16 e-Letters

  • 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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