OBJECTIVE: To study general practitioners' (GP) assessment of the probability of ischaemic heart disease (IHD) and GP action in daily practice regarding chest pain patients. METHODS: All chest pain patients aged 20-79 years, attending three primary health-care centres in south-east Sweden and assessed by the GP to have high, low or very low probability of IHD, were included consecutively over a two year period. The "GP action in daily practice" was classed as "active decisions" (investigation or treatment) or "wait and see". "IHD" or "not IHD" was settled according to the results of acute hospital investigation or exercise testing/myocardial perfusion scintigraphy. RESULTS: 516 patients were included, 93 high, 145 low and 278 very low probability cases. The outcome was "IHD" in 47%, 9% and 1% respectively. The sensitivity and specificity of the "GP assessment of the probability of IHD" were 72% and 89%. The sensitivity and specificity of the "GP action in daily practice" were 88% and 72%, respectively. The negative predictive value was 98%. CONCLUSION: GP assessment, after clinical evaluation, that the probability of IHD was low did not safely rule out IHD. GP action in daily practice however, indicates that general practice is an appropriate level of care for chest pain patients.
We determine success rates of endotracheal intubation performed in emergency departments (EDs) by North American emergency medicine residents.
During 58 months, physicians performing intubations at 31 university-affiliated EDs in 3 nations completed a data form that was entered into the National Emergency Airway Registry 2 database. Included were all patients undergoing endotracheal intubation in the ED. The data form included patients' age, sex, weight, indication for intubation, technique of airway management, names and dosages of all medications used to facilitate intubation, level of training and specialty of the intubator, number of attempts, success or failure, and adverse events. We queried this prospectively gathered, observational data to analyze intubations done by US and Canadian emergency medicine residents.
Enrollment was incomplete (eg, 85% at the main study center), so the study sample did not include all consecutive patients. Emergency medicine residents performed 77% (5768/7498; 95% confidence interval [CI] 76% to 78%) of all initial intubation attempts in the United States and Canada. The first intubator was successful in 90% (5,193/5,757; 95% CI 89% to 91%) of cases, including 83% (4,775/5,757; 95% CI 82% to 84%) on the first attempt. Success rates on the first attempt were as follows: postgraduate year 1 = 72% (498/692; 95% CI 68% to 75%), postgraduate year 2 = 82% (2,081/2,544; 95% CI 80% to 83%), postgraduate year 3 = 88% (1,963/2,238; 95% CI 86% to 89%), postgraduate year 4+ = 82% (233/283; 95% CI 77% to 87%), and attending physician = 89% (689/772; 95% CI 87% to 91%). Success rates by the first intubator were as follows: postgraduate year 1 = 80% (553/692; 95% CI 77% to 83%), postgraduate year 2 = 89% (2,272/2,544; 95% CI 88% to 90%), postgraduate year 3 = 94% (2,105/2,238; 95% CI 93% to 95%), postgraduate year 4+ = 93% (263/283; 95% CI 89% to 96%), and attending physician = 98% (755/772; 95% CI 96% to 99%). Rapid sequence intubation technique was used in 78% (4,513/5,768; 95% CI 77% to 79%) of initial attempts: it resulted in 85% (3,843/4,513; 95% CI 84% to 86%) success on the first attempt and 91% (4,117/4,513; 95% CI 90% to 92%) success by the first intubator. The overall rate of cricothyrotomy for all emergency resident intubations was 0.9% (50/5,757; 95% CI 0.6% to 1.1%). When an initial intubator failed, 40% (385/954; 95% CI 37% to 44%) of rescue attempts were performed by emergency medicine residents. Among emergency medicine residents, success on the first rescue attempt was 80% (297/371; 95% CI 76% to 84%), and success by the first rescue intubator was 88% (328/371; 95% CI 85% to 91%).
Success of initial intubation attempts increased over the first 3 years of residency. This large multicenter study demonstrates the success of airway management by emergency medicine residents in North America. Using rapid-sequence intubation predominantly, emergency medicine residents achieved high levels of success.
This study aimed to examine anaesthetists' perceptions of facilitative weaning from the mechanical ventilator in the intensive care unit (ICU).
Explorative qualitative interviews in a phenomenographic reference frame with a purposive sample of 14 eligible anaesthetists from four different ICUs with at least one year of clinical experience of ICU and of ventilator weaning.
Four categories of anaesthetists' perceptions of facilitative decision-making strategies for ventilator weaning were identified. These were the instrumental, the interacting, the process-oriented and the structural strategies" for ventilator weaning. The findings refer to a supportive multidisciplinary holistic ICU quality of care. Choice of strategy for ventilator weaning was flexible and individually tailored to the patients'.
Choice of strategy was flexible and individually adjustable. Introduction of evidence-based guidelines from ventilator weaning is necessary in the ICU. The guidelines should also cover the responsibilities of various professional groups. Regular evaluations of methods and strategies used in practice need to be implemented. This may facilitate decision-making strategies for ventilator weaning in practice at the ICU. Greater attention needs to focus on family members' experiences. The strategies should be an integral part of continuous staff training.
To explore the type and frequency of activities and multitasking performed by emergency department clinicians.
Eighteen clinicians (licensed practical nurses, registered nurses and medical doctors), six from each occupational group, at two Swedish emergency departments were followed in their clinical work for 2 h each to observe all their activities and multitasking practices. Data were analysed using qualitative and quantitative content analysis.
Fifteen categories of activities could be identified based on 1882 observed activities during the 36 h of observation. The most common activity was information exchange, which was most often performed face-to-face. This activity represented 42.1% of the total number of observed activities. Information exchange was also the most common activity to be multitasked. Registered nurses performed most activities and their activities were multitasked more than the other clinicians. The nurses' and doctors' offices were the most common locations for multitasking in the emergency department.
This study provides new knowledge regarding the activities conducted by clinicians in the emergency department. The most frequent activity was information exchange, which was the activity most often performed by the clinicians when multitasking occurred. Differences between clinicians were found for activities performed and multitasked, with registered nurses showing the highest frequencies for both.
Viral respiratory infections (VRIs) are a common reason for ambulatory visits, and 35% are treated with an antibiotic. Antibiotic use for VRIs is not recommended, and it promotes antibiotic resistance. Effective patient-physician communication is critical to address this problem. Recognizing the importance of physician communication skills, licensure examinations were reformed in the United States and Canada to evaluate these skills.
To assess whether physician clinical and communication skills, as measured by the Canadian clinical skills examination (CSE), predict antibiotic prescribing for VRI in ambulatory care.
A total of 442 Quebec general practitioners and pediatricians who wrote the CSE in 1993-1996 were followed from 1993 to 2007, and their 159,456 VRI visits were identified from physician claims.
The outcome was an antibiotic prescription from a study physician dispensed within 7 days of the VRI visit. Multivariate logistic regression analyses were used to estimate the association between antibiotic prescribing for VRI and CSE score, adjusting for physician, patient, and encounter characteristics.
Better clinical and communication skills were associated with a reduction in the risk of antibiotic prescribing, but only for female physicians. Every 1-standard deviation increase in CSE score was associated with a 19% reduction in the risk of antibiotic prescribing (risk ratio, 0.81; 95% confidence interval, 0.68-0.97). Better clinical skills were associated with an even greater reduction in risk among female physicians with higher workloads (risk ratio, 0.48; 95% confidence interval, 0.29-0.79).
Physician clinical and communication skills are important determinants of antibiotic prescribing for VRI and should be targeted by future interventions.
In an effort to evaluate the perceived utility of specific Royal College of Physicians and Surgeons of Canada (RCPSC) urology residency training objectives we conducted a survey of the practicing urologists of British Columbia (BC).
A two page semi-structured survey was designed. Validity was evaluated for clarity, content and ease of completion. The survey was mailed-out to all 61 practicing urologists in BC. The survey population was divided into urban, rural, and academic according to location of practice.
Survey response rate was 79% with varying subgroup rates: urban-69% (20/29), rural-94% (17/18) and academic 86% (12/14). Specific clinical components of training were rated as "useful" by the majority of all respondents: pediatric urology (93%), laparoscopy (88%), TRUS (77%), percutaneous renal access (74%), urethral surgery (72%), microsurgery (62%). Renal transplantation was rated "not useful" by 74% of respondents. TRUS, percutaneous renal access and adrenal surgery were perceived as useful by the majority of those practicing in rural and non-academic urban centers compared to those in academic centers where the majority rated these skills as "not useful". Virtually all non-clinical components of training were rated as "useful". The majority of respondents felt that residency training prepared them for the following challenges: accepting responsibility for patient care, assessing scientific literature, ethical decision-making and communication. The majority of respondents felt that residency did not prepare them for the following challenges: time and office management, hospital administration and providing care within a constrained system.
Specific clinical and non-clinical areas of training have high perceived utility in all settings of practice. Certain clinical components of training have high perceived utility only in specific settings of practice. There are many non-clinical components of practice, which are perceived to be important, but for which BC urologists feel inadequately prepared for by their residency training programs. If consistent across Canada, these findings may facilitate a rational approach to the modification of the objectives for urology residency training.
Many health professionals believe they practice collaboratively. Providing insight into their actual level of collaboration requires a means to assess practice within health settings. This chapter reports on the development, testing, and refinement process for the Assessment of Interprofessional Team Collaboration Scale (AITCS). There is a paucity of literature and measurement tools addressing interprofessional collaborative team performance and the nature of effective teamwork processes and patient roles within collaborative teams. These gaps limit our knowledge about how health care teams form and function. Instruments are therefore needed to assess collaborative relationships.
The AITCS, with its 47 items within 4 subscales (partnership, cooperation, coordination, and shared decision making) and assessed on a 5-point Likert scale, was administered to a total of 125 practitioners from 7 health care teams practicing within a variety of settings, in 2 provinces in Canada.
Principal components and factor analysis of data resulted in 37 items loading onto 3 factors, explaining 61.02% of the variance. The internal consistency estimates for reliability of each subscale ranged from 0.80 to 0.97, with an overall reliability of 0.98. Thus, the AITCS is a reliable and valid instrument.
The psychometric analysis of this instrument supports its value in measuring collaboration within teams and when patients are included as team members. The AITCS can be applied to continuing professional education interventions to determine change over time. It has limitations to the Canadian context and within the settings where participants practiced. Further test and retest reliability and longitudinal study application is needed.
Catheter ablation for atrial fibrillation (AF) is an important but expensive procedure that is the subject of some debate. Physicians' attitudes toward catheter ablation may influence promotion and patient acceptance. This is the first study to examine the attitudes of Danish cardiologists toward catheter ablation for AF, using a nationwide survey.
We developed a purpose-designed questionnaire to evaluate attitudes toward catheter ablation for AF that was sent to all Danish cardiologists (n = 401; response n = 272 (67.8%)). There was no association between attitudes toward ablation and the experience or age of the cardiologist with respect to patients with recurrent AF episodes with a duration of 7 days and/or need for cardioversion. The majority (69%) expected a recurrence of AF after catheter ablation in more than 30% of the cases. For patients with persistent longstanding AF with a duration of >1 year, the attitude toward ablation for longstanding AF was more likely to be positive with increasing age (P 7 days, or those who needed medical/electrical conversion, but a more negative attitude toward treating longstanding AF patients.
The purpose of this study was to investigate to what extent school nurses in Sweden inform adolescent men about testicular cancer (TC) and testicular self-examination (TSE). A questionnaire was completed by 129 school nurses from 29 randomly selected municipalities. All respondents were women, with a mean age of 42 years. The results showed that about 6% of the school nurses had provided information on TC and 9% on TSE; however, the majority was open to presenting such information. The major reason reported for not providing this guidance was insufficient knowledge about the subject. The nurses who had given information were knowledgeable about both TC and TSE and more often informed young men about TC and TSE, whereas those who had only received information about TC were not as likely to provide information about TC or TSE. The results of this study highlight the need to educate school nurses about TC and TSE so they can include this information in their health teaching to adolescent males.
To assess challenges in providing palliative care in long-term care (LTC) facilities from the perspective of medical directors.
Cross-sectional mailed survey. A questionnaire was developed, reviewed, pilot-tested, and sent to 450 medical directors representing 531 LTC facilities. Responses were rated on 2 different 5-point scales. Descriptive analyses were conducted on all responses.
All licensed LTC facilities in Ontario with designated medical directors.
Medical directors in the facilities.
Demographic and practice characteristics of physicians and facilities, importance of potential barriers to providing palliative care, strategies that could be helpful in providing palliative care, and the kind of training in palliative care respondents had received.
Two hundred seventy-five medical directors (61%) representing 302 LTC facilities (57%) responded to the survey. Potential barriers to providing palliative care were clustered into 3 groups: facility staff's capacity to provide palliative care, education and support, and the need for external resources. Two thirds of respondents (67.1%) reported that inadequate staffing in their facilities was an important barrier to providing palliative care. Other barriers included inadequate financial reimbursement from the Ontario Health Insurance Program (58.5%), the heavy time commitment required (47.3%), and the lack of equipment in facilities (42.5%). No statistically significant relationship was found between geographic location or profit status of facilities and barriers to providing palliative care. Strategies respondents would use to improve provision of palliative care included continuing medical education (80.0%), protocols for assessing and monitoring pain (77.7%), finding ways to increase financial reimbursement for managing palliative care residents (72.1%), providing educational material for facility staff (70.7%), and providing practice guidelines related to assessing and managing palliative care patients (67.8%).
Medical directors in our study reported that their LTC facilities were inadequately staffed and lacked equipment. The study also highlighted the specialized role of medical directors, who identified continuing medical education as a key strategy for improving provision of palliative care.