Critical thinking, curiosity and parsimony in (emergency) medicine:‘Doing nothing’ as a quality measure?

Current medical decision-making is influenced by many factors, such as competing interests, distractions, as well as fear of missing an important diagnosis. This can result in ordering tests or providing treatments that can be harmful. Unnecessary tests are more likely to lead to false positive diagnosis or incidental findings that are of uncertain clinical relevance. Estimates indicate that almost one-third of all health spending is wasteful. The ‘Choosing Wisely’ campaign has identified many of these wasteful tests and treatments. This perspective proposes some suggestions to focus on our critical thinking, embrace shared decision-making and stay curious about the patient we are treating. Most importantly, ‘doing nothing’ could be a quality indicator for EDs, and ACEM supported audits and research to develop benchmarks for certain tests and procedures in the ED are important to achieve a cultural change.Griffith Health, School of MedicineNo Full Tex

Do you really know your consumers? : analyzing the impact of consumer knowledge on use and failure evaluation of consumer electronics

The field of Consumer Electronics (CE) can be characterized by continuous technological innovation, fierce global competition, strong pressure on time-to-market, fast adoption cycles and increasingly complex business processes. In this context it is increasingly challenging for product designers and developers to provide products with unique features and excellent price / performance characteristics, as well as having to provide products that meet all the consumer’s expectations. From a business perspective, research has shown that the number of consumer complaints and even product returns is increasing for complex CE (Den Ouden, 2006). Further research on the causes of these complaints showed that almost half of the complaints were due to non-technical reasons. Therefore, more insight is needed into product quality and reliability from a consumer point of view. A literature review showed that quality and reliability methods that are currently used in product development insufficiently prevent the large variety of consumer complaints: the number of consumer complaints is rising while at the same time the root cause of these complaints is more difficult to retrace. Product failures need to be measured and analyzed from a consumer’s point of view since the traditional fault-complaint propagation model fails to capture all potential sources of consumer complaints. More insight is needed into the relation between the diversity of consumers and the propagation of product development faults to these "Consumer-Perceived Failures" (CPFs).A conceptual framework was developed to model the underlying factors related to the propagation of product development faults to consumer complaints from a consumer point of view. This framework is based on insights from human-computer interaction and consumer behavior literature and the results of an explorative experiment. Furthermore, the most commonly used consumer selection criteria for consumer tests based on demographics and/or product adoption related characteristics do not sufficiently cover differences in CPFs. The consumer characteristic "consumer knowledge" is hypothesized to have a strong impact on differences in the underlying variables of this framework. A review of relevant consumer models and consumer characteristics used in human-computer interaction and consumer behavior research shows that this construct relates to cognitive structures consumers have about a product’s functioning as well as cognitive processes needed to use a complex CE product. This dissertation therefore aimed to investigate the hypothesized effect of consumer knowledge on two important variables of the conceptual framework: product usage behavior and failure attribution. By using multiple surveys, two laboratory experiments and a web-based experiment, the following aspects of the conceptual framework were investigated in this dissertation: • How and to what extent consumers can be differentiated on knowledge of complex CE • The effect of consumer knowledge on differences in product usage behavior • The effect of consumer knowledge on differences in attribution of product failures The results of the surveys to differentiate consumers on knowledge (both core and supplemental domains) of innovative LCD televisions demonstrated the successful development and validation of measurements of both subjective and objective measurements of expertise and familiarity. It was concluded that the selection of consumer knowledge constructs as criterion for differentiating consumers for a consumer test depends on the target consumer group for a product (e.g. a very narrow homogeneous consumer group versus mass consumer markets), the type of product (e.g. passive versus active interaction) and the goal of the consumer test. The laboratory experiment which investigated the effect of subjective expertise and objective familiarity on product usage behavior showed that higher levels of subjective expertise on both the television and computer domain result in significantly better effectiveness and efficiency and less interaction problems when performing complex product related tasks. Next, the results also showed that differences in subjective expertise stronger relate to differences in product usage behavior than those in objective familiarity. The findings of this study help product developers and designers to better understand differences in product usage behavior when consumers encounter interaction problems and can therefore help the product designers and developers to take better design decisions.The results of both failure attribution experiments with simulated failure scenarios of picture quality failures in an LCD television showed that only objective expertise differences affect differences in consumer perception of product failures. However, although the failure attribution of consumers with higher levels of objective expertise has more dimensions and is more refined, higher levels of objective expertise on a product do not automatically result in attributions that are more in accordance with the real physical cause of the failure. This has important implications because currently used test methods often differentiate consumers only on previous experience (i.e. familiarity) with a product. The results of both studies also demonstrated that both failure cause and failure impact do not significantly affect how consumers attribute the failures. In total it can be concluded that, when evaluating the effect of consumer diversity on fault-complaint propagation, consumer knowledge can be used to differentiate product use and failure attribution for complex CE. However, it should be noted that especially for failure attribution this effect is not consistent across different types of failures. In addition, compared to objective and subjective familiarity and subjective expertise, objective expertise has the strongest impact. In the context of fast evolving complex CE, objective expertise measurements are becoming increasingly important because familiarity or subjective expertise measurements on the (technical) functioning of currently available products can quickly become "incorrect" or "incomplete" for the next generation of products. These insights can support product designers and developers to make the right design decisions to enhance consumer satisfaction

What is the effect of a formalised trauma tertiary survey procedure on missed injury rates in multi-trauma patients? Study protocol for a randomised controlled trial

Background: Missed injury is commonly used as a quality indicator in trauma care. The trauma tertiary survey (TTS) has been proposed to reduce missed injuries. However a systematic review assessing the effect of the TTS on missed injury rates in trauma patients found only observational studies, only suggesting a possible increase in early detection and reduction in missed injuries, with significant potential biases. Therefore, more robust methods are necessary to test whether implementation of a formal TTS will increase early in-hospital injury detection, decrease delayed diagnosis and decrease missed injuries after hospital discharge. Methods/Design: We propose a cluster-randomised, controlled trial to evaluate trauma care enhanced with a formalised TTS procedure. Currently, 20 to 25% of trauma patients routinely have a TTS performed. We expect this to increase to at least 75%. The design is for 6,380 multi-trauma patients in approximately 16 hospitals recruited over 24 months. In the first 12 months, patients will be randomised (by hospital) and allocated 1:1 to receive either the intervention (Group 1) or usual care (Group 2). The recruitment for the second 12 months will entail Group 1 hospitals continuing the TTS, and the Group 2 hospitals beginning it to enable estimates of the persistence of the intervention. The intervention is complex: implementation of formal TTS form, small group education, and executive directive to mandate both. Outcome data will be prospectively collected from (electronic) medical records and patient (telephone follow-up) questionnaires. Missed injuries will be adjudicated by a blinded expert panel. The primary outcome is missed injuries after hospital discharge; secondary outcomes are maintenance of the intervention effect, in-hospital missed injuries, tertiary survey performance rate, hospital and ICU bed days, interventions required for missed injuries, advanced diagnostic imaging requirements, readmissions to hospital, days of work and quality of life (EQ-5D-5 L) and mortality. Discussion: The findings of this study may alter the delivery of international trauma care. If formal TTS is (cost-) effective this intervention should be implemented widely. If not, where already partly implemented, it should be abandoned. Study findings will be disseminated widely to relevant clinicians and health funders.Griffith Health, School of MedicineFull Tex

Survey of paediatric intravenous fluid prescription: Are we safe in what we know and what we do?

Objective: The administration of i.v. fluids to children is common in hospital. There are risks associated with fluid therapy, especially iatrogenic hyponatraemia. The objective of this study was to assess the workplace practices and knowledge of tertiary hospital doctors regarding paediatric i.v. fluid prescription. Methods: This is a prospective, questionnaire-based observational study conducted at a 570-bed teaching hospital in June 2009. A convenience sample of doctors (n = 150), representing all levels of experience and all specialties that regularly prescribe paediatric i.v. fluids, were invited to participate. The main outcome measures consisted of demographical data and the ability to correctly prescribe paediatric fluids measured as 'fluid calculation', 'fluid choice' and 'total' percentage scores based on a percentage score of correctly answered questions using eight clinical scenarios. Results: One hundred and six (71%) doctors returned a completed questionnaire. The great majority of respondents had a method for calculating a fluid bolus and maintenance rates (91% and 97%, respectively). Scenarios involving infants, especially where an increased risk of antidiuretic hormone secretion was possible, were answered poorly. Senior doctors performed better than junior doctors. ED and paediatric doctors performed better than those in other specialities. Conclusions: Most doctors in this Australian tertiary hospital have a correct method for prescribing bolus and maintenance fluid rates. However, the potential for adverse events from i.v. fluid prescription remains. Further education in this area for junior doctors, introduction of standardized guidelines for fluid use and restriction of available fluid choice may reduce the risk of iatrogenic hyponatraemia in children.No Full Tex

Doctors' knowledge of patient radiation exposure from diagnostic imaging requested in the emergency department

Objective: To assess emergency department (ED) doctors' knowledge of radiation doses associated with diagnostic imaging and to describe their practice with regard to informing patients of risk. Design, participants and setting: Prospective, questionnaire-based observational study in May 2009 among all 110 doctors in the EDs of a 570-bed teaching hospital and a 200-bed district hospital. Main outcome measures: Percentage knowledge score; and frequency of discussing radiation risk with patients, based on responses to three scenarios rated on a visual analogue scale (VAS), where a score of 100 indicates doctors would always discuss it. Results: 96 doctors (87%) completed the questionnaire. The overall mean knowledge score was 40% (95% CI, 38%-43%). Senior doctors scored somewhat higher than junior doctors, but not significantly (42% v 39%; P = 0.75). Over three-quarters of doctors (78%) underestimated the lifetime risk of fatal cancer attributable to a single computed tomography scan of the abdomen. Most doctors (76%) reported never having had any formal training on risks to patients from radiation exposure. The frequency at which doctors would inform patients of the risk of radiation varied greatly depending on the clinical scenario (mean VAS scores, between 38 and 90). Conclusion: Emergency doctors in our sample had a varied knowledge of the risks from radiation exposure, but overall knowledge was poor. Staff should receive education, and the diagnostic imaging request process may need to include information on radiation doses and risks.Griffith Health, School of MedicineFull Tex

Deliberate clinical inertia: Using meta-cognition to improve decision-making

Deliberate clinical inertia is the art of doing nothing as a positive response. To be able to apply this concept, individual clinicians need to specifically focus on their clinical decision-making. The skill of solving problems and making optimal clinical decisions requires more attention in medical training and should play a more prominent part of the medical curriculum. This paper provides suggestions on how this may be achieved. Strategies to mitigate common biases are outlined, with an emphasis on reversing a 'more is better' culture towards more temperate, critical thinking. To incorporate such an approach in medical curricula and in clinical practice, institutional endorsement and support is required

The thymus: when a rudimentary organ becomes active

Maastricht University Medical Centre is a specialist centre for the surgical treatment of thymomas and the treatment of the muscular disorder myasthenia gravis (MG). Thymoma removal by means of robotic surgery proved to be a safe and reliable treatment option based on an analysis of all patients who underwent a robotic thymectomy between April 2004 and April 2012. The study also examined the role of robotic thymectomy in the treatment of MG among 125 patients. This form of treatment appeared to be safe, with a low morbidity rate and mortality rate of zero. After a median follow-up study 33 months later, 77% of MG patients had improved neurological function and nearly 33% of patients were in remission. This study also describes the discovery of the human polyomavirus in 39 thymomas

The Effect of Mechanical Resonance on Josephson Dynamics

We study theoretically dynamics in a Josephson junction coupled to a mechanical resonator looking at the signatures of the resonance in d.c. electrical response of the junction. Such a system can be realized experimentally as a suspended ultra-clean carbon nanotube brought in contact with two superconducting leads. A nearby gate electrode can be used to tune the junction parameters and to excite mechanical motion. We augment theoretical estimations with the values of setup parameters measured in the samples fabricated. We show that charging effects in the junction give rise to a mechanical force that depends on the superconducting phase difference. The force can excite the resonant mode provided the superconducting current in the junction has oscillating components with a frequency matching the resonant frequency of the mechanical resonator. We develop a model that encompasses the coupling of electrical and mechanical dynamics. We compute the mechanical response (the effect of mechanical motion) in the regime of phase bias and d.c. voltage bias. We thoroughly investigate the regime of combined a.c. and d.c. bias where Shapiro steps are developed and reveal several distinct regimes characteristic for this effect. Our results can be immediately applied in the context of experimental detection of the mechanical motion in realistic superconducting nano-mechanical devices.Comment: 18 pages, 11 figure

Emergency department management of acute exacerbations of chronic obstructive pulmonary disease and factors associated with hospitalization

Background: Currently there is a paucity of information about biomarkers that can predict hospitalization for acute exacerbations of chronic obstructive pulmonary disease (AECOPD) patients presenting to the emergency department (ED). There is limited data on the consistency of ED management of AECOPD with local COPD guidelines. The aim of this study was to identify biomarkers associated with hospitalization in AECOPD patients and to determine if the ED management was concordant with local COPD guidelines. Materials and Methods: We performed a retrospective audit of consecutive AECOPD patients presenting to the Gold Coast Hospital ED over a 6-month period. Results: During the study period, 122 AECOPD patients (51% male, mean age (SE) 71 (±11) years) presented to the ED. Ninety-eight (80%) patients were hospitalized. Univariate analysis identified certain factors associated with hospitalization: Older age, former smokers, home oxygen therapy, weekday presentation, SpO 2 < 92%, and raised inflammatory markers (white cell count (WCC) and C-reactive protein (CRP)). After adjustment for multiple variable, increased age was significantly associated with hospitalization (odds ratio (OR) 1.09; 95% confidence interval (CI): 1.00-1.18; P = 0.05). Radiology assessment and pharmacological management was in accordance with COPD guidelines. However, spirometry was performed in 17% of patients and 28% of patients with hypercapneic respiratory failure received noninvasive ventilation (NIV). Conclusion: We identified several factors on univariate analysis that were associated with hospitalization. Further research is required to determine the utility of these biomarkers in clinical practice. Also, while overall adherence to local COPD guidelines was good, there is scope for improvement in performing spirometry and provision of NIV to eligible patients

"I was prepared to become infected as a frontline medical staff": a survey of Australian emergency department staff experiences during COVID-19

OBJECTIVE: To identify challenges faced by Australian hospital healthcare staff during the COVID‐19 pandemic. METHODS: We conducted an online survey (30 June–15 August 2020) of healthcare staff from Australian emergency and infectious disease departments. Participants were contacted via professional organisations and asked about preparedness, personal protective equipment (PPE), information flow, patient care, infection concerns, workload and mental health. We calculated the proportion of answers to yes/no and Likert‐style questions; free‐text responses were analysed thematically. RESULTS: Respondents (n = 162) were 23–67 years old, 98% worked in EDs, 68% were female, 87% from Queensland, and most worked as nurses (46%) or specialists (31%). Respondents felt their workplace was prepared for the pandemic (79%), had sufficient information about PPE (83%); none were sent home because of PPE shortages. Eighty‐five percent received sufficient information from official bodies and 50% were aware of the National COVID‐19 Clinical Evidence Taskforce guidelines. Most (83%) had sufficient information to provide optimal patient care, but 24% experienced unfair/abusive patient behaviour. Most (76%) were concerned about becoming infected by patients, 67% about infecting patients, and 78% about infecting someone at home. Workload decreased for 82% but 42% looked after more patients. Fifty‐seven percent experienced additional work‐related stress: 60% reporting experiencing anxiety and 53% experiencing burnout, with 36% and 46% continuing to experience these, respectively. Key challenges included: emotional, workplace/organisational, family/loved ones and PPE factors. CONCLUSION: The Australian system provided sufficient information and PPE. Staff experienced considerable stress, infection concerns and emotional challenges, which merit consideration in preparing for the future