Trainee doctor clinics after 24-hour shifts: Effects on patient satisfaction and prescription errors

Introduction: Sleep deprivation impacts clinical performance. However, literature is conflicting, with insufficient focus on patient outcomes. The aim of this study was to assess if patient satisfaction and prescription errors in outpatient clinics were adversely affected when consulting post-call versus non-post-call registrars. Methods: This prospective, quantitative study was set in a large teaching hospital in Singapore. Between November 2015 and February 2016, patients from clinics run by a registrar after 24-hour shift were recruited to post-call group. Patients from non-post-call clinics run by the same registrar were controls. Outcome measures were patient satisfaction, using 5-item 4-point Likert scale questionnaire, and prescribing error rate, defined as number of errors over number of orders. Differences were analysed using chi-squared test. Results: 103 of 106 (97%) patients in 9 post-call clinics and 93 of 105 (90%) patients in 9 non-post-call clinics were recruited. Questionnaire completion rate was 99%. 536 and 526 prescriptions were ordered in post-call and non-post-call groups, respectively. Percentage of top-box responses (greatest satisfaction) was higher in post-call group overall (79.3% versus 62.4%, p<0.001), and for each questionnaire item. There was no significant difference in prescribing errors (1.31% versus 2.28%, p=0.23). Conclusion: Patient satisfaction and prescribing error rates in outpatient clinics were not detrimentally affected. This provides some objective evidence that patients may safely consult post-call registrars. True impacts of sleep deprivation remain poorly understood, and larger, longer term, multicentre studies would inform generalisability. Qualitative studies of fatigue may shed light on complex interactions of emotions that compensate for tiredness.

The Impact of implementing multisource feedback on behaviors of young doctors

Objectives: Multisource feedback (MSF) is a workplace-based assessment tool that offers 360-degree evaluation of the trainee doctor. Little is known about its receptiveness among stakeholders in Pakistan. This study explores house officers’ perceptions regarding MSF since its implementation in Eye Unit-II, Institute of Ophthalmology, King Edward Medical University/ Mayo Hospital, Lahore. Methods: A qualitative case study was conducted from July 2019 to February 2020 in Eye Unit II. A purposive (maximum variation) sample of 12 house surgeons was taken. Two focus group discussions were conducted. Data were transcribed and analyzed thematically. Results: The study identified the impact of MSF on house surgeons. Most participants reported positive experiences. The feedback they received increased their motivation, management skills and team working. A number of factors affecting the receptiveness of MSF were also identified which mainly included characteristics of raters and emotional response to MSF. Conclusion: Multisource Feedback is a useful tool for feedback that impacts the young doctors in many ways. It contributes to increasing their sense of responsibility, management skills and self-directed learning. The improvement in individual abilities and teamwork also helped in improving patient care. doi: https://doi.org/10.12669/pjms.37.7.4155 How to cite this:Ahmad CN, Sethi A, Khan RA. Impact of implementing multisource feedback on behaviors of young doctors. Pak J Med Sci. 2021;37(7):---------. doi: https://doi.org/10.12669/pjms.37.7.4155 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

The quality of handover on an inpatient psychiatric unit - information is key!

AimsTo study the quality of handover, between nursing staff and doctors, on an inpatient psychiatric unit.Effective handover between professionals is vital to ensure the accurate transfer of useful information to enable quality care and patient safety.Implementation of a handover tool has been shown to improve patient safety, especially when used to structure communication over the phone.Feedback at trainee doctor forums highlighted insufficient handover from nursing staff whilst on-call, a problem which prompted further exploration.MethodStandards were developed for the expected quality of handover, consisting of a set of criteria for the minimum information required to ensure a safe and effective handover, stemming from the SBAR (Situation, Background, Assessment, Recommendation) approach, with adequate identification of patients, clear communication of the current situation and relevant details.In an inpatient psychiatric setting, telephone calls to the on-call doctor were recorded for a two-week period, documenting whether key information was communicated.ResultTotal number of calls to on-call doctor recorded: 68. The patients name was given in 49% and the ID number in just 10%. Both relevant diagnosis/history and NEWS score was provided in 18%. However, the current issue and recommendation was given in 90% and 95% respectively.ConclusionThe results thus far demonstrate a lack of structure and often limited information delivered in handover from nursing staff to the on-call doctor. This leads to difficulties in prioritisation, identifying the urgency of the situation and inefficiencies, as time is spent requesting further information which is not readily available.After nursing colleagues were made aware, results from a further two-week period, from 65 total calls, demonstrated some improvement. Patient name given in 51%, ID number in 18%, relevant diagnosis/history in 12%, NEWS score in 17%, current issue in 92% and recommendation in 51%. It is clear that with marginal improvement, there remains a problem which we aim to address by collaborating further with senior nursing leads whilst implementing a succinct handover proforma. It is likely that with COVID-19 as the priority on the agenda this past year, quality improvement projects such as this has not been the main focus. We hope that we will be able to implement these changes in the coming months.

Improving access to the physical health clinic in a community first-episode psychosis service

AimsPhysical health outcomes are poor for patients with severe mental illness as demonstrated by the significant mortality gap present globally.[1] Access to and engagement with care is a key factor underpinning this disparity.[2] The Early Intervention in Psychosis service works with young people from 14-35 experiencing a first episode of psychosis in the community. Within the service, difficulties in engagement have been reflected in the high ‘no-show’ rates observed in the Foundation Year 2 trainee doctor-led physical health clinic. This quality improvement project aimed to reduce the ‘did not attend’ (DNA) rate in the physical health clinic by 20% in order to improve patient outcomes, particularly in the context of their physical health.MethodThe project took place between September and November 2020, over the course of 10 weeks. A driver diagram was constructed to identify key influencing factors and subsequent change ideas. In order to implement each of these changes, three cycles within the Plan, Do, Study, Act (PDSA) ramp framework were completed. These consisted of phone reminders within 48 hours of appointments, a teaching session for staff alongside the distribution of an accompanying information leaflet and increased flexibility in clinic times with opportunistic appointments. The change ideas were cumulative with each cycle lasting a duration of seventeen days.ResultThe baseline DNA rate was calculated based on the preceding month and found to be 55%. Following cycle one of the project, there was a significant reduction in DNA rates to 30% although this remained relatively stable at 33% after cycle two. By the end of cycle three when all interventions had been introduced, the DNA rate had dropped to 22%. As such, a total drop in DNA rate of over 30% was achieved which surpassed the initial aim of the project.ConclusionThe outcomes of this project demonstrate that the introduction of even simple measures can lead to positive change. Successful implementation of these changes requires teamwork and a culture of openness and flexibility. Feedback from team members, particularly care coordinators, also indicated better resulting engagement of clients with the service overall, suggesting potential for both improved mental and physical health outcomes. Next steps for this project may involve not only continued implementation of established changes but also service user input and scope for virtual consultations particularly in light of current COVID-19 restrictions.

A Feasibility Trial of HoloLens 2™; Using Mixed Reality Headsets to Deliver Remote Bedside Teaching During COVID-19

Background COVID-19 has had a catastrophic impact measured in human lives. Medical education has also been impacted: appropriately stringent infection control policies have precluded medical trainees from attending clinical teaching. Lecture-based education has been easily transferred to a digital platform, but bedside teaching has not transitioned so well. The aim of this study was to assess the feasibility of using a mixed reality (MR) headset to deliver remote bedside teaching to trainee doctors during the COVID-19 pandemic.Methods Two MR sessions were led by senior specialty registrars (the clinical trainers) wearing the HoloLens™ headset. The trainers selected patients admitted with pathology requiring their specialist input; thus, the educational sessions were opportunistic. The headset allowed bi-directional video and audio communication between the trainer and trainee doctors during the consultation. Trainee doctor conceptions of bedside teaching, impact of COVID-19 on bedside teaching and technical success of the session was evaluated using pre- and post-round questionnaires using 1 (‘strongly disagree’ or ‘never’) to 7 (‘strongly agree’ or ‘always’) Likert scales and white space questions. Feedback on acceptability of the round was collected verbally from patients after each encounter. Data related to clinician exposure to at risk patients and use of PPE were also collected.Results Pre-questionnaire respondents (n=24) strongly agreed that bedside teaching is key to educating clinicians (7, IQR 6-7). It was also apparent that bedside teaching had become a rarity during COVID-19 (2, IQR 2-4). Session 1 feedback (n=6) was adversely affected by a loose microphone connection. With the issue rectified for session 2 (n=4), most respondents strongly agreed that they felt like they were physically present for the session (7, IQR 6.75-7). Mixed-reality versus in-person teaching led to a 79.5% reduction in cumulative clinician exposure time and 83.3% reduction in PPE use. Conclusions This study is proof of principle that HoloLens™ can be used effectively to deliver high-quality clinical bedside teaching. This novel format confers significant advantages in terms of: minimising exposure of trainees to COVID-19; saving PPE; enabling larger attendance; and convenient accessible real-time clinical training.

Oxford Textbook of the Psychiatry of Intellectual Disability

Intellectual Disability (ID), a lifelong condition characterized by an impairment of intellectual functioning and deficits in adaptive skills is part of a spectrum of developmental disorders which also includes other conditions like autism and ADHD. While psychiatric problems are three to four times more common in those with ID, diagnosing it can be fraught with difficulties due to associated communication problems, atypical presentations, overlap with physical conditions, and experience of marginalization and abuse. In addition, treatment approaches may be different and the potential for treatment-related side effects greater. With a range of international experts authoring its chapters and providing the up-to-date evidence base in assessment, diagnosis, and treatment of mental health problems in people with ID, this book will be useful not just for the trainee doctor in psychiatry, but also for those in allied professions like general practice, nursing, psychology, speech and language therapy, social work, and occupational therapy as well as family members and carers and all those involved in any way with organizing or delivering care and treatment for people with intellectual disability and mental health problems. Throughout, the book addresses issues that are of relevance to those on the frontline and hence most chapters offer examples of clinical issues that come up in day to day practice. There are also a number of single response multiple choice questions that will serve as an aid to learning.

Evaluation of Accuracy of Episiotomy Incision in a Governmental Maternity Unit in Palestine: An Observational Study

Episiotomy should be cut at certain internationally set criteria to minimize risk of obstetric anal sphincter injuries (OASIS) and anal incontinence. The aim of this study was to assess the accuracy of cutting right mediolateral episiotomy (RMLE). An institution-based prospective cohort study was undertaken in a Palestinian maternity unit from February 1, to December 31, 2016. Women having vaginal birth at gestational weeks ≥24 or birthweight ≥1000 g and with intended RMLE were eligible (n=240). Transparent plastic films were used to trace sutured episiotomy in relation to the midline within 24-hour postpartum. These were used to measure incisions’ distance from midline, and suture angles were used to classify the incisions into RMLE, lateral, and midline episiotomy groups. Clinical characteristics and association with OASIS were compared between episiotomy groups. A subanalysis by profession (midwife or trainee doctor) was done. Less than 30% were RMLE of which 59% had a suture angle of <40° (equivalent to an incision angle of <60°). There was a trend of higher OASIS rate, but not statistically significant, in the midline (16%, OR: 1.7, CI: 0.61–4.5) and unclassified groups (16.5%, OR: 1.8, CI: 0.8–4.3) than RMLE and lateral groups (10%). No significant differences were observed between episiotomies cut by doctors and midwives. Most of the assessed episiotomies lacked the agreed criteria for RMLE and had less than optimal incision angle which increases risk of severe complications. A well-structured training program on how to cut episiotomy is recommended.