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PubMed2006

The multitasking clinician: decision-making and cognitive demand during and after team handoffs in emergency care.

Several studies have shown that there is information loss during interruptions, and that multitasking creates higher memory load, both of which contribute to medical error. Nowhere is this more critical than in the emergency department (ED), where the emphasis of clinical decision is on the timely evaluation and stabilization of patients. This paper reports on the nature of multitasking and shift change and its implications for patient safety in an adult ED, using the methods of ethnographic observation and interviews. Data were analyzed using grounded theory to study cognition in the context of the work environment. Analysis revealed that interruptions within the ED were prevalent and diverse in nature. On average, there was an interruption every 9 and 14 min for the attending physicians and the residents, respectively. In addition, the workflow analysis showed gaps in information flow due to multitasking and shift changes. Transfer of information began at the point of hand-offs/shift changes and continued through various other activities, such as documentation, consultation, teaching activities and utilization of computer resources. The results show that the nature of the communication process in the ED is complex and cognitively taxing for the clinicians, which can compromise patient safety. The need to tailor existing generic electronic tools to support adaptive processes like multitasking and handoffs in a time-constrained environment is discussed.

Continuity of Patient Care↗

PubMed1989

The development of a medical ethics curriculum in a General Internal Medicine Residency Program.

Since 1984, a three-year curriculum in medical ethics has operated at Rhode Island Hospital as part of the General Internal Medicine Residency Program at the Rhode Island Hospital and Brown University. The residency program was founded in 1980 to develop a model training program for internal medicine residents with a primary care focus. The three objective of the curriculum are (1) to enable residents to recognize the ethical implications of both inpatient and outpatient clinical cases, (2) to teach residents to recognize ethics issues and alternatives in order to arrive at a well-rounded clinical strategy, and (3) to help them learn to communicate sensitively with patients and others about these ethics issues and proposed management plans. The six major topics covered by the curriculum (for example, informed consent) are co-taught in a seminar format by one or more of the three members of the multidisciplinary ethics faculty (a philosopher, an internist, and a communications specialist) and experienced physicians. The authors describe the program, the roles of the various faculty members, the program's focus on case discussions, the receptivity of the residents and faculty to the program, the use and training of a multidisciplinary faculty, efforts aimed at evaluation, and future directions of the program.

Bioethical Issues↗

PubMed2006

Specifications provided by practitioners for fabrication of removable acrylic prostheses in Tanzania.

This study aimed at determining the standard of communication between practitioners and dental laboratory technicians in fabrication of removable acrylic prosthetic appliances using written prescriptions. Three hundred and seventy-nine prescriptions submitted to the Dental Laboratory of Muhimbili National Hospital (January 1998-May 2004) were assessed for their instructive quality. Only specifications necessary for the fabrication of a removable acrylic prosthesis were considered. Analysis was according to type of appliances and indicated specifications by practitioners. EPI 6 was used with chi-square test for statistical analysis at a 0.05 level of significance. All 379 prescriptions had designation of practitioner and type of appliance indicated and most were authorized by doctors (67%; n = 254) and for partial dentures (86.5%; n = 328). The majority of the complete dentures (13.5%; n = 51) were authorized by students (49%; n = 25) in comparison with partial dentures (86.5%; n = 328) that were authorized mainly by doctors (71.9%; n = 236). Teeth required (83.4%; n = 316) was the most indicated specification and interns were the most instructive of practitioners. For complete dentures, the only significantly indicated specification was appointment date for occlusal registration. The most significantly indicated specifications for partial dentures was teeth required followed by appointment date for fitting, shade, claSPS and secondary impression. The standards of communication between practitioners and dental laboratory technicians in the fabrication of removable acrylic prostheses are generally inadequate as most required specifications were not indicated by practitioners. Work undertaken by technicians should be accompanied by a detailed written prescription, completion of work authorization be included in the curriculum and Dental Laboratory Vouchers in use be evaluated.

Acrylic Resins↗

PubMed2006

Partnerships in specialty care: exploring rural haemophilia provider resource needs.

OBJECTIVE: The purpose of this study was to determine whether rural providers have adequate preparation for safe and effective haemophilia care. DESIGN: This qualitative study proceeded in two phases: focus group (phase I) and telephone (phase II) interviews. SETTING: Five Canadian rural hospitals served by one urban haemophilia treatment centre and providing service to at least one haemophilia family. PARTICIPANTS: Phase I: focus groups of rural health professionals (site 1: n = 5; site 2: n = 6), including nursing, medicine and lab technology. Phase II: telephone interviews with nine participants from nursing, medicine, lab technology, social work and physiotherapy across three sites. MAIN OUTCOME MEASURES: Qualitative content analysis yielded categorical themes for specialty care resource requirements in a rural context. RESULTS: Resource needs reflected five main categories: communication network, subjective knowledge, team roles, objective knowledge and partnerships (C-STOP). CONCLUSIONS: The five C-STOP categories require resources and alignment of urban specialist, rural provider and family expertise. Specialty clinic efforts promoting self-care are incomplete without matched resources for rural providers.

Canada↗

PubMed1990

Neonatal ethics: development of a consultative group.

Experience of a neonatal ethics advisory group in a tertiary care setting was reviewed to identify which aspects of the experience have been most valuable in the development of a consultative group. Consultations were requested for 31 patients seen from August 1984 through December 1988. Review of these patients indicated that 21 of 31 infants were born after full-term gestations, 11 of 31 infants were seen beyond the neonatal period, and some type of congenital anomaly was the principal diagnosis for 64.7% of the patients. The reasons for seeking consultation primarily involved decisions regarding withdrawal or withholding of treatment. For 22 of the 31 patients, the consensus of the group supported the decision of the health care team. In the remaining consultations, the recommendation of the group was that more information and/or communication was needed. In the analysis of the neonatal ethics advisory group's experience with consultations the characteristics of neonatal patients were identified and the value of having a forum for discussing the difficult ethical issues facing members of the health care team were validated.

Abnormalities, Multiple↗

PubMed2006

Operating room teamwork among physicians and nurses: teamwork in the eye of the beholder.

BACKGROUND: Teamwork is an important component of patient safety. In fact, communication errors are the most common cause of sentinel events and wrong-site operations in the US. Although efforts to improve patient safety through improving teamwork are growing, there is no validated tool to scientifically measure teamwork in the surgical setting. STUDY DESIGN: Operating room personnel in 60 hospitals were surveyed using the Safety Attitudes Questionnaire. Surgeons, anesthesiologists, certified registered nurse anesthetists, and operating room nurses rated their own peers and each other using a 5-point Likert scale (1 = very low, 5 = very high). RESULTS: Overall response rate was 77.1% (2,135 of 2,769). Ratings of teamwork differed substantially by operating room caregiver type, with the greatest differences in ratings shown by physicians: surgeons (F[4, 2058] = 41.73, p < 0.001), and anesthesiologists (F[4, 1990] = 53.15, p < 0.001). The percent of operating room caregivers rating the quality of collaboration and communication as "high" or "very high" was different by caregiver role and whether they were rating a peer or another type of caregiver: surgeons rated other surgeons "high" or "very high" 85% of the time, and nurses rated their collaboration with surgeons "high" or "very high" only 48% of the time. CONCLUSIONS: Considerable discrepancies in perceptions of teamwork exist in the operating room, with physicians rating the teamwork of others as good, but at the same time, nurses perceive teamwork as mediocre. Given the importance of communication and collaboration in patient safety, health care organizations should measure teamwork using a scientifically valid method. The Safety Attitudes Questionnaire can be used to measure teamwork, identify disconnects between or within disciplines, and evaluate interventions aimed at improving patient safety.

Analysis of Variance↗

PubMed2004

Classification system for the completely dentate patient.

The American College of Prosthodontists (ACP) has developed a classification system designed for use by dental professionals in the diagnosis and treatment of completely dentate patients. This classification is the third in a series and is similar to the Classifications for Complete Edentulism and Partial Edentulism previously developed by the ACP. These guidelines are intended to aid practitioners in the systematic diagnosis of each patient which, in turn, should lead to an appropriate treatment. Four categories of a completely dentate situation are defined (Class I-IV), differentiated by specific diagnostic criteria, with Class I representing an uncomplicated clinical situation and Class IV representing the most complex clinical situation. Potential benefits of the system include (1) improved intraoperator consistency, (2) improved professional communication, (3) insurance reimbursement commensurate with complexity of care, (4) an improved screening tool for dental school admission clinics, (5) standardized criteria for outcomes assessment and research, (6) enhanced diagnostic consistency, and (7) a simplified aid in the decision-making process associated with referral.

Diagnosis, Oral↗

PubMed2002

Establishing a transdisciplinary research team in academia.

The establishment of a transdisciplinary research team, the Applied Developmental Neuroscience group, is described. The group, which initially included a physical therapist, occupational therapist, speech-language pathologist, and developmental pediatrician, is focused on linking theory and practice for intervention with children with disabilities. The group encountered challenges related to personal attributes such as trust, communication, time, and commitment; the task of finding a common theoretical perspective; and the autonomous academic environment. The strategies used to address these challenges and the benefits of a transdisciplinary model, such as cross-fertilization of theoretical perspectives and more powerful application and testing of theoretical frameworks in a research context, are described.

Allied Health Occupations↗

PubMed2006

A transdisciplinary approach to improve health literacy and reduce disparities.

A challenge to public health professionals, health care providers, and consumers is to come together to improve the quality of health care and to eliminate disparities. Improving health literacy skills along with a transdisciplinary approach to care contributes to effective patient-provider communication. This article addresses a team approach to health care, a community health center experience, self-management skills, patient education, and cultural competency training. In addition, the authors provide concepts that can be incorporated in health care settings to eliminate health disparities and improve health literacy.

Community Health Centers↗

PubMed2003

Hormesis: public health policy, organizational safety and risk communication.

Thirty years of research suggests low doses of toxic substances may have positive health effects. If confirmed, hormesis will imply radical changes in risk assessment and management of existing industrial toxic sources (chemical and nuclear). Renn analyses risk communication issues and positions hormesis--largely unknown to the public today--as a hypothetical risk object in society. Our comments stress the necessity to consider hormesis first as a public health issue (versus an industrial regulatory issue), to consider the impact of managerial changes upon organizational safety culture, and to assess effects on public health from the 'bad news' of toxic exposure.

Animals↗

PubMed2006

Multidisciplinary care of the dying adolescent.

The adolescent at the end of life poses a unique combination of challenges resulting from the collision of failing health with a developmental trajectory meant to lead to attainment of personal independence. Because virtually all spheres of the dying adolescent's life are affected, optimal palliative care for these young persons requires a multidisciplinary team whose members have a good understanding of their complementary roles and a shared commitment to providing well-coordinated care. Members of the team include the physician (to initiate and coordinate palliative care management); the nurse (to work collaboratively with the physician and adolescent, especially through effective patient advocacy); the psychologist (to assess and manage the patient's neurocognitive and emotional status); the social worker (to assess and optimize support networks); the chaplain (to support the adolescent's search for spiritual meaning); and the child life specialist (to facilitate effective communication in preparing for death). A crucial area for dying adolescents is medical decision making, where the full range of combined support is needed. By helping the young person continue to develop personal autonomy, the multidisciplinary team will enable even the dying adolescent to experience dignity and personal fulfillment.

Adaptation, Psychological↗

PubMed2006

The impact of the implementation of a rehabilitation tool on the contents of the communication during multidisciplinary team conferences in rheumatology.

OBJECTIVE: Problems with multidisciplinary team conferences in health care include the exchange of too much (discipline-specific) information. The aim of this study was to investigate the effect of the implementation of a rehabilitation tool on the contents of communication during multidisciplinary team conferences in a rheumatology setting. METHODS: All initial and follow-up team conferences of 25 consecutive patients with rheumatoid arthritis admitted to a day patient care ward were videotaped during a period before (period I) and after (period II) the introduction of a rehabilitation tool. The aims of the rehabilitation tool were to enhance discussions on the co-ordination of care rather than merely exchange of information. This was achieved by providing a framework for the setting and evaluation of common treatment goals and management strategies as well as accompanying electronic and printed records. For every team conference, the duration of time spent on three types of communication was recorded: (1) grounding regarding the patient's health status, (2) the making of practical arrangements by no more than two health professionals, and (3) the co-ordination of common treatment goals or management strategies. Comparisons of the proportions of time spent on the different types of communication between the two periods were done by means of the Mann-Whitney U-test. RESULTS: Apart from the 25 initial team conferences in both periods, 86 and 71 follow-up team conferences were available in periods I and II, respectively. Regarding the initial team conferences, the proportion of time spent on grounding and practical arrangements was significantly smaller in period II than in period I. In addition, the proportion of time spent on common goals or management strategies was significantly greater in period II than in period I. For the follow-up team conferences, the proportion of time spent on practical arrangements was significantly smaller in period II, than in period I. Moreover, the proportions of time spent on the other types of communication did not differ significantly between the two periods. CONCLUSION: The implementation of a rehabilitation tool including a computer application increased the proportion of time spent on the discussion of common treatment goals or management strategies during initial but not during follow-up team conferences in a day patient rheumatology clinic.

Cohort Studies↗

PubMed2005

The development and implementation of a regional network of physiotherapists for exercise therapy in patients with peripheral arterial disease, a preliminary report.

BACKGROUND: Exercise therapy (ET) is the main conservative and proven effective treatment of patients with intermittent claudication. Currently, the most frequent exercise prescription is a single 'go home and walk' advise, without supervision or follow-up. There is no evidence to support the efficacy of this advise and compliance is known to be low. Therefore, a systematic approach was used to guarantee quality and standardisation of treatment, optimal guideline adherence and improved of inter-professional communication between vascular surgeons and physiotherapists. In this preliminary report we would like to outline the steps taken for the development and implementation of the Network Exercise Therapy Parkstad. METHODS: In October 2003 all 59 regional physiotherapy practices were invited to attend a symposium regarding ET in a physiotherapeutic setting. Attending physiotherapists interested in providing ET and willing to follow a certified course on ET, were asked to register. Three tastk groups were formed to accomplish the set targets: Exercise therapy education, Exercise therapy implementation and continuity, and Inter-professional communication in the Parkstad region. RESULTS: In total 27 physiotherapists, from 22 different practices followed the educational program and are now trained and accredited to provide ET according to the guideline of the Royal Dutch Society for Physiotherapy. A web-based database was designed to contain information on disease specific items provided by the vascular surgery department, and aspects with respect to ET registered by the physiotherapist. The information is regularly updated and available online. Access to the database is restricted to vascular surgeons and physiotherapists in the network. The secondary purpose of the database is to register essential benchmark data for future analysis of ET in a physiotherapeutic setting in the Netherlands and to enable physiotherapists continuous feedback on patient performance. A triage system was developed to detect patients with a compromised cardiac history. This group receives ET at the in-hospital department of revalidation with the possibility of immediate consultation of a cardiologist in case of cardiac complications or even CPR. CONCLUSION: The Network Exercise Therapy Parkstad of supervised ET is the first initiative in the Netherlands to provide ET close to the patient's home environment. With the implementation of supervised ET in an outpatient physiotherapeutic setting for all eligible patients with symptomatic PAD, the access to care has been improved. A web-based communication system provides physiotherapists and vascular surgeons with all the necessary and continues updated patient information. Future research, currently in progress, will investigate the therapeutic benefits and cost-effectiveness of exercise therapy in a physiotherapeutic setting.

Ambulatory Care↗

PubMed2003

Living in the new age: using collaborative digital technology to deliver health care improvement.

States that finding an effective method for helping teams to make better use of time is critical to the delivery of the current policy agenda within the UK National Health Service (NHS). Details the introduction of a communication technology into the work of the NHS, piloted by the Learning Alliance, a virtual team of development staff providing support to over 100 organisations, which hopefully will help solve the problem of time wastage. Concludes that the key to successful technology supported collaboration depends not only on the technology, but also on the organisation's ability to adopt an entirely new way of working.

Cooperative Behavior↗

PubMed2006

A preliminary survey of interprofessional education.

The purpose of this article is to review the literature on interprofessional education (IPE) and report on a preliminary survey of the current status of interprofessional education in seven academic health centers (AHCs) that have schools of dentistry associated with them. There is wide variability in interpretation of the term "interprofessional," and many barriers to interprofessional education exist including already overcrowded curricula in health professions schools, lack of support from faculty and administration, and financial constraints. Based on interviews completed at the authors' home institutions, it was recommended that topics such as ethics, communication skills, evidence-based practice, and informatics could be effectively taught in an interprofessional manner. Currently, some academic health centers are attempting to develop interprofessional education programs, but most of these efforts do not include dental students. Of the seven AHCs investigated in this study, only two had formal interprofessional educational activities that involved students from two or more health professions education programs. Dental school participants in this study professed a strong interest in interprofessional programs, but many interviewees from other professional schools and AHC administrators perceived that the dental school was isolated from other schools and disinterested in IPE. Many health care setting models in the future will include dentists as part of an interdisciplinary health care team; consequently, it is important for dental schools to become an active participant in future interprofessional educational initiatives.

Academic Medical Centers↗

PubMed2006

[Disagreement between physicians' medication records and information given by patients].

INTRODUCTION: A survey was conducted to evaluate the level of disagreement between the drug records of family doctors and information provided by patients at the time of hospitalisation. MATERIALS AND METHODS: One hundred patients acutely admitted to a hospital department of medicine were consecutively included if the patient ingested more than two non-OTC drugs. A second drug interview was performed shortly after admission, and the patient's current medication was recorded. If no written medical record from the referring family doctor was available at the time of admission, the doctor was contacted by phone for supplementary information. Discrepancies between the information given by the patient and the medical records of family doctors were recorded. The results were analysed blindly by two of the authors (one senior and one junior doctor) to determine if the discrepancies were clinically relevant for the patient. RESULTS: We found at least one clinically relevant and potentially dangerous discrepancy in the medical records of 40% (95% CI 30%-50%) of the patients. In all, discrepancies were found in the drug lists of 63% of the patients. The patients with discrepancies were similar in age, sex, way of hospitalization and number of drugs ingested, compared to those without discrepancies. Afterwards the family doctors were invited to a meeting in which these problems were evaluated. CONCLUSION: We conclude that there is an urgent need for improvement in the communication between the primary and secondary health care sectors concerning medication being prescribed for patients with chronic diseases. The large number of discrepancies in the drug records of patients in this study is discouraging.

Adult↗

PubMed1995

Incommensurability: its implications for the patient/physician relation.

Scientific authority and physician authority are both challenged by Thomas Kuhn's concept of incommensurability. If competing "paradigms" or "world views" cannot rationally be compared, we have no means to judge the truth of any particular view. However, the notion of local or partial incommensurability might provide a framework for understanding the implication of contemporary philosophy of science for medicine. We distinguish four steps in the process of translating medical science into clinical decisions: the doing of the science, the appropriation of the scientific findings by the clinician, the transfer of the findings from the clinician to the patient, and the choice of a treatment regimen. Incommensurability can play a role in each stage. There is at least some theory- and value-ladenness in science that is dependent on the world view of those who construct the scientific theories. Clinicians who must use the results of scientific research will inevitably interpret the research from the standpoint of their own world view. There may be further incommensurability when these data are communicated to the patient. Finally, clinician and patient values must come into play in any decision about choice of treatment. No stage of medical research or practice is value-free. This position does not imply relativism; some scientific accounts are better than others. However, the challenge of the incommensurabilists shows that further analysis is needed to establish how particular accounts are better or worse.

Biomedical Research↗

PubMed2004

"Statistics" is not a sausage machine: a statistician's viewpoint and some comments on experimental design.

Any experiment involving the use of animals which is not well-planned, meticulously carried out, and scrupulously analysed, is unethical. Planning, or good experimental design, followed by analysis appropriate for the design, will help to ensure the optimal use of animals. Thus, collaboration between biologist and statistician, especially at the planning and analysis stages, is one of the best ways of achieving an ethical and successful experiment. However, genuine communication is necessary for any collaboration, and this requires time and patience, on the part of both biologist and statistician. Although the three fundamental principles of experimental design, replication, randomisation and local control, are straightforward in theory, there is substantial scope for misunderstanding and misinterpretation in practice. Each experiment presents unique and interacting biological and statistical problems, and both the right design and the correct analysis should be decided on a case-by-case basis.

Interdisciplinary Communication↗