eLetters

12 e-Letters

  • Turnover times on the same day are not statistically independent

    Riveros Perez et al. analysed 636 turnover times from a surgical suite with 16 theatres before and after intervention, a dedicated nurse anaesthetist for each of four theatres [1]. Their “overall” statistical analysis, reported in their abstract, seems to treat all turnovers as statistically independent events (i.e., treated the sample size as 16 x # analysed days). That probably was incorrect because the 636 turnover times likely were correlated among theatres on the same day [2]. The authors’ Wilcoxon-Mann-Whitney overall P-value (0.0121) likely is an underestimate of the correct result [2].

    To understand, consider that the authors’ intervention was one extra nurse anaesthetist for four theatres. If there were more than one turnover among the four theatres simultaneously, the nurse anaesthetist’s efforts would be diluted. That is precisely what happens routinely (e.g., for housekeeping staff [3,4]). Earlier, we showed validity and reliability of choosing the optimal number of shared personnel (e.g., nurse anaesthetist) by analysing those simultaneous turnovers [3].

    The authors state in their paper that the turnover times were skewed. Analysis methods tested by Monte-Carlo simulation for accurate P-values and confidence intervals are to take the mean of the turnovers among the 16 theatres, for each day, although the median could be used [2]. There then is one number per day as a summary measure. By central limit theorem (and in practice [2,5]), those means g...

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  • Improving access to PrEP using a pharmacist-centric model

    The Virginia Mason Medical Center’s Department of Primary Care partnered with their Proudly VM LGBTQIA+ interest group to increase the number of patients receiving new PrEP prescriptions in Seattle. VM’s initiative targeted PCPs instead of pharmacist as the main touch point for PrEP prescribing citing scope of practice concerns (Lumsden et al., 2022). The Lumsden article demonstrated that the program helped to increase new PrEP prescriptions but there were limitations. Research indicates that Pharmacist may be better positioned than PCPs to not only increase new PrEP prescriptions, but also increase PrEP adherence.

    Nationally, the scope of care for pharmacist has been expanded through collaborative practice agreements (CPA). CPAs allow pharmacist to fulfil additional responsibilities under the supervision of a physician. Washington is 1 of 48 states that have legalized CPAs, which despite Lumsden’s findings would allow VM to empower pharmacist to be more involved in the recruitment and retention of PrEP patients (Lopez et al., 2020).

    Over 90% of Americans live within 5 miles of a pharmacy; making pharmacies one of the most accessible healthcare entry points (Tung et al., 2018). Moreover, populations that have high risk for HIV, such as POC LGBTQ+ individuals and intravenous drug users, tend to live in disadvantaged neighborhoods that have fewer physicians (Crawford et al., 2020). This population is likely to rely on resources that are easy to access within...

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  • SSCL adherence

    The authors have provided an admirable example of how the SSCL utilization can be improved via a dedicated and sustained effort. In some ways I wish they had been able to provide a pathway that didn't involve so many steps, as I think their observation that 'administrative' vs 'real' view of success of SSCL process is probably greatly wrong - it was in our hospital too.
    In our hospital the OR record is where the SSCL process is recorded and quite often the "briefing", "time-out" and "debriefing" components were "ticked" at a random time, often before they might actually have taken place. A four page form with a couple of hundred entries does not lend itself to accuracy!
    I was disappointed in their reported revision of the actual checklist. I thought it was still overlong, and I didn't feel it adequately reflected the most important point about the SSCL process, which is to develop a team from what is an often changing group of individuals, and thusly to engage all of the OR staff in the process.
    They state "the number of items on the form decreased from 21 to 19". I count 26 separate questions requiring responses. Gawande in The Checklist Manifesto" suggests that 5 or 7 is the optimal number of questions - less being better. This form has more and I do question whether they are all "necessary" in contributing to teamwork and safety.
    As a couple of...

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  • The continued use of Virtual Clinics post COVID-19: Patient feedback Study

    We read the report by Gilbert et al on the rapid implementation of virtual clinics in reponse to COVID-19, with particular interest into the high satisfaction scores given by patients and clinicians into the use of virtual clinics.

    We conducted a retrospective patient feedback survey at Brighton at Sussex University Hospital looking at patient feedback on the use of Virtual Clinics as an alternative to face to face clinic appointments in General Surgery during the COVID-19 pandemic. We found that virtual clinics are well accepted by patients and should continue to be utilised post COVID-19 forming part of integrated care pathways in outpatient care.

    The use of Virtual clinics are novel to the department and were implemented as a consequence of the social distancing measures introduced to stop the spread of coronavirus during the COVID-19 pandemic. We identified the need to seek feedback from the patients attending these clinics, recognising that patient opinion is invaluable to the development and sustainability of services.

    Over 100 patients were contacted asking them to fill out an online survey, patients who did not have an email address were asked if they wanted to complete a shorted survey over the telephone; 73 patients responded across both surveys.

    Data collected suggests that virtual clinics are well received by patients. 77.8% (n=42) reported that they had no problems accessing the virtual clinic. 87.7% (n=64) of patients reported...

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  • FMTVDM Quantification.

    We appreciate the recognition by the authors of FMTVDM quantification. We would note that it not only is applicable for SPECT imaging but also PET, planar and any nuclear imaging modality. Congratulations on your work and publication.

  • Managing a community eating disorder service with virtual clinics during Covid 19

    We read with interest the RNOH report regarding rapid implementation of virtual clinics due to Covid-19 (Gilbert et al, BMJ Open, 21 May 2020). The Royal Free Child and Adolescent Eating Disorder Service (RF-EDS) has similarly been required to adapt the service rapidly during the Covid-19 crisis, such that 95% of our patients have been treated by telephone or videoconferencing.

    The clinical needs of our patients to receive evidence-based treatment, needed to be balanced with the risks of Covid infection. Eating disorders have the highest mortality of all psychiatric disorders and early treatment has been shown to improve outcomes. Treatment is usually outpatient care with a minority requiring short hospital admissions for medical stabilisation. The RF-EDS has a day service, which has managed higher risk patients in the community as paediatric wards in North Central London have closed/relocated during the pandemic.

    Since the pandemic, all routine treatment to current patients has been via video or telephone, with high-risk patients continuing face-to-face care (socially distanced or with PPE). This can be stepped-up to prevent hospital admission. Meal support, a weekly parent support group and drop-in clinic have been set up to run via videoconference.

    From 23/03/20 to 01/05/20, the number of new referrals to the service was similar to the same period in 2019 (19). The number of outpatient contacts was 731 and 96% of these were treated in virtual cli...

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  • Building on feedback to maximise quality improvement

    Optimising the quality of recovery following anaesthesia, with a focus on both physiological and emotional wellbeing, is an important goal for anaesthesia quality improvement.(1) I was interested to read the paper by Collyer and colleagues(2) which reports an reduction in the incidence of nausea, hypothermia, significant pain and unplanned admission from the relatively simple intervention of audit followed by individual performance feedback which included a comparison to the departmental averages. It is commendable that they have chosen issues in anaesthesia recovery aligned with NICE quality standards and indicators,(3) and which are both important and common, so that even a small change in outcome will have a significant impact on healthcare.
    A continuous observational study of outcome provides the best information to highlight opportunities for improvement, although data collection can be onerous. The improvements reported have the potential to reduce indirect costs of hospitalisation and variation in practice standards. This study includes metrics which are of interest to both patients and providers. No doubt this contributed to the high level of acceptance and engagement reported in the survey of participants. The inclusion of a wide variety of patients both in- and out of hours and the use of a custom data recording instrument is likely to have increased the validity of the findings.
    However, there are a number of issues with the reliability of the...

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  • A further patient safety addition to the structured handover tool

    Dear Sir,

    Your recently published article by Heller and Hu looking at improving the weekend handover system in their hospital is interesting and thought provoking. They found that they improved the standard of the written handover between weekday and weekend teams by introducing a structured intranet-based handover tool.1

    A similar project was recently undertaken at our Orthopaedic Department. Our methodology and reasons for undertaking the quality improvement project were similar.

    One part of our intervention was different however, and I wonder if the study’s authors would be interested in incorporating it into their excellent handover tool?

    We too developed a handover tool, albeit not as sophisticated as the author’s intranet based tool. We redesigned our Microsoft Word document to be more user friendly, comprehensive and fulfil standards from the BMA and RCS.2,3 Our key addition was that of traffic light colour-coding of patients. We used colours to assign patients to levels of clinical input needed over the weekend.

    This served to address one of the most daunting part of the weekend on call, identifying who are the most vulnerable patients.

    Patients are assigned to one of three colours, red, amber or green. Red patients are day one post operative or unstable patients, perhaps septic or with difficult to manage fluid balances. Amber patients are stable patients with a higher possibility of becoming unstable, those recently c...

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  • “Learning pyramid theory” is bogus

    It is unfortunate that the authors have poorly cited a justification for not using lectures. In their “Lessons and Limitations,” they write: “Lecture-based education has its own limitations. Learning pyramid theory suggests that average retention following a lecture can be as low as 5%.” They cite Lalley and Miller as their source.

    If they look closely at Lalley and Miller, however, they will see that that paper does not support their contention. Worse, Lalley and Miller actually argue against that model. Other papers on the topic reinforce the point that the “Learning pyramid theory” is bogus, and not to be trusted. (e.g. Masters, K (2013) Edgar Dale's Pyramid of Learning in medical education: A literature review, Medical Teacher, 35:11, e1584-e1593, DOI: 10.3109/0142159X.2013.800636 (Note possible conflicts of interests, as I am the author of that article.))

  • Lack of embeddedness of Electronic Fit Notes in the NHS Secondary Care

    Moran et al1 report the uptake and practice of issuing Electronic Fit Notes (e- Fit Notes) in a secondary care setting in the NHS highlighting several issues including lack of doctors’ training on e–fit notes, variation in the practice of issuance of e-fit notes and technological issues supporting e-fit notes.
    This study is timely and important as it reveals the lack of full embeddedness of e-Fit Notes in the NHS secondary care despite introduction of e-fit notes (eMed3) in 2012 initially in the primary care.2 While there are no precise statistics on e-Fit Notes issued in the secondary care, 12,671,880 e-fit notes were issued in the primary care from December 2014 to March 2017.3 Nevertheless, the number of e-fit notes issued in secondary care is expected to be less than in the primary care (general practice) because e-fit notes issued in the secondary care will relate to patients attending A&E, hospital in patients such as those admitted for an elective surgery / procedure, patients with mental health issues requiring regular review and some patients attending hospital out-patients, for these types of patients issuance of e-fit notes is the responsibility of hospital doctors attending the patients.4
    Medical doctors working in the NHS include doctors who have been trained in the UK, other EU member countries and non-EU countries such as India where the practice of Fit Notes could be different from the UK. In addition, medical doctors either trained in the U...

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