprised that our goal of encouraging identity development in clinical supervisors seemed to be unmet. Whilst our evaluation suggests that the program made important contributions to the registrars' knowledge, application and readiness as clinical supervisors, challenges linked to developing a supervisor identity and managing the dual identity of supervisor and clinician remain. In this article we describe our program and argue for the importance of designing faculty development programs to support professional identity formation. We present the findings from our program evaluation and discuss the surprising outcomes and ongoing challenges of developing a cohesive clinical educator identity. Informed by recent evidence and workplace learning theory we critically appraise our program, explain the mechanisms for the unintended outcomes and offer suggestions for improving curricular and pedagogic practices of embedded faculty development programs. A key recommendation is to not only consider identity formation of clinical supervisors from an individualist perspective but also from a social perspective.

Gender and workforce in urology - use of the BG Index to Assess Female Career Promotion in Academic Urology

PURPOSE

Today, the majority of medical graduates in countries such as the UK, the US or Germany are female. This poses a major problem for workforce planning especially in urology. We here use first the first time the previously established Brüggmann Groneberg (BG) index to assess if female academic career options advance in urology.

METHODS

Different operating parameters (student population, urology specialist population, urology chair female:male (f:m) ratio) were collected from the Federal Office of Statistics, the Federal Chamber of Physicians and the medical faculties of 36 German universities. Four time points were monitored (2000, 2005, 2010 and 2015). From these data, female to male (f:m) ratios and the recently established career advancement (BG) index have been calculated.

RESULTS

The German hospital urology specialists' f:m ratios were 0.257 (499 female vs. 1944 male) for 2015, 0.195 for 2010, 0.133 for 2005 and 0.12 for 2000. The career advancement (BG) index was 0.0007 for 2000, 0,0005 for 2005, 0.094 for 2010 and 0.073 for 2015. The decrease from 2010 to 2015 was due to an increase in the f:m ratio of hospital urologists and female medical students.

CONCLUSION

The BG index clearly illustrated that there is an urgent need for special academic career funding programs to counteract gender problems in urology. The BG index has been shown to be an excellent tool to assess female academic career options and will be very helpful to assess and document positive or negative changes in the next decades.

Regional disparities in health care resources in traditional Chinese medicine county hospitals in China

OBJECTIVE

We aimed to analyze regional disparities of health care resources in traditional Chinese medicine (TCM) county hospitals and their time trends, and to assess the changes of regional disparities before and after 2009 health care reforms.

METHODS

We used hospital-based, longitudinal data from all TCM county hospitals in China between 2004 and 2016. To measure the key development features of TCM county hospitals, data were collected on government hospital investment, hospital numbers (the average number of TCM hospitals per county), hospital scale (the number of medical staff and hospital beds) and doctors' workload (the daily visits and inpatient stays per doctor). We used segmented linear regression to test the time trend for outcome variables. We set a breakpoint at 2011, dividing the pre-reform (2004-2011) and post-reform (2012-2016) periods.

RESULTS

After the 2009 health reforms, TCM hospitals continued to display large disparities in the number, scale, and doctors' workload across the three regions. In the pre-reform period, yearly government subsidies for TCM hospitals in western area were roughly RMB0.6 million (US$89 thousand) more than those in central and eastern region, which increased under the 2009 reforms to roughly RMB2 million (US$298 thousand) more per yer in post-reform period. These increased subsidies saw an increase in the number of TCM hospitals in the western area, partly addressing regional disparities. But there was no improvement in the regional disparities in terms of scale (number of beds) and the doctors' workload (daily outpatient visits and inpatients per doctor) increased or remained unchanged between the western and other regions.

CONCLUSION

Although TCM hospital number, scale, and doctors' workload increased over the past 13 years, substantial regional disparities remained. The 2009 health reforms did not significantly change the regional disparities in health care resources, especially between the eastern and western regions.

The Influence of Inpatient Physician Continuity on Hospital Discharge

BACKGROUND

Inpatient attending physicians may change during a patient's hospital stay. This study measured the association of attending physician continuity and discharge probability.

METHODS

All patients admitted to general medicine service at a tertiary care teaching hospital in 2015 were included. Attending inpatient physician continuity was measured as the consecutive number of days each patient was treated by the same staff-person. Generalized estimating equation methods were used to model the adjusted association of attending inpatient physician continuity with daily discharge probability.

RESULTS

6301 admissions involving 41 internists, 5134 patients, and 38,242 patient-days were studied. The final model had moderate discrimination (c-statistic = 0.70) but excellent calibration (Hosmer-Lemeshow statistic 11.5, 18 df, p value 0.89). Daily discharge probability decreased significantly with greater severity of illness, higher patient death risk, and longer length of stay, on admission day, for elective admissions, and on the weekend. Discharge likelihood increased significantly with attending inpatient physician continuity; daily discharge probability increased for the average patient from 15.3 to 20.9% when the consecutive number of days the patient was treated by the same attending inpatient physician increased from 1 to 7 days.

CONCLUSIONS

Inpatient attending physician continuity is significantly associated with the likelihood of patient discharge. This finding could be considered if resource utilization is a factor when scheduling attending inpatient physician coverage.

Trends in Surgeon Wellness (Take a Sad Song and Make It Better): A Comparison of Surgical Residents, Fellows, and Attendings

We aim to investigate the prevalence of posttraumatic stress disorder (PTSD), physician burnout (PBO), and work-life balance (WLB) among surgical residents, fellows, and attendings to illustrate the trends in surgeon wellness. A cross-sectional national survey of surgical residents, fellows, and attendings was conducted screening for PTSD, PBO, and WLB. The prevalence of screening positive for PTSD was more than two times that of the general population at all levels of experience, and more than half have an unhealthy WLB. The prevalence of PTSD, PBO, and unhealthy WLB declined with increasing level of experience (P < 0.001). One deviation in this trend was a lower prevalence of PBO among surgical fellows compared with residents and attendings (P < 0.001). Surgeon wellness improved with increasing level of experience. The incorporation of wellness programs into surgical residencies is essential to the professional development of young surgeons to cultivate healthy lasting habits for a well-balanced career and life.

Coding Discrepancies Between Medical Student and Physician Documentation

OBJECTIVE

Accurate medical documentation is a core competency in medical education and is critical to successful surgical practice. The following study aims to assess the coding accuracy of medical student documentation.

DESIGN

Retrospective chart review identified patient encounters in a surgery clinic that contained documentation by both a faculty member and a third-year medical student. Records were de-identified and assigned a level of service (LOS) and diagnostic code by trained, expert coders. Differences in LOS and diagnostic code were then compared between medical student and faculty documentation.

SETTING

A single academic health system.

PARTICIPANTS

Third-year medical students.

RESULTS

80 full patient evaluations and 20 postoperative visits were analyzed. Median faculty and student LOS was 4 (range 3-4) and 3 (range 0-4) respectively (p < 0.001). Students failed to document a sufficient number of elements in the evaluation, failed to specify studies ordered, and documented low medical decision making. Diagnostic code was concordant between students and faculty for only 31% of documentation.

CONCLUSION

Student documentation of clinical encounters is coded at a lower LOS than faculty documentation. These results likely reflect the lack of education regarding E/M coding in medical school, which is integral to real world practice.

SUMMARY

Accurate medical documentation is critical to the correct diagnostic coding and billing of a medical encounter. We found that compared to faculty documentation of the same patient evaluations, student documentation was typically coded at a lower level of service and assigned a different diagnostic code by professional medical coders. Addressing these topics in medical school may better prepare students for real-world practice.

Do HCAHPS Doctor Communication Scores Reflect the Communication Skills of the Attending on Record? A Cautionary Tale from a Tertiary-Care Medical Service

BACKGROUND

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores measure patient satisfaction with hospital care. It is not known if these reflect the communication skills of the attending physician on record. The Four Habits Coding Scheme (4HCS) is a validated instrument that measures bedside physician communication skills according to 4 habits, namely: investing in the beginning, eliciting the patient's perspective, demonstrating empathy, and investing in the end.

OBJECTIVE

To investigate whether the 4HCS correlates with provider HCAHPS scores.

METHODS

Using a cross-sectional design, consenting hospitalist physicians (n = 28), were observed on inpatient rounds during 3 separate encounters. We compared hospitalists' 4HCS scores with their doctor communication HCAHPS scores to assess the degree to which these correlated with inpatient physician communication skills. We performed sensitivity analysis excluding scores returned by patients cared for by more than 1 hospitalist.

RESULTS

A total of 1003 HCAHPS survey responses were available. Pearson correlation between 4HCS and doctor communication scores was not significant, at 0.098 (-0.285, 0.455; P = 0.619). Also, no significant correlations were found between each habit and HCAHPS. When including only scores attributable to 1 hospitalist, Pearson correlation between the empathy habit and the HCAHPS respect score was 0.515 (0.176, 0.745; P = 0.005). Between empathy and overall doctor communication, it was 0.442 (0.082, 0.7; P = 0.019).

CONCLUSION

Attending-of-record HCAHPS scores do not correlate with 4HCS. After excluding patients cared for by more than 1 hospitalist, demonstrating empathy did correlate with the doctor communication and respect HCAHPS scores. Journal of Hospital Medicine 2017;12:421-427.

Resident and Attending Perceptions of Resident Involvement: An Analysis of ACGME Reporting Guidelines

OBJECTIVE

For general surgery residents (Residents) to log an operation, the ACGME requires "significant involvement" in diagnosis (DX), operation selection (SEL), operation (OPR), preoperative (PRE), and postoperative (POC) care. We compared how residents and attending surgeons (Attendings) perceived residents' role in each of these core requirements.

DESIGN

Residents and attendings completed surveys postoperatively regarding responsibility for each core requirement on a 5-point Likert scale from "Completely Attending" to "Completely Resident." Significance was determined using Chi-square analysis (p < 0.05) and degree of agreement was calculated using Spearman's rank correlation (r_s).

SETTING

Boston Medical Center, Boston, MA (tertiary institution).

RESULTS

A total of 302 paired surveys were analyzed. Residents more often performed a significant portion of the later stages of care (DX = 27%, PRE = 29%, SEL = 27%, OPR = 87%, and POC = 84%). Residents completed the majority of each requirement more frequently in operations performed in the acute setting compared to elective operations: DX (70% vs 8%, p < 0.01), PRE (74% vs 10%, p < 0.01), SEL (65% vs 11%, p < 0.01), OPR (100% vs 89%, p = 0.02), POC (100% vs 77%, p < 0.01). Resident participation was inversely related to operational complexity for DX (p < 0.01), PRE (p < 0.01), SEL (p < 0.01), and OPR (p = 0.01). Resident involvement in OPR increased at the end of the academic year (p = 0.05) and when working with junior attendings (<5 years in practice) (p = 0.01). Interpair agreement was greatest for DX (r_s = 0.70) and lowest for POC (r_s = 0.35). When residents and attendings did not agree in their answers, residents generally overstated their contribution to the DX (68%), PRE (58%), and SEL (64%) but understated their contribution in OPR (63%) and POC (62%).

CONCLUSIONS

Residents and attendings demonstrated reliable agreement for most core requirements, but residents were often unable to be involved in all 5 core requirements. Resident involvement was weighted toward later stages of patient care, yet residents often underestimated their contributions. Operational acuity, complexity, and attending experience correlated with resident operative involvement.

Provision of stroke thrombolysis services in New Zealand: changes between 2011 and 2016

AIMS

To obtain an overall picture of the organisation of stroke thrombolysis provision in New Zealand hospitals and compare changes between 2011 and 2016.

METHODS

Surveys were distributed to all New Zealand district health boards (DHBs) in 2011 and 2016, and included questions about the infrastructure, staffing, training, guidelines and audit provided for stroke thrombolysis.

RESULTS

Responses were received from all DHBs, with 86% offering stroke thrombolysis in 2011 and 100% in 2016. In 2016, thrombolysis rosters of large DHBs (those with a population >250,000 people) had a mean (range) of 14 (5-34) clinicians, approximately double that of medium-sized DHBs (population 125-250,000) who had eight (3-15) and small DHBs (population <125,000) with seven, (2-13) clinicians. While a similar distribution of senior medical officer clinical specialty was seen across medium and small DHBs in both years, large DHBs in 2016 had a higher number of neurologists (5, 1-12) and an increasing number of general physicians (8, 0-30) rostered to provide thrombolysis compared to 2011. Thrombolysis services at medium and small DHBs are chiefly managed by general physicians and geriatricians, while telestroke support was only available in three medium-sized DHBs. In 2016, all hospitals had developed thrombolysis guidelines and audited thrombolysed patients in the National Stroke Thrombolysis Register, which is an improvement compared with 2011 when only seven (39%) DHBs reported regular audit. Challenges in staffing and training remain greatest in smaller and geographically isolated DHBs.

CONCLUSION

While there have been improvements in the provision of stroke thrombolysis throughout New Zealand, regional variations in service quality remains. The needs for better solutions to geographical barriers and formal training must be addressed as priorities.

[EMOTIONAL INTELLIGENCE EQ--A NECESSARY SKILL FOR SUCCESS OF MEDICAL STAFF IN THE 21ST CENTURY]

During the last decade, medical organizations have undergone major changes worldwide and these continue to evolve at a rapid pace. Today the medical profession faces many new challenges that will eventually have an impact on almost every aspect of daily hospital routine. To a large extent, these issues arise from emerging new technologies, the entry of a new generation of trained workers who have different views and characteristics than previous generations, and the introduction of stricter regulations and accreditation procedures in recent years. In addition, the various hospital staff members now have different professional expectations and demands; there is also an important need to reduce costs, accompanied by a shift towards the concept of patients perceiving themselves as clients rather than only as people needing medical assistance. Facing all these challenges, undoubtedly, medical teams will need to acquire a more comprehensive set of professional skills critical for their continued success in the 21st century. These skills will have to include the ability to be more flexible, so as to be able to adapt to changing environments, to remain effective at work under stress, to develop positive personal interactive working relationships, while providing excellent service to patients, and to maintain the ability to guide and lead others in a changing medical environment. People with the above skills reflect the positive attributes of high emotional intelligence. Recent studies show that emotional intelligence plays an important role in the success of the entire medical staff and particularly for those in management roles. Hospitals will have to take into consideration all the necessary characteristics, if they wish to maintain and further consolidate their previous achievements in the 21st century. In particular, they will need to pay attention to the EQ of both new and existing staff, using it as a meaningful parameter for new recruits and for the further development of their existing medical staff. Two years ago, the Bnai-Zion Medical Center in Haifa, Israel made an important strategic decision to prepare itself to cope more successfully with the future challenges posed by the 21st century, by adopting the "language" of emotional intelligence within the different departments. This program, unique in Israel, was designed as a comprehensive in-house process for the entire hospital at all levels. It was designed as an evolving multi-stage development program with additional wards joining in at every stage, with a special design. A summary of the key points necessary for understanding the design of EQ in Bnai-Zion Medical center is described in this review. Disclosure: Ayalla Reuven-Lelong and Niva Dolev are the owners of EQ-EL--the emotional intelligence center in Israel.

Duty hours as viewed through a professionalism lens

Understanding medical professionalism and its evaluation is essential to ensuring that physicians graduate with the requisite knowledge and skills in this domain. It is important to consider the context in which behaviours occur, along with tensions between competing values and the individual’s approach to resolving such conflicts. However, too much emphasis on behaviours can be misleading, as they may not reflect underlying attitudes or professionalism in general. The same behaviour can be viewed and evaluated quite differently, depending on the situation. These concepts are explored and illustrated in this paper in the context of duty hour regulations. The regulation of duty hours creates many conflicts that must be resolved, and yet their resolution is often hidden, especially when compliance with or violation of regulations carries significant consequences. This article challenges attending physicians and the medical education community to reflect on what we value in our trainees and the attributions we make regarding their behaviours. To fully support our trainees’ development as professionals, we must create opportunities to teach them the valuable skills they will need to achieve balance in their lives. [P]rofessionalism has no meaningful existence independent of the interactions that give it form and meaning. There is great folly in thinking otherwise. Hafferty and Levinson (2008)[1] Understanding and evaluating professionalism is essential to excellence in medical education and is mandated by organizations that oversee medical training [2]. Historically, attention has been focused largely on the professionalism of individual students or residents, at least for the purposes of evaluation. Yet there is now a growing appreciation that professionalism can be defined, understood, and evaluated from multiple perspectives [3]. Importantly, context has been recognized as critical to shaping trainees’ behaviours, and hence as important to our understanding of them [4]. A restriction in duty hours for trainees is clearly an important environmental and contextual factor to consider in evaluating professional behaviour. In this paper I will review some key issues with respect to understanding and evaluating professionalism, and then discuss these in the context of duty hour reform. Readers should note that this is not intended to be a comprehensive review of the literature of either professionalism or duty hour reform, but rather a critical narrative review that uses selected articles.

Building continuity in handovers with shorter residency duty hours

As junior doctors work shorter hours in light of concerns about the harmful effects of fatigue on physician performance and health, it is imperative to consider how to ensure that patient safety is not compromised by breaks in the continuity of care. By reconceptualizing handover as a necessary bridge to continuity, and hence to safer patient care, the model of continuity-enhanced handovers has the potential to allay fears and improve patient care in an era of increasing fragmentation. "Continuity-enhanced handovers" differ from traditional handovers in several key aspects, including quality of information transferred, greater professional responsibility of senders and receivers, and a different philosophy of "coverage." Continuity during handovers is often achieved through scheduling and staffing to maximize the provision of care by members of the primary team who have first-hand knowledge of patients. In this way, senders and receivers often engage in intra-team handovers, which can result in the accumulation of greater common ground or shared understanding of the patients they collectively care for through a series of repeated interactions. However, because maximizing team continuity is not always possible, other strategies such as cultivating high-performance teams, making handovers active learning opportunities, and monitoring performance during handovers are also important. Medical educators and clinicians should work toward adopting and testing principles of continuity-enhanced handovers in their local practices and share successes so that innovation and learning may spread easily among institutions and practices.

Quality and safety during the off hours in medicine units: a mixed methods study of front-line provider perspectives

BACKGROUND

Hospital off-hours care is associated with poor outcomes. Mutual conceptualization among provider groups may facilitate improvement efforts. Provider-perceived threats to quality are unreported.

OBJECTIVES

The objectives of this study were to identify perceived off-hours quality and safety issues, assess the most significant, and evaluate differences between nurses, and attending and housestaff physicians, and providers with day and night experience.

DESIGN

Prospective, sequential, exploratory mixed-methods study.

MEASURES

Open-ended descriptions of adverse events/near misses occurring overnight (n = 190) were analyzed using thematic analysis. From these results, a survey was developed to assess perceptions of quality/frequency of each issue (7-point scale, 7 = the highest rating) and highest-quality overnight period (7-10 pm, 10 pm-1 am, 1-4 am, 4-7 am).

RESULTS

Primary issues related to mismanagement, delivery processes, and communication/coordination. Of 214 surveys, 160 responses (75%) were received. Least-optimal issues related to "communication" (2.93) and "timeliness/safety" (3.89) of emergency department transfers; most-optimal issues related to timely lab reporting (4.70). On the 7-point scale, comparisons among nurses, and attending and housestaff physicians revealed differences in quality of "communication between physicians" (4.29 vs 6.00 vs 5.14) and "communication between consultants-primary providers" (3.46 vs 5.75 vs 4.35, P < 0.001). Comparisons between day-night providers revealed lower ratings from day providers in 12/24 items (P < 0.05), including "communication during emergency department transfers" (4.81 vs 3.86). All groups ranked 4 to 7am lowest in quality.

CONCLUSIONS

Nurses, and attending and housestaff physicians lack a shared mental model of off-hours care. Several issues, including emergency department transfers and timeliness of consults, were identified by all providers as problematic, meriting further investigation and intervention.

Educational impact of using smartphones for clinical communication on general medicine: more global, less local

BACKGROUND

Medical trainees increasingly use smartphones in their clinical work. Similar to other information technology implementations, smartphone use can result in unintended consequences. This study aimed to examine the impact of smartphone use for clinical communication on medical trainees' educational experiences.

DESIGN

Qualitative research methodology using interview data, ethnographic data, and analysis of e-mail messages.

ANALYSIS

We analyzed the interview transcripts, ethnographic data, and e-mails by applying a conceptual framework consisting of 5 educational domains.

RESULTS

Smartphone use increased connectedness and resulted in a high level of interruptions. These 2 factors impacted 3 discrete educational domains: supervision, teaching, and professionalism. Smartphone use increased connectedness to supervisors and may improve supervision, making it easier for supervisors to take over but can limit autonomy by reducing learner decision making. Teaching activities may be easier to coordinate, but smartphone use interrupted learners and reduced teaching effectiveness during these sessions. Finally, there may be professionalism issues in relation to how residents use smartphones during encounters with patients and health professionals and in teaching sessions.

CONCLUSIONS

We summarized the impact of a rapidly emerging information technology-smartphones-on the educational experience of medical trainees. Smartphone use increase connectedness and allow trainees to be more globally available for patient care but creates interruptions that cause trainees to be less present in their local interactions with staff during teaching sessions. Educators should be aware of these findings and need to develop curriculum to address the negative impacts of smartphone use in the clinical training environment.

How do attendings perceive housestaff autonomy? Attending experience, hospitalists, and trends over time

BACKGROUND

Graduated supervision is necessary for residents to progress to independence, but it is unclear what factors influence attendings' perception of housestaff autonomy.

OBJECTIVE

To determine if attending characteristics and secular trends are associated with variation in attendings' perception of housestaff autonomy.

DESIGN

Secondary data analysis of monthly survey data collected from 2001 to 2008.

SETTING/PARTICIPANTS

Attending hospitalists and nonhospitalists on teaching internal medicine services at an academic tertiary care center.

MEASUREMENTS

Attendings' perception of intern decision making and resident autonomy.

RESULTS

Response rate was 70% (514/738). Compared with early-career attendings, experienced attendings perceived more intern involvement in decision making (odds ratio [OR]: 2.16, 95% confidence interval [CI]: 1.17-3.97, P=0.013). Hospitalists perceived less intern involvement in decision making (OR: 0.19, 95% CI: 0.06-0.58, P=0.004) and resident autonomy (OR: 0.27, 95% CI: 0.11-0.66, P=0.004) compared with nonhospitalists. A significant interaction existed between hospitalists and experience; experienced hospitalists perceived more intern decision making (OR: 7.36, 95% CI: 1.86-29.1, P=0.004) and resident autonomy (OR: 5.85, 95% CI: 1.75-19.6, P=0.004) compared with early-career hospitalists. With respect to secular trends, spring season of the academic year was associated with greater perception of intern decision making compared with other seasons (OR: 1.94, 95% CI: 1.18-3.19, P=0.009). The 2003 resident duty-hours restrictions were associated with decreased perception of intern decision making (OR: 0.51, 95% CI: 0.29-0.87, P=0.014) and resident autonomy (OR: 0.49, 95% CI: 0.28-0.86, P=0.012).

CONCLUSIONS

Perception of housestaff autonomy varies with attending characteristics and time trends. Hospitalists perceive autonomy and clinical decision making differently, depending on their attending experience.

Changes in the workload composition in a plastic surgery unit over a 12 year period

BACKGROUND

Guidelines issued by the British Association of Plastic Reconstructive and Aesthetic Surgeons suggest that the ratio of elective to emergency cases in plastic surgery units should be 2:1.

AIM

To investigate how the workload composition of a regional plastic surgery unit compared with these guidelines.

METHODS

The changes in the workload composition of a regional plastic surgery unit were examined by retrospectively analysing all plastic and reconstructive surgery cases performed over 12 years (1998-2009).

RESULTS

This time period saw a change from a 1:2 ratio of elective to trauma procedures, to the recommended ratio, at a time when the overall caseload increased by almost 40 % (3,281 procedures in 1998 to 4,529 procedures in 2009).

CONCLUSION

Expansion of staff numbers at consultant and non-consultant grades, and increased resources (allocated theatre sessions and outpatient clinics) were pivotal to this change.

Avoid costly mistakes of the past

Physician employment is here to stay. The challenge for healthcare finance professionals is to make physician relationships work without the financial losses experienced by hospitals that tried physician employment in the past. Capturing market share should be a key strategy in any physician employment effort. Physicians who are engaged and actively involved in the process make great business partners because they understand the productivity, efficiencies, and cost controls needed to succeed.

Growth of an academic palliative medicine program: patient encounters and clinical burden

CONTEXT

Information regarding the challenges of clinical growth and staffing of palliative care programs is limited.

OBJECTIVES

Our aim was to describe the growth and staffing structure of a palliative care program at a comprehensive cancer center.

METHODS

During fiscal years ending in 2000 through 2010, we recorded all billed palliative care consultations and follow-ups. To determine the yearly clinical burden per physician, advanced practice nurse (APN), and physician assistant (PA), we calculated the mean number of patient encounters per clinical full-time equivalents. Increase in absolute number of patient encounters and relative (%) growth from year to year were calculated.

RESULTS

Over the 10-year history of the program, the number of outpatient consultations tripled, whereas the inpatient consultations increased from 73 to 1880. In all cases, with the exception of the first year of operation, the vast majority of clinical activity was in the inpatient hospital setting. Growth in the ratio of inpatient consultations per operational hospital beds was noted during the first five years of the program followed by a more modest increase in the succeeding five years. In fiscal year 2010, palliative care physicians had 6.2 patient encounters per working day, and APNs/PAs independently evaluated and treated 4.0 additional patients.

CONCLUSION

Over the 10-year history, there has been an increase in the number of patient consultations seen by our palliative care program. The clinical burden was manageable during the first three years but quickly became too burdensome. Active recruitment of new faculty was required to sustain the increased clinical activity.

Rising hospital employment of physicians: better quality, higher costs?

In a quest to gain market share, hospital employment of physicians has accelerated in recent years to shore up referral bases and capture admissions, according to the Center for Studying Health System Change's (HSC) 2010 site visits to 12 nationally representative metropolitan communities. Stagnant reimbursement rates, coupled with the rising costs of private practice, and a desire for a better work-life balance have contributed to physician interest in hospital employment. While greater physician alignment with hospitals may improve quality through better clinical integration and care coordination, hospital employment of physicians does not guarantee clinical integration. The trend of hospital-employed physicians also may increase costs through higher hospital and physician commercial insurance payment rates and hospital pressure on employed physicians to order more expensive care. To date, hospitals' primary motivation for employing physicians has been to gain market share, typically through lucrative service-line strategies encouraged by a fee-for-service payment system that rewards volume. More recently, hospitals view physician employment as a way to prepare for payment reforms that shift from fee for service to methods that make providers more accountable for the cost and quality of patient care.

Does a general practitioner support unit reduce admissions following medical referrals from general practitioners?

BACKGROUND

Emergency medical admissions to UK hospitals have been increasing steadily over the past few decades and there are likely to be a proportion of these admissions that are avoidable. This evaluation aims to demonstrate whether a general practitioner support unit (GPSU) reduces general practitioner (GP) referred emergency medical admissions to an acute hospital.

METHODS

The GPSU comprises a team of GPs based in the hospital with the purpose of providing alternatives to admission for medical referrals from community GPs. This is an observational study of patients referred and admitted to the Medical Admissions Unit (MAU) of an acute hospital over two six-month periods, in 2007 prior to and in 2008 after the introduction of the GPSU.

RESULTS

The number of GP referrals to the MAU per day decreased by 1.55 (confidence interval -2.45 to -0.51) patients with the GPSU in place. The number admitted to the hospital per day from MAU decreased by a mean of 0.48 patients but with confidence intervals that included the null hypothesis (-1.39 to 0.44). In comparison, non-GP admissions that were not targeted by the GPSU increased by 3.99 per day (2.64 to 5.33).

CONCLUSION

An acute GP led service run from within the hospital to provide support to community GPs led to a modest reduction in the number of GP admissions to the MAU, but did not reduce the number of GP admissions to the hospital wards.

Rural hospitals in New Zealand: results from a survey

AIM

To describe the variety and range of work that New Zealand rural hospitals perform, and to examine the factors that might influence either of these, including: the characteristics of the doctors who work in rural hospitals; the facilities available; and environmental factors (such as geographical isolation and the size of the catchment population).

METHOD

Structured postal questionnaire.

RESULTS

There are about 44 rural hospitals in New Zealand, depending on definition. Catchment populations range from 750 to 45,000. They are staffed by either Medical Officers of Special Scale (MOSSes) or General Practitioners (GPs). They have varying levels of resources such as laboratory services and radiology services available on-site. They care for a wide range of patients and manage health conditions covering many different vocational areas of practice.

CONCLUSION

Rural hospitals should be defined and recognised as a distinct entity to assist the development of appropriate vocational training pathways for their staff. They play an important and unique role in New Zealand's healthcare system which is currently unrecognised.

[Manpower in anesthesiology and intensive therapy services of medical institutions of II-III level of health care in Ukraine]

The article presents results of the study of peopleware of anesthesiology and intensive therapy service of medical institutions in Ukraine of II-III levels.

Implementation and evaluation of an alpha-numeric paging system on a resident inpatient teaching service

BACKGROUND

Numeric pagers are commonly used communication devices in healthcare, but cannot convey important information such as the reason for or urgency of the page. Alphanumeric pagers can display both numbers and text, and may address some of these communication problems.

OBJECTIVE

Our primary aim was to implement an alphanumeric paging system.

DESIGN

Continuous quality improvement study using rapid-cycle change methods.

SETTING

General Internal Medicine (GIM) inpatient wards at 1 tertiary care academic teaching hospital.

PARTICIPANTS

All residents, attending physicians, nurses, and allied health staff working on the general medicine (GM) wards.

MEASUREMENTS

We measured: (1) the proportion of pages sent as text pages, (2) the source of the pages, (3) the content of the text pages, (4) the pages that disrupted scheduled education activities, and (5) satisfaction with the alphanumeric paging system.

RESULTS

After implementation, 52% of pages sent from physicians or the GM wards were sent as text pages (P < 0.001). 93% of pages between physicians were text pages, compared to 27% of pages from the GM wards to physicians (P < 0.001). The most common reason for text paging among physicians was to arrange work or teaching rounds (33%). The most common reason for text paging from the GM wards was to request a patient assessment or for notification of a patient's clinical status (25%). There was a 29% reduction in disruptive pages sent during scheduled educational rounds (P < 0.001).

CONCLUSIONS

We successfully implemented an alphanumeric paging system that reduced disruptive pages on a GM inpatient service.

[The complexity of medical organizations in the 21st century]

Our conception of medicine in the 21st Century is different from the way it was conceived in the 20th Century, and parallel to that, and medical organizations have changed and become more complex. These changes demand transition in traditional thought patterns and perception of the medical system as a "Complex Adaptive System" (CAS). In this article, the authors describe medical organizations as macro systems comprised of micro systems. They present a model of a Complex Adaptive System that permits us to address the challenges that face medical systems in the 21st Century. Management actions can no longer be based on a linear thought pattern and solutions such as "Planning-Study-Action". Action must be innovative and based on the advantages latent in micro systems, as an effective way to realize the macro system mission. In hospitals, for example, a clinical department consisting of the physician and medical staff, certainly a focal point of clinical knowledge and skill, can advance the quality of medicine, and the service and performance of the entire organization. But this is with the stipulation that synchronization is maintained between the micro system and macro system, which ensured that the organization function will serve the goals and vision of the hospital, while still contending with the challenges and competitive environment of the 21st Century.

Nurse labor effects of residency work hour limits

Hospitals employing large numbers of residents increased their hiring of registered nurses, (including nurse practitioners, nurse anesthetists, and other RNs with greater training) significantly more than hospitals with smaller numbers of residents as a result of the ACGME work hours reforms. Patient safety was the main intent of the regulation and should remain the central concern when discussing the merits of resident work-hours limitations. However, the regulations also reduced the number of resident labor hours available to hospitals. This analysis suggests that nurses have compensated for reduced resident workload, with an additional full-time nurse for every 5.5 residents. This finding contributes to a better understanding of the hospital labor response to the regulation that resulted in the reduction in resident hours.

The patient, the doctor and the emergency department: a cross-sectional study of patient-centredness in 1990 and 2005

OBJECTIVE

To compare and contrast the duration and content of physician-patient interaction for patients presenting to an emergency department with problems of low acuity in 1990 and 2005 treated by different grades of physician.

METHODS

Observational study with data collection in May-July 1990 and May-July 2005. Patients identified at nurse triage as presenting with 'primary care' problems were allocated by time of arrival to senior house officers (1990, n=7; 2005, n=10), specialist registrars/staff grades (1990, n=4; 2005, n=7) or sessionally employed general practitioners (1990, n=8; 2005, n=12) randomly rostered to work in a consulting room that had a wall-mounted video camera. A stratified sample of 430 video-taped consultations (180 (42%) from 1990 and 250 (58%) from 2005) was analysed using the Roter Interaction Analysis System. Main outcome measures -- length of consultation; numbers of utterances of physician and patient talk related to building a relationship, data gathering, activating/partnering (i.e. actively encouraging the patient's involvement in decision-making), and patient education/counselling.

RESULTS

On average consultation length was 251s (95% CI for difference: 185-316) longer in 2005 than in 1990. The difference was especially marked for senior house officers (mean duration 385s in 1990 and 778s in 2005; 95% CI of difference: 286-518). All groups of physician showed increased communication related to activating and partnering and building a therapeutic relationship with the patient. While senior house officers demonstrated a greatly increased focus on data gathering, only general practitioners substantially increased the amount of talk centred on patient education and counselling; compared to senior house officers, the odds ratio for the number of such utterances included in consultations was 2.8 (95% CI: 1.4, 5.3).

CONCLUSION

Although patient-centredness together with consultation length increased for all three physician groups over the duration of this study, senior house officers and specialist registrars/staff grades continued to place less emphasis on advice-giving and counselling than did general practitioners. The extent to which these observed changes in practice were determined by policy, management and training initiatives, and their impact on patient outcome, needs further study.

PRACTICE IMPLICATIONS

Video-recording consultations is feasible in an acute hospital setting, and could be used to support training and workforce development. General practitioners can make a distinctive contribution to the workforce of emergency departments. Their consulting style differs from that of hospital physicians and may benefit patient care through a greater focus on patient education and counselling.