Nick Sevdalis

Factors underlying parental decisions about combination childhood vaccinations including MMR: a systematic review.

Suboptimal childhood vaccination uptake results in disease outbreaks, and in developed countries is largely attributable to parental choice. To inform evidence-based interventions, we conducted a systematic review of factors underlying parental vaccination decisions. Thirty-one studies were reviewed. Outcomes and methods are disparate, which limits synthesis; however parents are consistently shown to act in line with their attitudes to combination childhood vaccinations. Vaccine-declining parents believe that vaccines are unsafe and ineffective and that the diseases they are given to prevent are mild and uncommon; they mistrust their health professionals, Government and officially-endorsed vaccine research but trust media and non-official information sources and resent perceived pressure to risk their own childs safety for public health benefit. Interventions should focus on detailed decision mechanisms including disease-related anticipated regret and perception of anecdotal information as statistically representative. Self-reported vaccine uptake, retrospective attitude assessment and unrepresentative samples limit the reliability of reviewed data - methodological improvements are required in this area.

Quality of Care Management Decisions by Multidisciplinary Cancer Teams: A Systematic Review

BackgroundFactors that affect the quality of clinical decisions of multidisciplinary cancer teams (MDTs) are not well understood. We reviewed and synthesised the evidence on clinical, social and technological factors that affect the quality of MDT clinical decision-making.MethodsElectronic databases were searched in May 2009. Eligible studies reported original data, quantitative or qualitative. Data were extracted and tabulated by two blinded reviewers, and study quality formally evaluated.ResultsThirty-seven studies were included. Study quality was low to medium. Studies assessed quality of care decisions via the effect of MDTs on care management. MDTs changed cancer management by individual physicians in 2–52% of cases. Failure to reach a decision at MDT discussion was found in 27–52% of cases. Decisions could not be implemented in 1–16% of cases. Team decisions are made by physicians, using clinical information. Nursing personnel do not have an active role, and patient preferences are not discussed. Time pressure, excessive caseload, low attendance, poor teamworking and lack of leadership lead to lack of information and deterioration of decision-making. Telemedicine is increasingly used in developed countries, with no detriment to quality of MDT decisions.ConclusionsTeam/social factors affect management decisions by cancer MDTs. Inclusion of time to prepare for MDTs into team-members’ job plans, making team and leadership skills training available to team-members, and systematic input from nursing personnel would address some of the current shortcomings. These improvements ought to be considered at national policy level, with the ultimate aim of improving cancer care.

Understanding the Determinants of Antimicrobial Prescribing Within Hospitals: The Role of “Prescribing Etiquette”

Prescribing etiquette is an important determinant of antimicrobial prescribing behaviors. Prescribing etiquette recognizes clinical decision-making autonomy and the role of hierarchy in influencing practice. Existing clinical groups and clinical leadership should be utilized to influence antimicrobial prescribing behaviors.

Emotional intelligence in medicine: a systematic review through the context of the ACGME competencies.

Medical Education 2010: 44: 749–764

Observational Teamwork Assessment for Surgery: Content Validation and Tool Refinement

BACKGROUND Effective teamwork is crucial for safe surgery. Failures in nontechnical and teamwork skills are frequently implicated in adverse events. The Observational Teamwork Assessment for Surgery (OTAS) tool assesses teamwork of the entire team in the operating room. Empirical testing of OTAS has yet to explore the content validity of the tool. STUDY DESIGN This was a cross-sectional observational study. Data were collected in 30 procedures by 2 trained researchers. Five teamwork behaviors were scored (ie, communication, leadership, cooperation, coordination, and monitoring) and behavior exemplar completion was recorded (phase 1). Expert operating room personnel (5 surgeons, 5 anesthesiologists, and 5 scrub nurses) assessed the content validity of the OTAS exemplar behaviors. Finally, a panel of operating room patient-safety experts refined the exemplars (phase 2). RESULTS In total, the observability (presence/absence) of 130 exemplars was assessed by 2 blinded observers in 30 general surgical cases. Observer agreement was high (Cohens κ ≥ 0.41) for 83.85% (109 of 130) of exemplar behaviors; 60.77% (79 of 130) of exemplar behaviors were observed frequently with high observer agreement. The majority of the exemplars were rated by expert operating room practitioners and an expert panel as substantial contributors to teamwork and patient safety. Based on expert consensus, 21 behavior exemplars were removed from OTAS and an additional 23 were modified. CONCLUSIONS The exemplars of OTAS demonstrated very good content validity. Taken together with recent evidence on the construct validity of the tool, these findings demonstrate that OTAS is psychometrically robust for capturing teamwork in the operating room.

Do Safety Checklists Improve Teamwork and Communication in the Operating Room? A Systematic Review

Objectives: The aim of this systematic review was to assess the impact of surgical safety checklists on the quality of teamwork and communication in the operating room (OR). Background: Safety checklists have been shown to impact positively on patient morbidity and mortality following surgery, but it is unclear whether this clinical improvement is related to an improvement in OR teamwork and communication. Methods: A systematic search strategy of MEDLINE, EMBASE, PsycINFO, Google Scholar, and the Cochrane Database for Systematic Reviews was undertaken to obtain relevant articles. After de-duplication and the addition of limits, 315 articles were screened for inclusion by 2 researchers and all articles meeting a set of prespecified inclusion criteria were retained. Information regarding the type of checklist, study design, assessment tools used, outcomes, and study limitations was extracted. Results: Twenty articles formed the basis of this systematic review. All articles described an empirical study relating to a case-specific safety checklist for surgery as the primary intervention, with some measure of change/improvement in teamwork and/or communication relating to its use. The methods for assessing teamwork and communication varied greatly, including surveys, observations, interviews, and 360° assessments. The evidence suggests that safety checklists improve the perceived quality of OR teamwork and communication and reduce observable errors relating to poor team skills. This is likely to function through establishing an open platform for communication at the start of a procedure: encouraging the sharing of critical case-related information, promoting team coordination and decision making, flagging knowledge gaps, and enhancing team cohesion. However, the evidence would also suggest that when used suboptimally or when individuals have not bought in to the process, checklists may conversely have a negative impact on the function of the team. Conclusions: Safety checklists are beneficial for OR teamwork and communication and this may be one mechanism through which patient outcomes are improved. Future research should aim to further elucidate the relationship between how safety checklists are used and team skills in the OR using more consistent methodological approaches and utilizing validated measures of teamwork such that best practice guidelines can be established.

Observational teamwork assessment for surgery: construct validation with expert versus novice raters.

Objective:To test the construct validity of the Observational Teamwork Assessment for Surgery (OTAS) tool. Summary Background Data:Poor teamwork in surgical teams has been implicated in adverse events to patients. The OTAS is a tool that assesses teamwork in real time for the entire surgical team. Existing empirical research on OTAS has yet to explore how expert versus novice tool users use the tool to assess teamwork in the operating room. Methods:Data were collected in 12 elective procedures by an expert/expert (N = 6) and an expert/novice (N = 6) pair of raters. Five teamwork behaviors (communication, coordination, leadership, monitoring, and cooperation) were scored via observation pre, intra, and postoperatively by blind raters. Results:Significant and sizeable correlations were obtained in 12 of 15 behaviors in the expert/expert pair, but only in 3 of 15 behaviors in the expert/novice pair. Significant differences in mean scores were obtained in 3 of 15 behaviors in the expert/expert pair, but in 11 of 15 behaviors in the expert/novice pair. Total OTAS scores exhibited strong correlations and no significant differences in ratings in the expert/expert pair. In the expert/novice pair no correlations were obtained and there were significant differences in mean scores. The overall size of inconsistency in the scoring was 2% for expert/expert versus 15% for expert/novice. Conclusions:OTAS exhibits adequate construct validity as assessed by consistency in the scoring by expert versus novices—ie, expert raters produce significantly more consistent scoring than novice raters. Further validation should assess the learning curve for novices in OTAS. Relationships between OTAS, measures of technical skill, and behavioral responses to surgical crises should also be quantified.

Catastrophizing: a predictive factor for postoperative pain

BACKGROUND postsurgical pain is a major cause of delayed recovery and discharge after surgery. A significant proportion of patients develop chronic postsurgical pain, which affects their quality of life. Cognitive and psychological factors are reported to play a significant role in the severity of reported postsurgical pain. High levels of catastrophizing are associated with a heightened pain experience and appear to contribute to the development of chronic pain. This article describes the concept of pain catastrophizing, its association with postsurgical pain, and its potential role in the management of postsurgical pain and postsurgical quality of life. METHODS data for this review were identified from MEDLINE, EMBASE, and PsycINFO. Reference lists of selected articles were cross-searched for additional literature. RESULTS High catastrophizing levels were found to be associated with increased pain severity, increased incidence of development of chronic pain, and poorer quality of life after surgery. There was no consensus on the relation between catastrophizing and analgesia consumption. CONCLUSIONS identifying and reducing catastrophizing levels can help to optimize pain management in surgical patients.

Information transfer and communication in surgery: a systematic review.

Objectives:We conducted a systematic review of published literature to gain a better understanding of interprofessional information transfer and communication (ITC) in hospital setting in the field of surgical and anesthetic care. Background:Communication breakdowns are a common cause of surgical errors and adverse events. Data Sources:Medline, Embase, PsycINFO, Cochrane Database of Systematic Reviews, and hand search of articles bibliography. Study Selection:Of the 4027 citations identified through the initial electronic search and screened for possible inclusion, 110 articles were retained following title and abstract reviews. Of these, 38 were accepted for this review. Data Extraction:Data were extracted from the studies about objectives, clinical domain, methodology including study design, sample population, tools for assessing communication, results, and limitations. Results:Information transfer failures are common in surgical care and are distributed across the continuum of care. They not only lead to errors in care provision but also lead to patient harm. Most of the articles have focused on ITC process in different phases especially in operating room. None of the studies have looked at whole of the surgical care process. No standard tool has been developed to capture the ITC process in different teams and to evaluate the effect of various communication interventions. Uses of standardized communication through checklist, proformas, and technology innovations have improved the ITC process, with an effect on clinical and patient outcomes. Conclusions:ITC deficits adversely affect patient care. There is a need for standard measures to evaluate this process. Effective and standardized communication among healthcare professionals during the perioperative process facilitates surgical safety.

Behavior change strategies to influence antimicrobial prescribing in acute care: a systematic review.

BACKGROUND Antimicrobial use in acute care is widely reported to be suboptimal. Inappropriate use of antimicrobials is a major contributing factor to the emergence of multidrug resistance and health care-associated infection. Addressing prescribing behavior is a key component of antimicrobial stewardship. METHODS We performed a novel systematic review of both qualitative and quantitative literature on antimicrobial prescribing behavior in acute care. We assessed the extent to which behavioral sciences and social marketing were used and whether this could be related to the effectiveness of reported outcomes. MEDLINE, Excerpta Medica Database (EMBASE), Applied Social Sciences Index and Abstracts (ASSIA), Business Source Complete, The Cochrane Library, PsychInfo, Database of Abstracts of Reviews of Effectiveness (DARE) and Health Management Information Consortium (HMIC) were searched for studies undertaken during the period January 1999-April 2011 and published in English. RESULTS Five qualitative and 5 quantitative studies met the quality criteria. Qualitative studies highlight the predominant influence of social norms, attitudes, and beliefs on antimicrobial prescribing behavior. Quantitative studies reporting interventions to optimize antimicrobial prescribing behavior do not use theoretical science or primary research to inform the design and choice of the interventions deployed. CONCLUSIONS Despite qualitative evidence demonstrating the impact of behavioral determinants and social norms on prescribing, these influences are not given due consideration in the design and evaluation of interventions. To ensure a better understanding of prescribing behaviors and to improve the quality of interventions and research in this area, the incorporation and application of behavioral sciences supported by appropriate multidisciplinary collaboration is recommended.