Supervision and feedback for junior medical staff in Australian emergency departments: findings from the emergency medicine capacity assessment study

<p>Abstract</p> <p>Background</p> <p>Clinical supervision and feedback are important for the development of competency in junior doctors. This study aimed to determine the adequacy of supervision of junior medical staff in Australian emergency departments (EDs) and perceived feedback provided.</p> <p>Methods</p> <p>Semi-structured telephone surveys sought quantitative and qualitative data from ED Directors, Directors of Emergency Medicine Training, registrars and interns in 37 representative Australian hospitals; quantitative data were analysed with SPSS 15.0 and qualitative data subjected to content analysis identifying themes.</p> <p>Results</p> <p>Thirty six of 37 hospitals took part. Of 233 potential interviewees, 95 (40.1%) granted interviews including 100% (36/36) of ED Directors, and 96.2% (25/26) of eligible DEMTs, 24% (19/81) of advanced trainee/registrars, and 17% (15/90) of interns. Most participants (61%) felt the ED was adequately supervised in general and (64.2%) that medical staff were adequately supervised. Consultants and registrars were felt to provide most intern supervision, but this varied depending on shift times, with registrars more likely to provide supervision on night shift and at weekends. Senior ED medical staff (64%) and junior staff (79%) agreed that interns received adequate clinical supervision. Qualitative analysis revealed that good processes were in place to ensure adequate supervision, but that service demands, particularly related to access block and overcrowding, had detrimental effects on both supervision and feedback.</p> <p>Conclusions</p> <p>Consultants appear to provide the majority of supervision of junior medical staff in Australian EDs. Supervision and feedback are generally felt to be adequate, but are threatened by service demands, particularly related to access block and ED overcrowding.</p

Perceptions of nurse practitioners by emergency department doctors in Australia

BACKGROUND: The Australian Medical Association is strongly opposed to the nurse practitioner (NP) role with concerns that NPs may become doctor substitutes without the requisite training and education that the medical role demands. Despite this, NPs have been heralded by some as a potential solution to the access block, workforce shortage and increased demand affecting emergency departments (EDs). AIMS: The purpose of this study was to determine the perception of NPs by medical staff working in Australian EDs. METHODS: Semi-structured telephone interviews were conducted with closed and open-ended questions. Participants were drawn from a representative stratified sample of two city, two metropolitan and two provincial hospitals of each State/Territory. RESULTS: A total of 95 doctors from 35 EDs participated in this study including 36 Departmental Directors; 36% of participating Directors indicated having an NP on staff. Doctors were strongly opposed to the statement that NPs could replace either nurses or other prevocational doctors; 71 interviewees commented on the role of NPs in the ED. Thematic analyses revealed polarised views held by doctors. Eight major themes were identified, the most common being that there is a lack of clarity of the NP role definition, their scope of practice and differentiation from the medical role. CONCLUSION: Although ED NPs represent a highly skilled professional group their role is poorly understood by ED doctors. Opposition to the NP role is a significant barrier to the introduction of great numbers of ED NPs as a strategy to overcome the medical workforce shortage. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1007/s12245-010-0214-8) contains supplementary material, which is available to authorized users

Light at the End of the Tunnel: A Technical Note on Thoracoscopic Repair of Congenital Diaphragmatic Hernia

Thoracoscopic repair of congenital diaphra­gmatic hernia (CDH) has been described by a number of authors and is increasingly widely practiced. We present a technical learning point. CDH is associated with the presence of a hernia sac in around 20% of all cases. In this case the presence of a ruptured hernia sac complicated the thoracoscopic repair of a left sided CDH, as it was initially difficult to recognise. Once the anatomy was clarified the repair was satisfactorily completed and the child made a rapid postoperative recovery. This technical note is to warn other surgeons that a tunnel like appearance of the diaphragmatic defect may in fact be due to the presence of a torn hernia sac, which requires excision before closure of the defect

Thigh-length compression stockings and DVT after stroke

Controversy exists as to whether neoadjuvant chemotherapy improves survival in patients with invasive bladder cancer, despite randomised controlled trials of more than 3000 patients. We undertook a systematic review and meta-analysis to assess the effect of such treatment on survival in patients with this disease

Risk of incomplete pyloromyotomy and mucosal perforation in open and laparoscopic pyloromyotomy

BackgroundDespite randomized controlled trials and meta-analyses, it remains unclear whether laparoscopic pyloromyotomy (LP) carries a higher risk of incomplete pyloromyotomy and mucosal perforation compared with open pyloromyotomy (OP).MethodsMulticenter study of all pyloromyotomies (May 2007–December 2010) at nine high-volume institutions. The effect of laparoscopy on the procedure-related complications of incomplete pyloromyotomy and mucosal perforation was determined using binomial logistic regression adjusting for differences among centers.ResultsData relating to 2830 pyloromyotomies (1802 [64%] LP) were analyzed. There were 24 cases of incomplete pyloromyotomy; 3 in the open group (0.29%) and 21 in the laparoscopic group (1.16%). There were 18 cases of mucosal perforation; 3 in the open group (0.29%) and 15 in the laparoscopic group (0.83%). The regression model demonstrated that LP was a marginally significant predictor of incomplete pyloromyotomy (adjusted difference 0.87% [95% CI 0.006–4.083]; P = 0.046) but not of mucosal perforation (adjusted difference 0.56% [95% CI ? 0.096 to 3.365]; P = 0.153). Trainees performed a similar proportion of each procedure (laparoscopic 82.6% vs. open 80.3%; P = 0.2) and grade of primary operator did not affect the rate of either complication.ConclusionsThis is one of the largest series of pyloromyotomy ever reported. Although laparoscopy is associated with a statistically significant increase in the risk of incomplete pyloromyotomy, the effect size is small and of questionable clinical relevance. Both OP and LP are associated with low rates of mucosal perforation and incomplete pyloromyotomy in specialist centers, whether trainee or consultant surgeons perform the procedure

Azithromycin in patients admitted to hospital with COVID-19 (RECOVERY): a randomised, controlled, open-label, platform trial

Background Azithromycin has been proposed as a treatment for COVID-19 on the basis of its immunomodulatory actions. We aimed to evaluate the safety and efficacy of azithromycin in patients admitted to hospital with COVID-19. Methods In this randomised, controlled, open-label, adaptive platform trial (Randomised Evaluation of COVID-19 Therapy [RECOVERY]), several possible treatments were compared with usual care in patients admitted to hospital with COVID-19 in the UK. The trial is underway at 176 hospitals in the UK. Eligible and consenting patients were randomly allocated to either usual standard of care alone or usual standard of care plus azithromycin 500 mg once per day by mouth or intravenously for 10 days or until discharge (or allocation to one of the other RECOVERY treatment groups). Patients were assigned via web-based simple (unstratified) randomisation with allocation concealment and were twice as likely to be randomly assigned to usual care than to any of the active treatment groups. Participants and local study staff were not masked to the allocated treatment, but all others involved in the trial were masked to the outcome data during the trial. The primary outcome was 28-day all-cause mortality, assessed in the intention-to-treat population. The trial is registered with ISRCTN, 50189673, and ClinicalTrials.gov, NCT04381936. Findings Between April 7 and Nov 27, 2020, of 16 442 patients enrolled in the RECOVERY trial, 9433 (57%) were eligible and 7763 were included in the assessment of azithromycin. The mean age of these study participants was 65·3 years (SD 15·7) and approximately a third were women (2944 [38%] of 7763). 2582 patients were randomly allocated to receive azithromycin and 5181 patients were randomly allocated to usual care alone. Overall, 561 (22%) patients allocated to azithromycin and 1162 (22%) patients allocated to usual care died within 28 days (rate ratio 0·97, 95% CI 0·87–1·07; p=0·50). No significant difference was seen in duration of hospital stay (median 10 days [IQR 5 to >28] vs 11 days [5 to >28]) or the proportion of patients discharged from hospital alive within 28 days (rate ratio 1·04, 95% CI 0·98–1·10; p=0·19). Among those not on invasive mechanical ventilation at baseline, no significant difference was seen in the proportion meeting the composite endpoint of invasive mechanical ventilation or death (risk ratio 0·95, 95% CI 0·87–1·03; p=0·24). Interpretation In patients admitted to hospital with COVID-19, azithromycin did not improve survival or other prespecified clinical outcomes. Azithromycin use in patients admitted to hospital with COVID-19 should be restricted to patients in whom there is a clear antimicrobial indication. Funding UK Research and Innovation (Medical Research Council) and National Institute of Health Research