Stuart McLennan

Quality of dying in a New Zealand teaching hospital

Objective: Studies suggest that there is a need to improve the way we deliver care at the end of life. Based on recommendations from end-of-life experts, metrics were identified to measure the quality of dying in Dunedin Hospital. Design: A retrospective observational study was performed to assess the care provided to patients who died in the hospital in 2003. Setting: Dunedin Hospital is a 350-bed tertiary care teaching hospital located in the South Island of New Zealand. Subjects and method: Medical records of 200 consecutive decedents were reviewed to evaluate communication, interventions, and symptom control during their terminal hospitalisation. Results: Mean hospital length-of-stay was 8 days; 38 patients (19%) died following an ICU admission. There was documentation of end-of-life discussion with either the patient or the family in 164 patients (82%). 74% had a DNR order. Pain status was documented in 140 patients (70%); 134 of these patients were pain-free. Conclusion: Overall, the results suggest that the ideals in end-of-life care pertaining to pain control, communication and avoidance of unnecessary interventions were achieved in a majority of the decedents during the study period. The socialised healthcare system, the availability of resources, societal expectations and a lack of a litigious environment are theorised to positively influence end-of-life care delivery in New Zealand.

Trends in severity of illness on ICU admission and mortality among the elderly

Background There is an increase in admission rate for elderly patients to the ICU. Mortality rates are lower when more liberal ICU admission threshold are compared to more restrictive threshold. We sought to describe the temporal trends in elderly admissions and outcomes in a tertiary hospital before and after the addition of an 8-bed medical ICU. Methods We conducted a retrospective analysis of a comprehensive longitudinal ICU database, from a large tertiary medical center, examining trends in patients’ characteristics, severity of illness, intensity of care and mortality rates over the years 2001–2008. The study population consisted of elderly patients and the primary endpoints were 28 day and one year mortality from ICU admission. Results Between the years 2001 and 2008, 7,265 elderly patients had 8,916 admissions to ICU. The rate of admission to the ICU increased by 5.6% per year. After an eight bed MICU was added, the severity of disease on ICU admission dropped significantly and crude mortality rates decreased thereafter. Adjusting for severity of disease on presentation, there was a decreased mortality at 28- days but no improvement in one- year survival rates for elderly patient admitted to the ICU over the years of observation. Hospital mortality rates have been unchanged from 2001 through 2008. Conclusion In a high capacity ICU bed hospital, there was a temporal decrease in severity of disease on ICU admission, more so after the addition of additional medical ICU beds. While crude mortality rates decreased over the study period, adjusted one-year survival in ICU survivors did not change with the addition of ICU beds. These findings suggest that outcome in critically ill elderly patients may not be influenced by ICU admission. Adding additional ICU beds to deal with the increasing age of the population may therefore not be effective.

International portability of health-cost coverage : concepts and experience

Social insurance and other arrangements for funding health-care benefits often establish long-term relationships, effectively providing insurance against lasting changes in an individual’s health status, engaging in burden-smoothing over the life cycle, and entailing additional elements of redistribution. International portability regarding this type of cover is, therefore, difficult to establish, but at the same time rather important both for the individuals affected and for the health funds involved in any instance of an international change in work place or residence. In this paper, full portability of health-cost cover is taken to mean that mobile individuals can, at a minimum, find comparable continuation of coverage under a different system and that this does not impose external costs or benefits on other members of the systems in the source and destination countries. Both of these aspects needs to be addressed in a meaningful portability framework for health systems, as lacking or incomplete portability may not only lead to significant losses in coverage for an individual who considers becoming mobile – which may impede mobility that is otherwise likely to be beneficial. It may also lead to financial losses, or windfall gains, for sources of healthcost funding which can ultimately lead to a detrimental process of risk segmentation across national health systems. Against this background, even the most advanced sets of existing portability rules, such as those agreed upon multilaterally at the EU-level or laid down in bilateral agreements on social protection, appear to be untargeted, inconsistent and therefore potentially harmful, either for migrants or for health funds operated at both ends of the migration process, and hence for other individuals who are covered there. Here, we develop a conceptual framework which can be used to clarify the implications of mobility for various types of systems covering health costs and the requirements which have to be met to ensure full portability. We conclude that, when individuals move from one source of healthcost funding to another, compensating payments between health funds may be needed that are based on changes in expected net costs – i.e., expected health costs minus expected contributions, adjusted for health-cost inflation, wage growth, long-term (non-) sustainability and properly discounted over time – in both of the systems involved. Through illustrative simulations, we show that there may indeed be sufficient leeway for this approach to be operative under real-world conditions.

Implementation status of error disclosure standards reported by Swiss hospitals

QUESTION UNDER STUDY To establish at what stage Swiss hospitals are in implementing an internal standard concerning communication with patients and families after an error that resulted in harm. METHODS Hospitals were identified via the Swiss Hospital Associations website. An anonymous questionnaire was sent during September and October 2011 to 379 hospitals in German, French or Italian. Hospitals were asked to specify their hospital type and the implementation status of an internal hospital standard that decrees that patients or their relatives are to be promptly informed about medical errors that result in harm. RESULTS Responses from a total of 205 hospitals were received, a response rate of 54%. Most responding hospitals (62%) had an error disclosure standard or planned to implement one within 12 months. The majority of responding university and acute care (75%) hospitals had introduced a disclosure standard or were planning to do so. In contrast, the majority of responding psychiatric, rehabilitation and specialty (53%) clinics had not introduced a standard. CONCLUSION It appears that Swiss hospitals are in a promising state in providing institutional support for practitioners disclosing medical errors to patients. This has been shown internationally to be one important factor in encouraging the disclosure of medical errors. However, many hospitals, in particular psychiatric, rehabilitation and specialty clinics, have not implemented an error disclosure policy. Further research is needed to explore the underlying reasons.

Disclosing and reporting medical errors : Cross-sectional survey of Swiss anaesthesiologists

BACKGROUND There is limited research on anaesthesiologists’ attitudes and experiences regarding medical error communication, particularly concerning disclosing errors to patients. OBJECTIVE To characterise anaesthesiologists’ attitudes and experiences regarding disclosing errors to patients and reporting errors within the hospital, and to examine factors influencing their willingness to disclose or report errors. DESIGN Cross-sectional survey. SETTING Switzerlands five university hospitals’ departments of anaesthesia in 2012/2013. PARTICIPANTS Two hundred and eighty-one clinically active anaesthesiologists. MAIN OUTCOME MEASURES Anaesthesiologists’ attitudes and experiences regarding medical error communication. RESULTS The overall response rate of the survey was 52% (281/542). Respondents broadly endorsed disclosing harmful errors to patients (100% serious, 77% minor errors, 19% near misses), but also reported factors that might make them less likely to actually disclose such errors. Only 12% of respondents had previously received training on how to disclose errors to patients, although 93% were interested in receiving training. Overall, 97% of respondents agreed that serious errors should be reported, but willingness to report minor errors (74%) and near misses (59%) was lower. Respondents were more likely to strongly agree that serious errors should be reported if they also thought that their hospital would implement systematic changes after errors were reported [(odds ratio, 2.097 (95% confidence interval, 1.16 to 3.81)]. Significant differences in attitudes between departments regarding error disclosure and reporting were noted. CONCLUSION Willingness to disclose or report errors varied widely between hospitals. Thus, heads of department and hospital chiefs need to be aware of the importance of local culture when it comes to error communication. Error disclosure training and improving feedback on how error reports are being used to improve patient safety may also be important steps in increasing anaesthesiologists’ communication of errors.

Low influenza vaccination rates among healthcare workers. Time to take a different approach

Despite decades of effort to encourage healthcare workers (HCWs) to be immunized against influenza, vaccination levels remain insufficient in Germany, with only one in five HCWs receiving the annual influenza vaccination. To prevent nosocomial influenza outbreaks and to ensure the protection of patients and HCWs, new approaches to increase vaccination rates are needed. The experience in the USA has shown that declination forms have increased vaccination coverage. One possible approach for Germany would be a combination of declination forms with the exclusive use of vaccinated staff in defined areas. This approach would respect a HCWs decision to refuse medical treatment, while at the same time protecting vulnerable patients. In addition, the influenza vaccination rates of HCWs should be collected in order to evaluate the implementation of vaccination policies. Similar to the setting of desired vaccination coverage for the chronically ill, a clearly defined vaccination goal should be established for HCWs.ZusammenfassungTrotz jahrzehntelanger Bemühungen, die Influenzaimpfquoten des medizinischen Personals zu verbessern, verbleiben diese auf einem unzureichenden Niveau. Lediglich jeder fünfte medizinisch Beschäftigte lässt sich in Deutschland impfen. Um nosokomiale Influenzaausbrüche zu vermeiden und den Schutz der Patienten sowie des medizinischen Personals sicherzustellen, sollten neue Konzepte zur Steigerung der Impfquoten erarbeitet werden. Erfahrungen aus den USA zeigen, dass die Einführung unterschriebener Impfablehnungen die Impfquoten erhöht. Ein möglicher Ansatz für Deutschland wäre eine Kombination aus unterschriebener Impfablehnung und dem ausschließlichen Einsatz geimpften Personals in definierten Bereichen. Hierdurch könnte auf der einen Seite die freie Entscheidung des medizinischen Personals über die Ablehnung einer medizinischen Behandlung respektiert werden, auf der anderen Seite würde dem Schutz der vulnerablen Patienten Rechnung getragen. In Deutschland sollten die Influenzadurchimpfungsquoten des medizinischen Personals erfasst werden, um die Umsetzung des Impfkonzeptes bewerten zu können. Analog zu den angestrebten Durchimpfungsquoten bei chronisch Kranken, sollte ein konkretes Impfziel für medizinisches Personal festgelegt werden.AbstractDespite decades of effort to encourage healthcare workers (HCWs) to be immunized against influenza, vaccination levels remain insufficient in Germany, with only one in five HCWs receiving the annual influenza vaccination. To prevent nosocomial influenza outbreaks and to ensure the protection of patients and HCWs, new approaches to increase vaccination rates are needed. The experience in the USA has shown that declination forms have increased vaccination coverage. One possible approach for Germany would be a combination of declination forms with the exclusive use of vaccinated staff in defined areas. This approach would respect a HCWs decision to refuse medical treatment, while at the same time protecting vulnerable patients. In addition, the influenza vaccination rates of HCWs should be collected in order to evaluate the implementation of vaccination policies. Similar to the setting of desired vaccination coverage for the chronically ill, a clearly defined vaccination goal should be established for HCWs.

Niedrige Influenzaimpfquoten bei Mitarbeitern im Gesundheitswesen

Despite decades of effort to encourage healthcare workers (HCWs) to be immunized against influenza, vaccination levels remain insufficient in Germany, with only one in five HCWs receiving the annual influenza vaccination. To prevent nosocomial influenza outbreaks and to ensure the protection of patients and HCWs, new approaches to increase vaccination rates are needed. The experience in the USA has shown that declination forms have increased vaccination coverage. One possible approach for Germany would be a combination of declination forms with the exclusive use of vaccinated staff in defined areas. This approach would respect a HCWs decision to refuse medical treatment, while at the same time protecting vulnerable patients. In addition, the influenza vaccination rates of HCWs should be collected in order to evaluate the implementation of vaccination policies. Similar to the setting of desired vaccination coverage for the chronically ill, a clearly defined vaccination goal should be established for HCWs.ZusammenfassungTrotz jahrzehntelanger Bemühungen, die Influenzaimpfquoten des medizinischen Personals zu verbessern, verbleiben diese auf einem unzureichenden Niveau. Lediglich jeder fünfte medizinisch Beschäftigte lässt sich in Deutschland impfen. Um nosokomiale Influenzaausbrüche zu vermeiden und den Schutz der Patienten sowie des medizinischen Personals sicherzustellen, sollten neue Konzepte zur Steigerung der Impfquoten erarbeitet werden. Erfahrungen aus den USA zeigen, dass die Einführung unterschriebener Impfablehnungen die Impfquoten erhöht. Ein möglicher Ansatz für Deutschland wäre eine Kombination aus unterschriebener Impfablehnung und dem ausschließlichen Einsatz geimpften Personals in definierten Bereichen. Hierdurch könnte auf der einen Seite die freie Entscheidung des medizinischen Personals über die Ablehnung einer medizinischen Behandlung respektiert werden, auf der anderen Seite würde dem Schutz der vulnerablen Patienten Rechnung getragen. In Deutschland sollten die Influenzadurchimpfungsquoten des medizinischen Personals erfasst werden, um die Umsetzung des Impfkonzeptes bewerten zu können. Analog zu den angestrebten Durchimpfungsquoten bei chronisch Kranken, sollte ein konkretes Impfziel für medizinisches Personal festgelegt werden.AbstractDespite decades of effort to encourage healthcare workers (HCWs) to be immunized against influenza, vaccination levels remain insufficient in Germany, with only one in five HCWs receiving the annual influenza vaccination. To prevent nosocomial influenza outbreaks and to ensure the protection of patients and HCWs, new approaches to increase vaccination rates are needed. The experience in the USA has shown that declination forms have increased vaccination coverage. One possible approach for Germany would be a combination of declination forms with the exclusive use of vaccinated staff in defined areas. This approach would respect a HCWs decision to refuse medical treatment, while at the same time protecting vulnerable patients. In addition, the influenza vaccination rates of HCWs should be collected in order to evaluate the implementation of vaccination policies. Similar to the setting of desired vaccination coverage for the chronically ill, a clearly defined vaccination goal should be established for HCWs.

Nurses’ attitudes towards enforced measures to increase influenza vaccination: A qualitative study

Despite studies demonstrating that the annual influenza vaccination of healthcare workers reduces morbidity and mortality among vulnerable patients, vaccination rates remain very low, particularly in nursing staff. Educational programmes have failed to improve rates, which has led to a diverse range of enforced approaches being advocated and implemented.

Should Health Care Providers Be Forced to Apologise After Things Go Wrong

The issue of apologising to patients harmed by adverse events has been a subject of interest and debate within medicine, politics, and the law since the early 1980s. Although apology serves several important social roles, including recognising the victims of harm, providing an opportunity for redress, and repairing relationships, compelled apologies ring hollow and ultimately undermine these goals. Apologies that stem from external authorities’ edicts rather than an offender’s own self-criticism and moral reflection are inauthentic and contribute to a “moral flabbiness” that stunts the moral development of both individual providers and the medical profession. Following a discussion of a recent case from New Zealand in which a midwife was required to apologise not only to the parents but also to the baby, it is argued that rather than requiring health care providers to apologise, authorities should instead train, foster, and support the capacity of providers to apologise voluntarily.

Racial and Geographic Disparities in Interhospital ICU Transfers

Objectives: Interhospital transfer, a common intervention, may be subject to healthcare disparities. In mechanically ventilated patients with sepsis, we hypothesize that disparities not disease related would be found between patients who were and were not transferred. Design: Retrospective cohort study. Setting: Nationwide Inpatient Sample, 2006–2012. Patients: Patients over 18 years old with a primary diagnosis of sepsis who underwent mechanical ventilation. Interventions: None. Measurements and Main Results: We obtained age, gender, length of stay, race, insurance coverage, do not resuscitate status, and Elixhauser comorbidities. The outcome used was interhospital transfer from a small- or medium-sized hospital to a larger acute care hospital. Of 55,208,382 hospitalizations, 46,406 patients met inclusion criteria. In the multivariate model, patients were less likely to be transferred if the following were present: older age (odds ratio, 0.98; 95% CI, 0.978–0.982), black race (odds ratio, 0.79; 95% CI, 0.70–0.89), Hispanic race (odds ratio, 0.79; 95% CI, 0.69–0.90), South region hospital (odds ratio, 0.79; 95% CI, 0.72–0.88), teaching hospital (odds ratio, 0.31; 95% CI, 0.28–0.33), and do not resuscitate status (odds ratio, 0.19; 95% CI, 0.15–0.25). Conclusions: In mechanically ventilated patients with sepsis, we found significant disparities in race and geographic location not explained by medical diagnoses or illness severity.