As an aspiring informatics nurse and masters of science student at Jacksonville University, previous Intensive Care Unit (ICU) nurse, and current case management nurse at Mayo Clinic, I would like to respond to the article: Inpatient Pharmacists Using a Readmission Risk Model in Supporting Discharge Medication Reconciliation to Reduce Unplanned Hospital Readmissions: A Quality Improvement Intervention (Gallagher et al., 2022). Beginning with applauding the insightful evidence provided, I would also like to reflect upon the model’s impact upon personal and organizational practices.
Experiences within education and personal practices are almost, if not as important as the supporting evidence. As referred to in the article, the Epic Readmission Risk Assessment (RRS) is incredibly helpful and accessible for healthcare team members to distinguish within charting systems. Involvement of pharmacy professionals is essential, however I propose an interdisciplinary approach that involves the healthcare team in its entirety.
Recommendations for this approach includes designating an advanced practice nurse as a healthcare team representative to ensure potential readmission risks are identified (Rovito & Fagan, 2022). Ideally, this position would replace a pharmacist’s role with the addition of collaboration among healthcare professionals to support readmissio...
As an aspiring informatics nurse and masters of science student at Jacksonville University, previous Intensive Care Unit (ICU) nurse, and current case management nurse at Mayo Clinic, I would like to respond to the article: Inpatient Pharmacists Using a Readmission Risk Model in Supporting Discharge Medication Reconciliation to Reduce Unplanned Hospital Readmissions: A Quality Improvement Intervention (Gallagher et al., 2022). Beginning with applauding the insightful evidence provided, I would also like to reflect upon the model’s impact upon personal and organizational practices.
Experiences within education and personal practices are almost, if not as important as the supporting evidence. As referred to in the article, the Epic Readmission Risk Assessment (RRS) is incredibly helpful and accessible for healthcare team members to distinguish within charting systems. Involvement of pharmacy professionals is essential, however I propose an interdisciplinary approach that involves the healthcare team in its entirety.
Recommendations for this approach includes designating an advanced practice nurse as a healthcare team representative to ensure potential readmission risks are identified (Rovito & Fagan, 2022). Ideally, this position would replace a pharmacist’s role with the addition of collaboration among healthcare professionals to support readmission risk findings, education, and interventions. In a similar study, drug-related readmissions accounted for 16% of the total 1,111 patients readmitted within one month (Uitvlugt et al., 2021).
Even though medication-related readmissions are prevalent, there are other collaborative efforts and interventions that have been studied thus proven to be as effective (if not more than) solely implementing inpatient pharmacist initiatives. With the aid of systems like RRS, trained clinicians could distinguish patients to be sent for Serious Illness Conversations (SICs) where one’s care plan or goals of care can be addressed by a member of the palliative, nursing, or physician team (Serna et al., 2022).
Given the multitude and consequences of hospital readmissions, integration of not only pharmacy but all members of patients’ healthcare team could improve readmission rates collaboratively.
I want to end by thanking you for your time. BMJ continuously provides insightful publications from various journals that significantly impact aspiring and practicing healthcare professionals.
Kind regards,
Megan D. Pike RN, BSN
Jacksonville University
Keigwin School of Nursing
References
Gallagher, D., Greenland, M., Lindquist, D., Sadolf, L., Scully, C., Knutsen, K., Zhao, C., Goldstein, B., Burgess, L. (2022). Inpatient pharmacists using a readmission risk model in supporting discharge medication reconciliation to reduce unplanned hospital readmissions: A quality improvement intervention. BMJ Open Quality. https://doi.org/doi:10.1136/bmjoq-2021-001560
Rovito, C. & Fagan, K. (2022). A quality improvement initiative: A nurse practitioner-led interdisciplinary approach to reducing readmissions in the subacute population. Journal of Doctoral Nursing Practice, 15(1). https://doi.org/DOI:10.1891/JDNP-D-20-00072
Serna, M., Fiskio, J., Yoon, C., Plombon, S., Lakin, J, Schnipper, J., & Dalal, A., (2022). Who gets (and who should get) a serious illness conversation in the hospital? An analysis of readmission risk score in an electronic health record. American Journal of Hospice and Palliative Medicine, 40(6). https://doi.org/10.1177/10499091221129602
Uitvlugt, E., Janssen, M., Siegert, C., Kneepkens, E., Bemt, B., Bemt, P., & Çarkit, F. (2021). Medication-related hospital readmissions within 30 days of discharge: Prevalence, preventability, type of medication errors, and risk factors. Frontiers in Pharmacology, 12. https://doi.org/10.3389/fphar.2021.567424
Healthcare systems mirror a nation's values, priorities, and societal challenges. The healthcare systems of the United Kingdom (UK) and Switzerland are frequently praised for their exceptional quality of care; however, they employ distinctive approaches to healthcare provision. Recent updates and personal experiences illuminate the evolving complexities and challenges confronted by these two systems. This article aims to offer a brief comparative analysis of the healthcare systems in the UK and Switzerland, accentuating their funding mechanisms, quality of care, contemporary challenges, and potential avenues for mutual learning.
Funding and Access
United Kingdom: The UK's healthcare system is predominantly financed through taxation and is renowned for providing free healthcare at the point of use. The National Health Service (NHS) is the cornerstone of healthcare provision in the UK, guaranteeing universal access to all residents.(1)
Switzerland: Switzerland employs a decentralised, market-driven approach governed by the Confederation LAMal constitution. Each Canton is responsible for managing its health system, with budgets allocated to health insurance providers who determine costs based on insurance types: basic, private, or semi-private.(2)
A Swiss resident of Canton de Vaud , illustrates to me the financial strain that the Swiss healthcare system can place on families. He reveals that his family's annual basic insurance costs a...
Healthcare systems mirror a nation's values, priorities, and societal challenges. The healthcare systems of the United Kingdom (UK) and Switzerland are frequently praised for their exceptional quality of care; however, they employ distinctive approaches to healthcare provision. Recent updates and personal experiences illuminate the evolving complexities and challenges confronted by these two systems. This article aims to offer a brief comparative analysis of the healthcare systems in the UK and Switzerland, accentuating their funding mechanisms, quality of care, contemporary challenges, and potential avenues for mutual learning.
Funding and Access
United Kingdom: The UK's healthcare system is predominantly financed through taxation and is renowned for providing free healthcare at the point of use. The National Health Service (NHS) is the cornerstone of healthcare provision in the UK, guaranteeing universal access to all residents.(1)
Switzerland: Switzerland employs a decentralised, market-driven approach governed by the Confederation LAMal constitution. Each Canton is responsible for managing its health system, with budgets allocated to health insurance providers who determine costs based on insurance types: basic, private, or semi-private.(2)
A Swiss resident of Canton de Vaud , illustrates to me the financial strain that the Swiss healthcare system can place on families. He reveals that his family's annual basic insurance costs amount to 20,000 Swiss Francs, impacting their quality of life and influencing decisions about family expansion. This personal experience underscores the challenges of rising healthcare costs in Switzerland, particularly for middle-class citizens with dependents and health needs which may deter families from seeking basic care due to the financial penalties imposed by costly yearly insurance excesses.
Quality and Specialisation of Care
United Kingdom: The NHS is globally renowned for providing quality healthcare services. In the UK, clinicians are incentivised based on improved health outcomes, fostering cost control and effective treatments such as the QoF (Quality Outcome Framework) in General Practice.(3)
Switzerland: Noted for its cutting-edge private medical services, Switzerland has become a destination for individuals seeking high-quality healthcare. The country boasts an extensive network of private clinics and hospitals equipped with advanced medical technology, favouring a two-tiered health system that benefits the private and semi-private sectors of affluent residents.
Professor Vincent Ribordy, President of the Swiss Medical Emergency Association, emphasises the necessity for a comprehensive overhaul of Switzerland's healthcare system. He points out rising costs impacting lower and middle-income families and acknowledges the absence of accessible public health data, hindering disease prevention strategies. A recent audit revealed challenges of overcrowding in his emergency department, impacting patient well-being and staff morale. His team has remained proactive in making rapid changes to avoid exacerbating this congestion (4)—a response unlikely to occur in the NHS during a crisis at the front door of A+Es, which can only be implemented by a centralised government less in touch with frontline realities. This has led to demoralised staff feeling unheard by health authorities, with no option other than resorting to strikes. This crisis is currently spiralling downward with a government unable to address the deadlock.
Comparatively in Switzerland, Dr. Henri Veuilleumier , an experienced Swiss General Surgeon, notes growing dissatisfaction among senior consultants working in state hospitals due to salary disparities and pension concerns compared to the private sector. This highlights the issue of equity and compensation discrepancies within the Swiss healthcare system.
Challenges: Aging Population and Inequality
Both the UK and Switzerland face challenges related to their aging populations. While the UK's NHS model aims to address inequalities through public health planning, Switzerland also acknowledges struggles, such as hospital overcrowding due to a shortage of suitable nursing home facilities. The Swiss focus on individualised care could potentially compromise generational longevity.
Switzerland's healthcare landscape is marked by a divide between affluent individuals with swift access to specialised care and a majority struggling to afford healthcare. This disparity exemplifies the complexities of providing equitable access within a system that also caters to specialised care for those who can afford it.
Conclusion: Learning from Each Other
While Switzerland excels in offering world-class private medical services, it grapples with challenges like rising healthcare costs and inequalities. On the other hand, the UK's NHS, with its emphasis on equitable access and outcome-based remuneration, offers valuable lessons. As both countries navigate post-COVID recovery plans, there may be opportunities for mutual learning to address challenges and improve healthcare systems. The insights from personal experiences, expert opinions and a comparative analysis provide a short view of the strengths, weaknesses, and potential pathways for enhancing healthcare in both the UK and Switzerland.
References
1. Mathew R. The challenges facing the NHS: deeper than the immediate crisis. BMJ. 2021;372:n313.
2. Henke N, Kelsey T, Whately H. The Swiss healthcare system: a model for the world? Health International. 2010;10:64-76.
3. Department of Health, About Quality and Outcomes Framework (QOF)
Available from: https://www.health-ni.gov.uk/articles/about-quality-and-outcomes-framewo... Accessed on 1.9.2023
4. Schmutz T, Le Terrier C, Ribordy V, et al. No waiting lying in a corridor: a quality improvement initiative in an emergency department. BMJ Open Quality 2023;12:e002431. doi: 10.1136/bmjoq-2023-002431
I really enjoyed reading your article. This topic that you chose to do your research on is very important in the health care field especially when dealing with hospitalized patients. It is so important for patients to feel safe and respected especially when it involves making a decision that can potentially be life or death. A nurse role is to be an advocate for the patient, therefore improving the comfort of our patients is what we should be about. I loved the research experiment and I would really like to see this experiment carried out across healthcare facilities.
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...
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 generally are normally distributed within groups. Compare among days, before and after the intervention (i.e., between the two groups), either using Wilcoxon-Mann-Whitney or Student’s two-group t-test.
What are the authors’ mean (SD) or median (IQR) among days, before/after intervention, when analysed using the mean or median among theatres on each day? What is the P-value testing the authors’ primary result? If the authors use Student’s t-test, they can report the corresponding confidence interval for the mean difference.
REFERENCES
1. Riveros Perez E, Kerko R, Lever N, White A, Kahf S, Avella-Molano B. Operating room relay strategy for turnover time improvement: a quality improvement project. BMJ Open Qual 2022; 11:e001957.
2. Dexter F, Epstein RH, Marcon E, Ledolter J. Estimating the incidence of prolonged turnover times and delays by time of day. Anesthesiology 2005; 102:1242-1248.
3. Dexter F, Marcon E, Aker J, Epstein RH. Numbers of simultaneous turnovers calculated from anesthesia or operating room information management system data. Anesth Analg 2009; 109:900-905.
4. Wang J, Dexter F, Yang K. A behavioral study of daily mean turnover times and first case of the day start tardiness. Anesth Analg 2013; 116:1333-1141.
5. Austin TM, Lam HV, Shin NS, Daily BJ, Dunn PF, Sandberg WS. Elective change of surgeon during the OR day has an operationally negligible impact on turnover time. J Clin Anesth 2014; 26:343-349.
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...
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 their community like local pharmacies (Okoro & Hillman, 2018). Additionally, the LGBTQ community has reported mistrust of physicians and concerns of discrimination in physician offices as deterrents to PrEP uptake (Zhao et al., 2021).
There is an opportunity to allow pharmacist to lead PrEP initiatives. Pharmacists are in the unique position to engage with patients from first consideration of PrEP through dispensing and continued medication management (Meyerson et al., 2019). Pharmacists are well situated in the community to recruit new PrEP patients through one-on-one, pharmacist-patient interactions and population-based initiatives. Pharmacists are geographically accessible and have regular interactions with patients in a site of care that has less associated stigma. They are often involved in community outreach programs like needle exchanges and Narcan distribution events which have a target population that overlap with those at risk for HIV (Meyerson et al., 2019). Pharmacists also have the knowledge required help patients navigate insurance and PrEP cost assistance programs, removing additional financial barriers to care (Tung et al., 2018).
Pharmacist-led service teams have already had great success with HIV related care. A 2021 literature review by Zhao et al., reviewed pharmacy-based interventions and found a positive association between pharmacist-centered HIV care with improvements of anti-retroviral adherence, care retention, and viral load suppression. Two specific pharmacy activities that contribute to these results are regular refill reminders and adherence counseling; both activities can be leveraged in VMs program improve PrEP uptake and adherence (Zhao et al., 2021).
Less than 2.5 miles away from VM Medical Center, during roughly the same time period the Kelley-Ross Pharmacy Group developed a pharmacist-managed PrEP clinic. The clinic operated under a CPA and allowed pharmacists to take the lead in the PrEP continuum of care. This model was successful and reported high PrEP initiation and adherence rates; 695 new patients started PrEP and 74% of patients began PrEP the same day as their initial visit. 90% of the patients were considered adherent to their PrEP regiment (Tung et al., 2018).
The VM’s PrEP program can be improved by shifting to a pharmacy-centric model by leveraging a CPA. Pharmacies are more accessible than PCP offices and pharmacists have a skill set that is better suited to handle the unique challenges associated with PrEP care.
Works Cited
Crawford, N. D., Josma, D., Morris, J., Hopkins, R., & Young, H. N. (2020). Pharmacy-based pre-exposure prophylaxis support among pharmacists and men who have sex with men. Journal of the American Pharmacists Association, 60(4), 602–608. https://doi.org/10.1016/j.japh.2019.12.003
Lopez, M. I., Cocohoba, J., Cohen, S. E., Trainor, N., Levy, M. M., & Dong, B. J. (2020). Implementation of pre-exposure prophylaxis at a community pharmacy through a collaborative practice agreement with San Francisco Department of Public Health. Journal of the American Pharmacists Association, 60(1), 138–144. https://doi.org/10.1016/j.japh.2019.06.021
Lumsden, J., Dave, A. J., Johnson, C., & Blackmore, C. (2022). Improving access to pre-exposure prophylaxis for HIV prescribing in a primary care setting. BMJ Open Quality, 11(2), e001749. https://doi.org/10.1136/bmjoq-2021-001749
Meyerson, B. E., Dinh, P. C., Agley, J. D., Hill, B. J., Motley, D. N., Carter, G. A., Jayawardene, W., & Ryder, P. T. (2019). Predicting Pharmacist Dispensing Practices and Comfort Related to Pre-exposure Prophylaxis for HIV Prevention (PrEP). AIDS and Behavior, 23(7), 1925–1938. https://doi.org/10.1007/s10461-018-02383-7
Myers, J. E., Farhat, D., Guzman, A., & Arya, V. (2019). Pharmacists in HIV Prevention: An Untapped Potential. American Journal of Public Health, 109(6), 859–861. https://doi.org/10.2105/ajph.2019.305057
Okoro, O., & Hillman, L. (2018). HIV pre-exposure prophylaxis: Exploring the potential for expanding the role of pharmacists in public health. Journal of the American Pharmacists Association, 58(4), 412–420.e3. https://doi.org/10.1016/j.japh.2018.04.007
Tung, E. L., Thomas, A., Eichner, A., & Shalit, P. (2018). Implementation of a community pharmacy-based pre-exposure prophylaxis service: a novel model for pre-exposure prophylaxis care. Sexual Health, 15(6), 556. https://doi.org/10.1071/sh18084
Zhao, A., Dangerfield, D. T., Nunn, A., Patel, R., Farley, J. E., Ugoji, C. C., & Dean, L. T. (2021). Pharmacy-Based Interventions to Increase Use of HIV Pre-exposure Prophylaxis in the United States: A Scoping Review. AIDS and Behavior, 26(5), 1377–1392. https://doi.org/10.1007/s10461-021-03494-4
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...
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 specfic examples, my medical radiographer here in Canada didn't understand the terminology "has image intensifier been contacted?" The image intensifier is a component of the portable xray machine and not a person (cf. "teamwork") and we don't think will respond to a question. "Essential imaging available" I guess refers to the pre-operative radiology results - this is obviously something that should be determined prior to induction of the patient if they are "essential"...
I think this is a good start to the discussion of a real problem but will optimally be able to look at a more robust solution for institutions generally.
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...
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 that they saved time and 65.8% (n=48) answered that they had made a financial saving by attending the virtual clinic. 48% (n=35) answered that they were overall ‘very satisfied’ with the care received in the virtual clinic, and 79.6% (n=43) felt that their care did not suffer as a result of non-face to face contact.
The majority of patients would recommend a virtual clinic to their friend or family 77% (n=56), however if given the option 60% (n=43) would prefer a face to face clinic appointment. This may suggest that whilst accepting of virtual clinics, patients may be reassured if they could access a face to face consultation if necessary. This gives scope for the use of such clinics as part of an integrated care pathway, perhaps for use as follow up or in triage.
As the pandemic progresses it is important to identify ways in which good patient care can be delivered whilst not putting patients at risk of contracting the virus. Virtual clinics not only maintain patient safety but also cause less disruption to patients’ lives with quantifiable savings in both time and money as demonstrated in the feedback received. With the relaxing of social distancing measures, now is a good time to reflect on the changes made during the pandemic to assess if any should remain. This study suggests that the use of virtual clinics should continue and could be utilised to provide efficient patient centred care without compromising the quality of care delivered.
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.
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...
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 clinics. There were 697 patient contacts during the same period in 2019. The day service provided a total of 338 patient contacts, 48% via remote working.
There has been positive feedback from families who have welcomed the flexibility of remote treatment and the reduced need to travel. Some young people have reported that they are happier not to sit in a waiting room with other patients and take time out from education. Clinicians have found home working has improved efficiency. Daily team videoconferencing has maintained multi-disciplinary working with team meetings and supervision continuing remotely. There has been an increase in collaborative work with other community mental health teams through videoconferencing.
The main challenges have been developing rapport with new patients via videoconferencing and to gather information from non-verbal cues or family interactions, particularly when family members are required to face the camera. Engagement is a key aspect of treatment and there are concerns that safeguarding risks may be missed. Individual sessions can be hindered by lack of privacy and reluctance to be open about difficulties. Young people who are struggling with their appearance dislike seeing themselves on camera and it has been difficult for patients who prefer non-verbal aids to express themselves. Risk assessment of patients with serious mental health symptoms has not been considered safe enough to do remotely. In addition, there have been on-going challenges with the video platforms used.
Our view is that virtual clinics have so far been effective in providing routine treatments and have improved efficiency. Going forward, we would collaborate with service-users to decide how much treatment should continue virtually.
To: Dr. David Gallagher
david.gallagher@duke.edu
As an aspiring informatics nurse and masters of science student at Jacksonville University, previous Intensive Care Unit (ICU) nurse, and current case management nurse at Mayo Clinic, I would like to respond to the article: Inpatient Pharmacists Using a Readmission Risk Model in Supporting Discharge Medication Reconciliation to Reduce Unplanned Hospital Readmissions: A Quality Improvement Intervention (Gallagher et al., 2022). Beginning with applauding the insightful evidence provided, I would also like to reflect upon the model’s impact upon personal and organizational practices.
Experiences within education and personal practices are almost, if not as important as the supporting evidence. As referred to in the article, the Epic Readmission Risk Assessment (RRS) is incredibly helpful and accessible for healthcare team members to distinguish within charting systems. Involvement of pharmacy professionals is essential, however I propose an interdisciplinary approach that involves the healthcare team in its entirety.
Recommendations for this approach includes designating an advanced practice nurse as a healthcare team representative to ensure potential readmission risks are identified (Rovito & Fagan, 2022). Ideally, this position would replace a pharmacist’s role with the addition of collaboration among healthcare professionals to support readmissio...
Show MoreHealthcare systems mirror a nation's values, priorities, and societal challenges. The healthcare systems of the United Kingdom (UK) and Switzerland are frequently praised for their exceptional quality of care; however, they employ distinctive approaches to healthcare provision. Recent updates and personal experiences illuminate the evolving complexities and challenges confronted by these two systems. This article aims to offer a brief comparative analysis of the healthcare systems in the UK and Switzerland, accentuating their funding mechanisms, quality of care, contemporary challenges, and potential avenues for mutual learning.
Funding and Access
United Kingdom: The UK's healthcare system is predominantly financed through taxation and is renowned for providing free healthcare at the point of use. The National Health Service (NHS) is the cornerstone of healthcare provision in the UK, guaranteeing universal access to all residents.(1)
Switzerland: Switzerland employs a decentralised, market-driven approach governed by the Confederation LAMal constitution. Each Canton is responsible for managing its health system, with budgets allocated to health insurance providers who determine costs based on insurance types: basic, private, or semi-private.(2)
A Swiss resident of Canton de Vaud , illustrates to me the financial strain that the Swiss healthcare system can place on families. He reveals that his family's annual basic insurance costs a...
Show MoreJospehine McCullagh - Transfusion Science
Paper: Making every drop count: reducing wastage of a novel blood component for transfusion of trauma patients
Publication: BMJ 30 June 2021
https://www.rcpath.org/profession/research-and-innovation/awards-prizes/...
Well done Jo!
Dear Editor,
I really enjoyed reading your article. This topic that you chose to do your research on is very important in the health care field especially when dealing with hospitalized patients. It is so important for patients to feel safe and respected especially when it involves making a decision that can potentially be life or death. A nurse role is to be an advocate for the patient, therefore improving the comfort of our patients is what we should be about. I loved the research experiment and I would really like to see this experiment carried out across healthcare facilities.
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...
Show MoreThe 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...
Show MoreThe 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.
Show MoreIn 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...
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...
Show MoreWe 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.
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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