28 e-Letters

published between 2017 and 2020

  • The éléphant in the room

    We thank the French Society of Emergency Medicine for such a large study. However it is difficult to conclude regarding a number of limitations due to the observational cross-sectional study scheme.
    The main critics concern the 3 measurements tools allowing to decide appropriateness of ED visits or not. Appropriate Use Score Method: the authors decide a cut-off based on Italian litterature data which is not French sounded; Possible GP Use Method : it would be more accurate to have an external evaluation instead of a judge and part one ; Resource Utilisation Method : the elephant in the room is the result of consultation and the final diagnostic as well.
    I don’t discuss here the relevance of a number of items as distance between home and ED Departments, medical density and so far.
    Specifically I doubt it is possible to interpret socioeconomic and territorial factors results without diagnostics and diagnostic frequency on June, 11, 2013
    We are looking forward for more studies informing use of ED departments.

  • Specialty differences in patient experience results: The patients or the doctors?

    As a non-physician often working as a researcher with physicians, I didn't know whether to laugh or cry at the explanation in this article as to why certain specialties might get lower patient satisfaction scores than internists. Yes, it may well be that the episodic nature of the encounter with a non-chosen physician leads to lower satisfaction. But given the long history of jokes within medicine based on the personality type differences among specialties, and, one would think, given the authors' personal experiences in say, their last dermatology appointment, might not differences among doctors rather than patient issues be at least be presented as a hypothesis? The briefest of Googling finds a post in the KevinMD blog, directed towards physicians, on "remarkably distinct" cultures. (The blog is here: https://www.kevinmd.com/blog/2018/07/what-personality-type-fits-your-med.... One of the literature links is here: https://onlinelibrary.wiley.com/doi/full/10.1111/j.1365-2923.2011.04099.x)

    I admire the question and rigor the researchers used in answering it. But, in the Discussion, simply assuming "differences in perception must be due to the patient" fails to meet the test of common sense.

  • The problem with non-clinical incident reports

    We can only reiterate the points brought forward by Carl Macrae in “The problem with incident reporting”. In our own work with incident reporting systems in the UK and Austria we observe that an estimated 50% of incident reports are eliminated without further consideration due to their non-clinical nature, even if they may affect patient safety. The remaining clinical reports are then pigeonholed to fit existing medical categories of expertise for further investigation. Hence, current incident reporting practices do not truly reflect the systemic complexities of medical errors, which are composed of both clinical and non-clinical elements. Incident reporting systems in healthcare need to either use more stringent reporting criteria to exclude non-clinical incidents upfront (even if they affect patient safety), but this would mean cutting themselves short of opportunities for whole system improvement. Alternatively, non-clinical reports should be further investigated to determine their potential contribution to (un)safe practice. This is likely to require the inclusion of non-clinical, organisational experts in the analysis of incident reports.

  • Authors response to comment by Maureen E. Burger

    We appreciate the concerns raised and agree that accurately presenting the findings of our study regarding patient-reported possible PICC-related complications is important. We took several steps to ensure transparency in how we presented our data. First, we were vigilant about consistently defining our outcomes as “possible complications” in all key areas of the paper including the main outcomes and conclusions section of the abstract, study measures section in the methods, main findings in the results section and in the discussion. The fact that the term “possible” or “potential” was not always used or some terms appeared to be used interchangeably was to improve readability of the article. In general, however, we were conscientious about clearly noting that we asked patients about signs or symptoms of a potential complication or adverse effect. Second, we purposefully chose to not present the data as complication rates (implying that these were actual events), but as the percentage of patients reporting a given event – thus we faithfully represented what we were told by patients during follow-up assessments. Third, we took these approaches because our primary objective was to accurately present the data collected from our patients; if something mattered enough to a patient to tell us about it, then it should matter to us as healthcare professionals regardless of internal standards that we may use to define serious medical complications. While that’s not to say that f...

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  • Optimal threshold of professional nurse staff and complementary staff needed to achieve optimal outcomes

    "What is needed now is an understanding of what is the threshold of professional nurse staff and complementary staff needed to achieve optimal outcomes, and how are these levels influenced by patient nursing acuity and the education, experience, organisation and work environment of the nurse workforce." --- I agree with you. Further, this study may be approached by Park's Optimized Nurse Staffing (Sweet Spot) Estimation Theory (Park, 2017): https://onlinelibrary.wiley.com/doi/full/10.1111/jan.13284. I am doing the research now.

  • Patient-reported complications related to peripherally inserted central catheters: a multicentre prospective cohort study

    Krein, et al (Patient-Reported Complications Related to Peripherally Inserted Central Catheters: A Multicenter Prospective Cohort Study; Feb 2019) should be commended for sharing the results of this very interesting study. After reading it a few times, I am compelled to share the following concerns with you and the research team. The knowledge regarding PICC-related complications is indeed incomplete, but I am not sure if the main outcome(s) of your study are clearly represented to the reader.

    The word “possible” is critical to correctly interpreting the results of this study. The term “complication” implies a medical diagnosis or medical confirmation – which your study attempted to do by conducting the chart reviews to confirm the presence or absence of a PICC complication, with limited success. Terms such as signs, symptoms, issues, adverse effects, and complications are used interchangeably throughout the paper to describe the patients’ self-reported experience, but without the benefit of operational definitions. These are not synonyms. Definitions help us to have a common understanding of a word or topic; they help us get on the same page when reading about an issue.

    The word “possible” seems appropriate in the main outcome(s) statement, but is curiously missing from the report title. The phrase “medical complications” is used in the title of Table 2 – which clearly reports predominantly patient self-reported symptoms. The same bias is exhibited...

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  • Beware the pitfalls of nudge theory

    O’Reilly-Shah et al. present a novel approach to quality improvement in anaesthesia by attempting to elicit change in practice using ‘nudge theory’ derived from the field of behavioural economics [1]. Translating new research evidence into common clinical practice is an important quality issue and cheap and effective strategies to achieve this are of interest. O’Reilly-Shah et al. hypothesised that using ‘nudge-type’ interventions, an audit-feedback dashboard as well as changes to mechanical ventilator default settings, might improve anaesthesia provider compliance with this ‘lung protective’ ventilation strategy in the general operating theatre environment.
    I disagree with the conclusion that the authors have drawn, that these interventions might improve clinical and financial outcomes. My disagreement stems from the clinical rationale of the intervention, which overlaps onto the assumptions built into the ‘nudge theory’ of behavioural economics itself.
    Sunstein & Thaler, who have influenced large scale policy making in several countries, describe nudge theory as a form of choice architecture that “alters people’s behaviour in a predictable way without forbidding any options or significantly changing their economic incentives” [2, 3]. Their philosophy is described as “libertarian paternalism”, as it influences choices that make people better off as judged by themselves, while preserving their freedom to choose otherwise. This is presumably what the interve...

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  • SPC and Complexity

    Conventional statistical process control (SPC) has limitations when used with hospital averse event (AE) data. Much data, especially hospital infections like bacteraemias, arise in complex systems.1 These differ from the simple or complicated industrial systems that produce data that are analysed with such success with conventional SPC. AE data arising in complex systems are often nonlinear. Expected values are often unknown. There is often delay in obtaining the AE data e.g. with bacteraemia data – the patient has symptoms, a blood sample is obtained, it is sent to pathology for culture, analysis and reporting and is finally placed in a suitable database then analysed (one of the benefits of conventional SPC is in providing rapid feedback so an industrial process that is going out of control is promptly identified). Most hospital AEs are relatively uncommon and alert staff such as those in Infection Management will frequently detect a change well before a statistical analysis. However, analysis using a time-series chart is still desirable. It can add confirmation to the observations of Infection Management and Quality Improvement staff. A hospital department can summarise its performance with a chart. Management and the public can be informed. A problem is devising control limits about an often non-existent expected value using a linear mean value that may be atypical of much of the data.

    How may this dilemma be overcome? The often changing predicted mean value can...

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  • External Validity Is Also an Ethical Consideration in Cluster-Randomized Trials of Policy Changes

    Hemming et al. (“Ethical Implications of Excessive Cluster Sizes in Cluster Randomized Trials,” 20 February 2018) cite the FIRST Trial as an example of a “higher risk” cluster-randomized trial in which large cluster sizes pose unjustifiable excess risk. The authors state, “[t]he obvious way to reduce the cluster size in this study is to reduce the duration of the trial…”

    We believe this to be an inappropriate recommendation stemming from an inaccurate appraisal of the FIRST Trial.

    The FIRST Trial was designed to inform a potential policy change in U.S. resident duty hours. In the Statistical Analysis Plan, which was made available at www.nejm.org, we clearly and prospectively stated that “[t]his study is a trial-based evaluation of potential policy effects on patient safety and resident wellbeing... this study is intended to inform real-world policy decision-making with respect to resident duty hours regulation.”[1] The SAP and Supplemental Appendix (www.nejm.org) also provides all assumptions for our power calculations and cluster sizes, which were not large in the case of resident outcomes.[2]

    As such, it was important that the trial closely resemble real-world conditions in which residency training occurs and duty hour policies are implemented. A shorter study would pose risks owing to non-standard, multiple policy shifts and would increase administrative/organizational bu...

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  • Physician Health in North America

    [This is a revision of a submission from earlier today that contains references.]

    To the editor:
    We read Weenink, et al.’s review of remediation and rehabilitation programs for healthcare professionals with interest.1 It is among the most systematic and certainly the most internationally focused reviews to date. The article noted, “the aim of these programs is two-fold: to help professionals with problems and to protect patients from professionals who are unable to perform adequately.” This important point is in direct alignment with the Federation of State Physician Health Program’s (FSPHP) philosophy of supporting our member programs in their mission of early detection of potentially impairing illness. As members of the leadership of the Federation of State Physician Health Programs (FSPHP), we laud this review and believe additional commentary is worthwhile.
    In the U.S. and Canada, each Physician Health Program (PHP) is unique in its scope of services, funding and the types of healthcare professionals served.2 In the U.S., we trace our roots back to a seminal paper that appeared in the Journal of the American Medical Association (AMA) in 1973.3 As Weenink, et al. noted, all programs provide services for professionals with substance use disorders and other mental health conditions. PHPs do not provide treatment, rather, we provide care coordination and monitoring for health professionals with impairing illness. The FSPHP brings together PHPs in the U....

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