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...
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 study which may impact on the conclusions drawn by the authors. As stated in the paper, there was no data collected regarding management processes and so the improvement in patient outcomes may not relate to the audit and feedback process. This could be tested by having a control group which was audited but which did not receive feedback. A recent study using audit and feedback as a behavioural change strategy failed to find a difference in intraoperative temperature management between the intervention groups and the control group.(4) By contrast this study showed rates of improvement between 9.6 and 30% which are higher than expected for an intervention of this type.(5)
One source of bias could have been explored in the operative time and anaesthesia category data collected as part of the study. A reduction in the use of prefilled morphine syringes was reported and other factors which could contribute to a fall in measured outcomes may have become evident, such as an increase in regional anaesthesia rates or shorter anaesthesia times. These may represent the evolution of patient care over the duration of the study.(6) Another factor which may confound the results is that outcome data was not collected for around one eighth of eligible patients. Since a failure to enter data could be expected to occur more often in complicated patients requiring a lot of attention from the recovery nurse, it would be helpful to report whether the patients left out were different in their baseline characteristics and whether the rate of missing data was the same throughout the study. Finally, although the data has been collected prospectively the duration of collection was not pre-planned. The graphs provided show steady improvement for some outcomes, however data in figure 1 suggests that rate of unexpected admissions varied significantly.
While the results of this study are encouraging, the use of other quality improvement strategies have the potential to achieve sustained and reliable results. One option is to measure and report on processes which lead to the outcomes of interest, such as whether practitioners follow established anti-emetic guidelines.(7) Although not an aim of this study by design, process improvement can be brought about by the use of education, clinical practice guidelines, cognitive aids and process mapping. This would facilitate the implementation of a complete quality improvement cycle process, with measured outcomes driving process change. The study period could also be extended beyond the immediate recovery period to capture other outcomes which would be of interest and use to practitioners, patients and the hospitals. Additional meaningful sources would include medical records, administrative databases and patient satisfaction surveys.
References
1. Myles PS. Measuring quality of recovery in perioperative clinical trials. Curr Opin Anaesthesiol. 2018;31(4):396-401.
2. Collyer T, Robertson M, Lawton T, Rothwell A. Comparative performance reports in anaesthesia: impact on clinical outcomes and acceptability to clinicians. BMJ Open Qual. 2018;7(3):e000338.
3. National Institute for Haelth and Care Excellence. Standards and indicators. 2018 [3/9/2018]. Available from: https://www.nice.org.uk/standards-and-indicators.
4. Boet S, Bryson GL, Taljaard M, Pigford AA, McIsaac DI, Brehaut J, et al. Effect of audit and feedback on physicians' intraoperative temperature management and patient outcomes: a three-arm cluster randomized-controlled trial comparing benchmarked and ranked feedback. Can J Anaesth. 2018.
5. Ivers N, Jamtvedt G, Flottorp S, Young JM, Odgaard-Jensen J, French SD, et al. Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev. 2012(6):CD000259.
6. Lin CJ, Williams BA. Postoperative nausea and vomiting in ambulatory regional anesthesia. Int Anesthesiol Clin. 2011;49(4):134-43.
7. Kolanek B, Svartz L, Robin F, Boutin F, Beylacq L, Lasserre A, et al. Management program decreases postoperative nausea and vomiting in high-risk and in general surgical patients: a quality improvement cycle. Minerva Anestesiol. 2014;80(3):337-46.
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...
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 converted to oral antibiotics or that required a blood test over the weekend. Green patients are those that are stable, unlikely to need any more than a daily review.
Using this simple colour coding has developed a departmental short hand, allowing juniors to more quickly identify patients they might need senior input for and to lead a ward round more efficiently, making sure the most vulnerable, and time consuming, patients are seen quickly and by a senior decision maker.
Informal feedback from junior and senior clinicians has been positive. Weekday FY1s reported higher levels of confidence about handing over patients for the weekend team. Weekend teams, both locum and substantive staff, reported greater efficiency over the weekend and much less unexpected deterioration of patients.
Much of this type of work has been completed to attempt to improve handovers and it seems a lot has been focused on orthopaedic departmental handovers. I wonder if this is to do with the trend in orthopaedic departments to have often quite frail and unwell patients on the wards which have a lot of input from medical doctors in hours, often a dedicated ortho-geris team, and at the weekends are left with surgical junior doctors and FY1s to manage them raising both potential patient safety concerns and anxiety levels of those looking after them!
Since both of these projects have been undertaken NICE has published new guidance (March 2018) where it makes a recommendation for the use of structured handover tools at all transitions of patient care. Handovers are a critical area for patient safety.2-4 It is very positive that they are the focus of not only large governing bodies but also of grass-roots innovators.
References
1. RA Heller and L Hu, Making the weekend work: a local quality improvement project to establish and improve the quality of weekend handover. BMJ Open Quality
2. British Medical Association. Safe handover: safe patients. Guidance on clinical handover for clinicians and managers. London: BMA; August 2004. Accessed on 2/7/17 at: https://www.bma.org.uk/
3. Royal College of Surgeons, Safe Handover: Guidance from the working time directive working party, 2007 Accessed on 2/7/17 at: https://www.rcseng.ac.uk/standards-and-research/gsp/domain-3/3-4-continu...
4. NICE guidance 32. Use of structured handovers, March 2018
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.))
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...
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 UK or outside may or may not have training in dealing with Fit Notes especially e-fit notes.
It is therefore imperative to support medical doctors working in secondary care in regards to e-Fit Notes. For example, providing a free training course on e-Fit Notes with CPD credits for NHS medical doctors, working in both the secondary and the primary care, who have had no experience or training in e-Fit Notes. In addition, as highlighted by Moran et al1, introduction of occupational health focusing on fitness to work and occupational functioning of patients of working age (18-65 years) would be useful for secondary care doctors; thus helping in the integration and adoption of e-Fit Notes in the secondary care, which could be helpful not only for patients requiring Fit Notes but will also reduce unnecessary burden on GPs who provide nearly 15 million appointments related to Fit notes and associated issues.
1. Moran A, Mainwaring C, Keane O, et al. Sick Note to Fit Note: one trust’s project to improve usage by hospital clinicians. BMJ Open Quality 2018;7(1) doi: 10.1136/bmjoq-2017-000220
2. NHS Digital. eMED3 (fit notes). Information Standards Notice SCCI2118 Amd 65/2015. Leeds, 2015.
3. NHS Digital. Fit notes issued by GP practices, England. December 2014 - March 2017. Leeds, 2017.
4. Department for Work and Pensions. Statement of Fitness for Work. A guide for hospital doctors. London, 2010.
5. British Medical Association. Primary and secondary care interface guidance 2017 [updated 04 July 2017. Available from: https://www.bma.org.uk/collective-voice/committees/general-practitioners....
Acknowledgements:
The views expressed in this letter are my personal views and my organisation bears no responsibility for these comments.
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.
Show MoreA 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...
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...
Show MoreIt 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.))
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.
Show MoreThis 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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