Michele Levinson

Cardiopulmonary resuscitation--time for a change in the paradigm?

Cardiopulmonary resuscitation (CPR) is the default treatment in hospital unless there is a decision to the contrary and this is documented in the patient record. The outcome of CPR in older chronically ill patients is very poor and discharge home is unlikely. Fewer not‐for‐resuscitation (NFR) orders are written than there are patients who would not benefit from CPR. NFR orders appear to be a marker of death, rather than the result of informed discussion about end‐of‐life care. There is a legal and ethical framework for the consideration of the suitability of CPR. Discussions about CPR are challenging, and uncertainty is introduced because of the lack of consensus around futility, the emotionally charged nature of the topic, misconceptions about the success of CPR and the failure to recognise that not offering CPR will allow a peaceful and supported death. Discussion around CPR can be misconstrued as a need for consent. A focus on patient and family involvement may result in an expectation that CPR is an entitlement. As part of evidence‐based patient‐centred care, CPR should only be offered to those for whom it is beneficial. CPR should no longer be the universal default. We propose an opt‐in model, which will drive discussion and evaluation of the efficacy and suitability of CPR for the individual. A CPR discussion should occur on admission for all elderly hospital inpatients.

Comparison of not for resuscitation (NFR) forms across five Victorian health services

Within Australian hospitals, cardiac and respiratory arrests result in a resuscitation attempt unless the patient is documented as not for resuscitation.

Barriers to the implementation of evidence in osteoporosis treatment in hip fracture

An audit at a private tertiary hospital showed low rates of assessment and treatment of osteoporosis in minimal trauma patients of hip fracture. A survey sent to all doctors involved in hip fracture care to establish medical beliefs about effective management of osteoporosis in minimal trauma hip fracture patients showed a lack of ownership for investigation and beliefs influencing treatment choices. Understanding the barriers to the translation of evidence into practice is vital to improve patient care.

Point prevalence of patients fulfilling MET criteria in ten MET equipped hospitals. The methodology of the RESCUE study

OBJECTIVE The RESCUE study examined the prevalence of patients at risk of a medical emergency in acute care settings by assessing the prevalence of cases where patients fulfil the hospital-specific criteria for MET activation. This article will detail the study methodology including the ethics applications and approvals process, organisational preparation, research staff training, tools for data collection, as well as barriers encountered during the conduct of the study. DESIGN AND SETTING A point prevalence design conducted at 10 hospitals, comprising of private and public, secondary and tertiary referral, ICU equipped, metropolitan and regional settings. PATIENTS All inpatients were eligible except intensive care and psychiatric patients. MEASUREMENT AND MAIN RESULTS On a single day consenting inpatients in each hospital had a single set of vital signs obtained, their observation chart reviewed and followed up for MET activations, unplanned ICU admissions, cardiac arrests and 30 and 60 day mortality. Of 2199 eligible patients, 1688 (76.76%) were assessed, 175 (7.95%) refused consent and 336 (15.28%) were unavailable. Access to patients was refused in some wards despite ethics approval. Data collection required 2 student nurses approximately 14 min per patient assessment. CONCLUSION In conducting a large multi-site point prevalence study, critical organisational processes were shown to influence the access to patients. This study demonstrated the impact of variation in Human Research Ethics Committee interpretations of protocols on consenting processes and the importance of communication and leadership at ward level to promote access to patients.

Shared decision making: what do clinicians need to know and why should they bother?

TO THE EDITOR: The article by Hoffman and colleagues1 outlines the importance of fully involving people in decisions about their health care. There is an ethical imperative to ensure that both patients and the community obtain the best value possible from the resources that are used to provide health care. A low-technology intervention that can help meet the expectations for better value care should be warmly embraced. We now need to find practical ways to increase the use of shared decision making in routine practice. As Hoffman et al note, this will require concerted effort across the system. Health professionals need the skills required to use shared decision-making approaches. Professionals and patients need high-quality decision aids that can help identify patient preferences where there are multiple options for treatment. And there is clearly a need for research that measures the uptake and effects of shared decision making in specific clinical areas. In October 2014, the Australian Commission on Safety and Quality in Health Care sponsored visits by two international experts in shared decision making, to explore what we can learn from overseas experience in this area. Professors Richard Thomson (Newcastle University, United Kingdom) and Dawn Stacey (University of Ottawa, Canada) led workshops that aimed to identify cost-effective ways of ensuring that high-quality patient decision aids are accessible, available and used in Australia. In the coming year, the Commission will be working with educational and consumer groups to develop content for an online risk communication training module for health professionals. We will also be undertaking work to develop and promote Further, many older people have cognitive impairment that does not allow a sufficiently sophisticated assessment of risk and benefit. In the clinical scenario provided in Hoffman et al, there was a single-system problem with good evidence. Even in this situation, I suspect that shared decision making would be challenging with a tired, distressed mother and a screaming child. We should also be mindful that shared decision making should not result in doctors abdicating responsibility for making difficult decisions.3

Medical scribes have no impact on the patient experience of an emergency department

We aimed to evaluate patient perceptions of medical scribes in the ED and to test for scribe impacts on ED Net Promoter Scores, Press Ganey Surveys and other patient‐centred topics.

The impact of intensive care in a private hospital on patients aged 80 and over: health-related quality of life, functional status and burden versus benefit

Greater numbers of persons aged over 80 years are admitted to intensive care units (ICU) compared with 15 years ago. Outcomes other than death such as physical dependence and cognitive impairment and treatment burden are important to older people.

How receptive are patients to medical students in Australian hospitals? A cross-sectional survey of a public and a private hospital

Medical student numbers in Australian universities have more than doubled since 2000. There are concerns about the ability for existing clinical training sites to accommodate this increase in student numbers, and there have been calls to increase training in private hospitals. The receptiveness of patients in private hospitals will influence the success of such placements.BACKGROUND Medical student numbers in Australian universities have more than doubled since 2000. There are concerns about the ability for existing clinical training sites to accommodate this increase in student numbers, and there have been calls to increase training in private hospitals. The receptiveness of patients in private hospitals will influence the success of such placements. AIMS We aimed to evaluate whether patients in a private hospital are as receptive to medical students as patients in a public hospital. METHODS Cross-sectional survey of patients conducted at a private and a public teaching hospital in Melbourne, Australia. Main outcome measures were willingness to allow a medical student to participate in an interview, physical examination and procedures (electrocardiogram, venepuncture and digital rectal examination), and patient attitudes towards medical students as assessed by a series of 20 attitude statements and a summative attitude score. RESULTS Patients at the private hospital were more willing than patients at the public hospital to allow a medical student to take their history unsupervised (112/146, 76.7% vs 90/141, 63.8%; P = 0.02). The distribution of patient willingness did not otherwise differ between hospitals for physical examination or procedures. There was no difference in the mean attitude score between hospitals (15.3 ± 0.8 private vs 15.4 ± 1.2 public, P = 0.38), and responses differed between hospitals for only four of the 20 attitude statements. CONCLUSIONS Our findings suggest that patients in a private hospital are at least as receptive to medical students as patients in a public hospital.

Sacroiliitis secondary to isotretinoin

Reported is the case of a 17‐year old male with sacroiliitis confirmed by magnetic resonance imaging (MRI) while undergoing isotretinoin treatment for acne vulgaris. The cessation of isotretinoin and symptomatic treatment resolved the symptoms within 6 weeks, with no signs of sacroiliitis on repeat MRI 10 months later. The temporal association of disease onset and commencement of isotretinoin along with rapid recovery on withdrawal supports the role of isotretinoin in this case.

Language and understanding of cardiopulmonary resuscitation amongst an aged inpatient population

Abstract Greater patient involvement in health decision-making requires exchange of information between the patient and the healthcare professionals. Decisions regarding healthcare at the end of life include consideration of cardiopulmonary resuscitation (CPR). The stated objectives of this study were to determine how often language around concepts of resuscitation is used in the community by examination of the English language corpora (ELC); to explore the understanding of the same language by a group of older hospital patients; and to determine the patients’ knowledge of the process and success of CPR, as well as the sources of their information. Medical inpatients aged 75 years and older were surveyed to this end in the setting of a tertiary university teaching hospital. Interrogation of the Australian, British and American English Corpora was accomplished by a linguist, and a questionnaire and semi-structured interview were administered to ascertain patient knowledge. We demonstrated that although medical inpatients have some familiarity with terms relating to resuscitation, there is a lack of understanding of the context, process and outcomes of CPR. The predominant sources of information were television and print media. Examination of the ELC revealed a paucity of the use of terms related to resuscitation. This finding indicates that physicians have a duty of care to determine patients’ understanding around resuscitation language, and terms used, in discussions of their preferences before assuming their engagement in shared decision-making. More open public discussion around death and resuscitation would increase the general knowledge of the population and would provide a better foundation for the discussions in times of need.