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Biomedical subjects

Edward Etchells

Publications and source records attributed to Edward Etchells.

15 recordsLinked to original sources
PubMed2006

Human factors in action: getting "pumped" at a nursing usability laboratory.

We describe our experience with a Nursing Usability Laboratory, where human factors design principles were applied to common nursing procedures. Our first step was to develop a human factors usability checklist. We then used this checklist while observing 11 nurses completing two standardized tasks on a simulated patient: (1) programming an insulin infusion and (2) programming a heparin infusion. We found that a usability checklist can help to uncover systematic error-provoking conditions in nursing tasks, that immediate improvements can be made in nursing training and practice and that participant nurses found the process useful. This paper will be of interest to any hospital seeking to enhance safety by applying human factors design principles.

Ergonomics↗
PubMed2005

A randomized trial of teaching bioethics to surgical residents.

BACKGROUND: Bioethics education has been recommended as a formal component of surgical residency training. The best method for teaching bioethics to residents is unclear. We compared the effectiveness of a standardized patient (SP)-based seminar to a traditional seminar format for teaching bioethics to surgical residents. METHODS: We randomized 31 first- and second-year surgical residents to either a SP-based seminar or a traditional seminar on informed consent. Immediately after the seminars, we evaluated resident performance in patient encounters on informed consent by using an objective structured clinical examination. Their knowledge of informed consent was also evaluated by using a 20-question short-answer written examination immediately after the seminars and then 3 weeks later. RESULTS: Twenty-nine residents completed the study; two withdrew because of an emergency. The SP seminar group had lower SP interview scores on the 22 item checklist compared with the traditional seminar group (57% versus 66%; difference -9%; 95% confidence interval [CI], -17% to -1%, P=.03). The SP seminar group also had lower knowledge scores on the questionnaire immediately after the seminar (60% versus 73%; difference -13%; 95% CI, -21% to -4%, P=.003). The difference in knowledge scores persisted at 3 weeks (41% for the SP group, 59% for the traditional seminar group; difference -18%; 95% CI, -29% to -7%; P=.002). CONCLUSIONS: A traditional seminar was superior to an SP-based seminar for teaching informed consent to surgical residents.

Adult↗
PubMed2004

Can a "good death" be made better?: A preliminary evaluation of a patient-centred quality improvement strategy for severely ill in-patients.

BACKGROUND: Prior studies attempting to improve end-of-life care have focused on specific outcomes deemed important to healthcare providers, with disappointing results. Improvement may be best achieved by identifying concerns important to individual patients, communicating the patients' concerns to the treating medical team, and repeating the process frequently until all concerns are addressed. Our objective was to conduct a preliminary evaluation of this innovative patient-centred quality improvement strategy. METHODS: Initial interviews elicited participants' ideas for improvement, which were then fed back to health care providers by the study investigator. A rapid-cycle change model ensured frequent reassessment and continued feedback. The study involved 36 seriously ill, hospitalized patients on teaching general medical inpatient units of a tertiary care hospital. The main outcome measure was participants' ratings of satisfaction within different domains of care on follow-up interviews. RESULTS: The proportion of participants who rated various aspects of their care as "excellent" or "very good" on initial interview was 72% for overall care, 64% for symptom control, 66% for level of support, and 75% for discussions about life sustaining treatments. Patients and families identified many actionable steps for improvement such as; better control of pain and shortness of breath, better access to physicians and medical information, more help with activities of daily living, improving the patient's environment, and shorter waits for nursing care, diagnosis, and treatment. Following feedback to the clinical team, participants reported improvement in overall care (32%), symptom control (44%), and support (40%). Only a minority had further discussions about life sustaining treatments. CONCLUSION: A patient-centred approach using rapid-cycle change was feasible and shows promise for improving the quality of end-of-life care. It should be evaluated on a larger sample in a controlled trial.

Journal Article↗
PubMed2004

Gaps in the care of patients admitted to hospital with an exacerbation of chronic obstructive pulmonary disease.

BACKGROUND: Patients admitted to hospital because of an exacerbation of chronic obstructive pulmonary disease (COPD) are at high risk of adverse events. We evaluated the association between gaps in care and adverse events during the hospital stay and after discharge. METHODS: We retrospectively reviewed the charts of 105 consecutive patients discharged from hospital between Jan. 1 and Dec. 31, 2001, with a diagnosis of COPD exacerbation. On the basis of published guidelines, prior studies and discussions with colleagues, we defined a care gap as having occurred if any of 9 important inpatient and 7 discharge-related processes of care did not take place correctly. Inpatient adverse events included worsening of condition after admission, transfer to a higher level of care, cardiac arrest and death. Discharge-related adverse events were defined as including readmission to the hospital, revisit to the emergency department or death within 30 days after discharge. RESULTS: Of the 105 patients studied, 88 (84%) had at least 1 inpatient gap in care and 16 (15%) an inpatient adverse event; 2 of the 16 died. Patients who had an inpatient adverse event had more gaps in their care (2.0 v. 1.3 gaps, p = 0.004) and longer stays (16.4 v. 8.6 days, p = 0.007). There were 6 adverse events (frequency 38%) among the 16 patients with 3 or more gaps in their care, 6 adverse events (28%) among the 21 patients with 2 gaps, 1 adverse event (2%) among the 51 patients with 1 gap and 3 adverse events (18%) among the 17 patients with no gaps in their care (p = 0.001 for trend). Of the 103 patients discharged alive, 102 (99%) had at least 1 gap in discharge-related care, but we found no association between these gaps and adverse events within 30 days after discharge. INTERPRETATION: Gaps in the inpatient care of patients with COPD exacerbation were common and were associated with inpatient adverse events. Gaps in discharge-related care were also common but were not associated with postdischarge adverse events.

Aged↗
PubMed2004

The effect of English language proficiency on length of stay and in-hospital mortality.

BACKGROUND: In ambulatory care settings, patients with limited English proficiency receive lower quality of care. Limited information is available describing outcomes for inpatients. OBJECTIVE: To investigate the effect of English proficiency on length of stay (LOS) and in-hospital mortality. DESIGN: Retrospective analysis of administrative data at 3 tertiary care teaching hospitals (University Health Network) in Toronto, Canada. PARTICIPANTS: Consecutive inpatient admissions from April 1993 to December 1999 were analyzed for LOS differences first by looking at 23 medical and surgical conditions (59,547 records) and then by a meta-analysis of 220 case mix groups (189,119 records). We performed a similar analysis for in-hospital mortality. MEASUREMENTS: LOS and odds of in-hospital death for limited English-proficient (LEP) patients relative to English-proficient (EP) patients. RESULTS: LEP patients stayed in hospital longer for 7 of 23 conditions (unstable coronary syndromes and chest pain, coronary artery bypass grafting, stroke, craniotomy procedures, diabetes mellitus, major intestinal and rectal procedures, and elective hip replacement), with LOS differences ranging from approximately 0.7 to 4.3 days. A meta-analysis using all admission data demonstrated that LEP patients stayed 6% (approximately 0.5 days) longer overall than EP patients (95% confidence interval, 0.04 to 0.07). LEP patients were not at increased risk of in-hospital death (relative odds, 1.0; 95% confidence interval, 0.9 to 1.1). CONCLUSIONS: Patients with limited English proficiency have longer hospital stays for some medical and surgical conditions. Limited English proficiency does not affect in-hospital mortality. The effect of communication barriers on outcomes of care in the inpatient setting requires further exploration, particularly for selected conditions in which length of stay is significantly prolonged.

Aged↗
PubMed2003

Patient safety in surgery: error detection and prevention.

Error in medicine is becoming a well recognized phenomenon. The U.S. Institute of Medicine's publication in 1999 included estimations that medical error is the eighth leading cause of death in the United States and results in up to 100,000 deaths annually. Retrospective studies and a few prospective studies are shedding more light on this challenging problem. Strategies to reduce error and increase patient safety have not been widely developed or embraced by surgeons for a variety of reasons. We provide a review on patient safety aimed at surgeons that includes definitions, incidence of errors including those in the surgical literature, causes of error, methods of error detection, and strategies to minimize errors and maximize patient safety.

Communication↗
PubMed2003

Successful implementation of perioperative beta-blockade utilizing a multidisciplinary approach.

PURPOSE: To describe how we implemented a protocol for perioperative beta-blockade in patients with or at risk of coronary artery disease (CAD) undergoing major non-cardiac surgery and to present our results. METHODS: After institutional approval, from May 1999 to April 2001, patients with surgical and medical indications (CAD as indicated by previous myocardial infarction, typical angina or atypical angina with a positive stress test or at least two risk factors for CAD: age 65 yr, hypertension, smoking, high cholesterol, diabetes mellitus) for perioperative beta-blockade were identified preoperatively by anesthesiology and referred to the General Internal Medicine Service (MED). MED initiated patients on outpatient beta-blockers. The intraoperative anesthetic management was left to the discretion of the anesthesiologist. In the postanesthesia care unit (PACU), patients received iv metoprolol according to hemodynamic criteria. Postoperatively, patients were followed by MED for adverse cardiac events. RESULTS: Sixty-nine patients received perioperative beta-blockade. Preoperatively, 60% were started on metoprolol, 39% on atenolol and 1% on propranolol. In PACU, 42%, 9% and 38% of patients were given iv metoprolol 0, 5 and 10 mg respectively. One patient was given glycopyrrolate in the PACU for bradycardia and none received vasoactive or inotropic agents. Three patients (4.3%) had postoperative cardiac events. CONCLUSIONS: With close collaboration between anesthesiologists, internists, PACU nurses and family physicians, a strategy for perioperative beta-blockade was implemented successfully in patients with cardiac risks. Beta-blockade was associated with few side effects and morbidities.

Adrenergic beta-Antagonists↗
PubMed2002

Interdisciplinary inpatient care for elderly people with hip fracture: a randomized controlled trial.

BACKGROUND: Hip fractures in elderly people are associated with impaired function and ambulation and high rates of death and admission to institutions. Interventions designed to improve the outcomes of hip fracture (e.g., mobility and discharge to own home) that have incorporated interdisciplinary care have had mixed results. We compared the effectiveness of postoperative interdisciplinary care with that of usual care for elderly patients with hip fracture. METHODS: The study population consisted of 279 patients at least 70 years of age from the community and from nursing homes who underwent surgical repair of hip fracture at a university-affiliated acute care hospital. The subjects were randomly assigned to receive postoperative interdisciplinary care (n = 141) or usual care (n = 138) during their hospital stay. Interdisciplinary care included routine assessment and care by an internist-geriatrician, physiotherapist, occupational therapist, social worker and clinical nurse specialist, as well as twice-weekly interdisciplinary rounds to set goals for the patients and to monitor their progress. The primary outcome measure was the proportion of patients alive with no decline in ambulation or transfers in and out of a chair or bed and no change in place of residence at 6 months after surgery. RESULTS: At 6 months, 56 patients (39.7%) in the interdisciplinary care group and 47 (34.1%) in the usual care group were alive and had no decline from baseline in terms of ambulation, chair and bed transfers or place of residence (difference 5.6%, 95% confidence interval -5.6% to 17.0%). Multiple logistic regression analysis with adjustment for baseline factors showed no significant difference between treatment groups for the primary outcome measure at 3 months (p = 0.44) or at 6 months (p = 0.67). The initial length of stay in hospital was longer for patients receiving interdisciplinary care: 29.2 (standard deviation [SD] 22.6) v. 20.9 (SD 18.8) days (p < 0.001). However, the mean number of days spent in an institution (including hospital, inpatient rehabilitation and nursing home) over the 6-month follow-up period was similar in the 2 groups (p = 0.84). A subgroup analysis suggested a trend to benefit from interdisciplinary care in patients with mild to moderate cognitive impairment. INTERPRETATION: Postoperative inpatient interdisciplinary care did not result in significantly better 3- or 6-month outcomes in elderly patients with hip fracture.

Activities of Daily Living↗
PubMed2002

Venous thromboembolism and its prevention in critical care.

BACKGROUND: Evidence-based guidelines for the prevention of venous thromboembolism (VTE) are available for most major surgical and medical patient groups. Such guidelines have not been established for critically ill patients. OBJECTIVE: To perform a systematic review of the prevalence of deep vein thrombosis (DVT), the efficacy of thromboprophylaxis, and the rates of thromboprophylaxis use in critically ill patients. METHODS: Computerized literature search for relevant studies meeting prespecified criteria. RESULTS: The rates of objectively confirmed DVT in 4 prospective studies ranged from 13% to 31%. We identified only 3 randomized trials (1 in abstract form) of thromboprophylaxis in critical care unit patients. These studies show the efficacy of low-dose heparin and low molecular weight heparin compared with no prophylaxis; however, we found no trials comparing these 2 interventions. Eleven compliance studies reported that some form of thromboprophylaxis was used in 33% to 100% of critically ill patients, although only 1 study addressed the issue of appropriate prophylaxis use. CONCLUSIONS: Data on the epidemiology of VTE and its prevention in critically ill patients are very limited. Further research is needed to better define patient risk factors for VTE, optimal methods of thromboprophylaxis, and strategies to improve compliance with prophylaxis recommendations. In the meantime, prevention strategies, shown to be effective in other related patient groups, and general principles of individual pharmacotherapy should guide the routine use of prophylaxis during critical illness.

Critical Care↗
PubMed2002

Semiquantitative dipyridamole myocardial stress perfusion imaging for cardiac risk assessment before noncardiac vascular surgery: a meta-analysis.

BACKGROUND: Semiquantitative dipyridamole myocardial perfusion scintigraphy may provide better estimates of perioperative cardiac risk than nonquantitative scintigraphy. OBJECTIVE: The purpose of this study was to conduct a metaanalysis of semiquantitive dipyridamole myocardial perfusion scintigraphy for the prediction of perioperative myocardial infarction and cardiac death in patients undergoing noncardiac vascular surgery. METHODS: The data sources used were MEDLINE (from 1975 to 1999), citation lists, and correspondence with study authors. We included studies that evaluated preoperative semiquantitative dipyridamole myocardial perfusion scintigraphy in patients undergoing noncardiac vascular surgery. For each study, we calculated results on the basis of the proportion of myocardial segments with reversible perfusion defects. The complications of interest were cardiac death and nonfatal myocardial infarction. We calculated likelihood ratios (LRs) and areas under the receiver operating characteristic curves for individual studies and for the combined data. DATA SYNTHESIS: We identified nine studies involving a total of 1179 patients with 82 cardiac complications (complication rate, 7.0%). Most studies were grade C in quality. Normal scans significantly reduced the likelihood of perioperative cardiac complications (LR, 0.42; 95% CI, 0.20 to 0.88). Fixed defects reduced the likelihood of complications, but the effect was not statistically significant (LR, 0.51; 95% CI, 0.24 to 1.1). Reversibility in less than 20% of myocardial segments did not change the likelihood of perioperative cardiac complications (LR, 1.3, 95% CI, 0.88 to 1.9). LRs for increasing extents of reversibility were: 20% to 29% reversibility (LR, 1.6; 95% CI, 1.0 to 2.6), 30% to 39% reversibility (LR, 2.9; 95% CI, 1.6 to 5.1), 40% to 49% reversibility (LR, 2.9; 95% CI, 1.4 to 6.2), and 50% or more reversibility (LR, 11; 95% CI, 5.8 to 20). The pooled area under the receiver operating characteristic curve was 0.78 (95% CI, 0.65 to 0.89). Heterogeneity was found among study results, but exclusion of heterogeneous studies did not significantly change the summary results. CONCLUSION: Reversible defects in less than 20% of myocardial segments do not significantly alter the risk of perioperative cardiac complications. Greater extents of reversibility on dipyridamole myocardial stress perfusion imaging increase the risk of perioperative complications after noncardiac vascular surgery, but the quality and amount of data regarding greater extents of reversibility are limited.

Dipyridamole↗