Perceived potentially inappropriate treatment in the PICU: frequency, contributing factors and the distress it triggers

BackgroundPotentially inappropriate treatment in critically ill adults is associated with healthcare provider distress and burnout. Knowledge regarding perceived potentially inappropriate treatment amongst pediatric healthcare providers is limited.ObjectivesDetermine the frequency and factors associated with potentially inappropriate treatment in critically ill children as perceived by providers, and describe the factors that providers report contribute to the distress they experience when providing treatment perceived as potentially inappropriate.MethodsProspective observational mixed-methods study in a single tertiary level PICU conducted between March 2 and September 14, 2018. Patients 0–17 years inclusive with: (1) ≥1 organ system dysfunction (2) moderate to severe mental and physical disabilities, or (3) baseline dependence on medical technology were enrolled if they remained admitted to the PICU for ≥48 h, and were not medically fit for transfer/discharge. The frequency of perceived potentially inappropriate treatment was stratified into three groups based on degree of consensus (1, 2 or 3 providers) regarding the appropriateness of ongoing active treatment per enrolled patient. Distress was self-reported using a 100-point scale.ResultsOf 374 patients admitted during the study, 133 satisfied the inclusion-exclusion criteria. Eighteen patients (unanimous - 3 patients, 2 providers - 7 patients; single provider - 8 patients) were perceived as receiving potentially inappropriate treatment; unanimous consensus was associated with 100% mortality on 3-month follow up post PICU discharge. Fifty-three percent of providers experienced distress secondary to providing treatment perceived as potentially inappropriate. Qualitative thematic analysis revealed five themes regarding factors associated with provider distress: (1) suffering including a sense of causing harm, (2) conflict, (3) quality of life, (4) resource utilization, and (5) uncertainty.ConclusionsWhile treatment perceived as potentially inappropriate was infrequent, provider distress was commonly observed. By identifying specific factor(s) contributing to perceived potentially inappropriate treatment and any associated provider distress, organizations can design, implement and assess targeted interventions

Job satisfaction and its modeling among township health center employees: a quantitative study in poor rural China

<p>Abstract</p> <p>Background</p> <p>Job satisfaction is important to staff management of township health centers (THCs), as it is associated with organizational performance, quality of care and employee retention. The purpose of this study was to measure job satisfaction level of THC employees in poor rural China and to identify relevant features in order to provide policy advice on human resource development of health service institutions in poor regions.</p> <p>Methods</p> <p>A self-completion questionnaire was used to assess the job satisfaction and relevant features (response rate: 90.5%) among 172 employees (i.e., clinic doctors, medico-technical workers and public health workers) of 17 THCs in Anhui and Xinjiang provinces of China. The study covered a time period of two months in 2007.</p> <p>Results</p> <p>The mean staff job satisfaction scored 83.3, which was in the category of "somewhat satisfied" on a scale ranging from 0 (extremely dissatisfied) to 100 (extremely satisfied) by employing Likert's transformation formula. Exploratory factor analysis (EFA) revealed eight domains involved in modeling of job satisfaction, among which, the caregivers were more satisfied with job significance (88.2), job competency (87.9) and teamwork (87.7), as compared with work reward (72.9) and working conditions (79.7). Mean job satisfaction in Xinjiang (89.7) was higher than that in Anhui (75.5).</p> <p>Conclusions</p> <p>Employees of THCs have moderate job satisfactions in poor areas, which need to be raised further by improving their working conditions and reward.</p

Patient Safety in the Cardiac Operating Room: Human Factors and Teamwork: A Scientific Study from the American Heart Association

The cardiac surgical operating room (OR) is a complex environment in which highly trained subspecialists interact with each other using sophisticated equipment to care for patients with severe cardiac disease and significant comorbidities. Thousands of patient lives have been saved or significantly improved with the advent of modern cardiac surgery. Indeed, both mortality and morbidity for coronary artery bypass surgery have decreased during the past decade. Nonetheless, the highly skilled and dedicated personnel in cardiac ORs are human and will make errors. Refined techniques, advanced technologies, and enhanced coordination of care have led to significant improvements in cardiac surgery outcomes

A cluster randomised controlled trial of the clinical and cost-effectiveness of a 'whole systems' model of self-management support for the management of long- term conditions in primary care: trial protocol

BackgroundPatients with long-term conditions are increasingly the focus of quality improvement activities in health services to reduce the impact of these conditions on quality of life and to reduce the burden on care utilisation. There is significant interest in the potential for self-management support to improve health and reduce utilisation in these patient populations, but little consensus concerning the optimal model that would best provide such support. We describe the implementation and evaluation of self-management support through an evidence-based 'whole systems' model involving patient support, training for primary care teams, and service re-organisation, all integrated into routine delivery within primary care.MethodsThe evaluation involves a large-scale, multi-site study of the implementation, effectiveness, and cost-effectiveness of this model of self-management support using a cluster randomised controlled trial in patients with three long-term conditions of diabetes, chronic obstructive pulmonary disease (COPD), and irritable bowel syndrome (IBS). The outcome measures include healthcare utilisation and quality of life. We describe the methods of the cluster randomised trial.DiscussionIf the 'whole systems' model proves effective and cost-effective, it will provide decision-makers with a model for the delivery of self-management support for populations with long-term conditions that can be implemented widely to maximise 'reach' across the wider patient population.Trial registration numberISRCTN: ISRCTN9094004

The Inuit discovery of Europe? The Orkney Finnmen, preternatural objects and the re-enchantment of early-modern science.

The late-seventeenth century saw a peak in accounts of supposed encounters with ‘Finnmen’ in Orkney. These accounts have shaped the folklore of the Northern Isles. Scholars linked to the Royal Society suggested the accounts represented encounters with Inuit. Subsequent explanations included autonomous travel by Inuit groups and abduction and abandonment. These accounts should be understood as part of a European scientific tradition of preternatural philosophy, occupied with the deviations and errors of nature. Far from indicating the presence of Inuit individuals in Orkney waters, they provide evidence of the narrative instability of early-modern science and its habit of ‘thinking with things’. Captivated by Inuit artefacts, the natural philosophers and virtuosi of the Royal Society imagined Orkney as a site of reverse contact with the ‘primitive’. Nineteenth-century antiquarians and folklorists reliant on these texts failed to understand the extent to which objectivity was not an epistemic virtue in early-modern science

Effects of human disturbance on the diet composition of wild red deer (Cervus elaphus)

Disturbance from human recreational activities may affect the nutrition of free-ranging herbivores due to trade-offs between feeding in preferred habitats and perceived predation risk. To test this hypothesis, we estimated diet composition for red deer in the Scottish highlands in spring, when recreational activity tends to be high, and in winter when it is lower. We analysed faecal samples from three habitat types (grassland, heather moorland and woodland) collected at sites close to a busy track (disturbed) and at a distance from it (less disturbed). The diet consisted of 39% grasses, sedges, herbs and rushes (GSHR) and 58% Calluna vulgaris and Erica spp. (heather) in spring, compared with 14% grasses and 77% heather in winter, with small quantities of Vaccinium spp. (berry) and Pinus sylvestris (tree) in both seasons. In spring, faeces from disturbed grass and woodland sites indicated a diet with less GSHR and more heather and tree than faeces from less-disturbed sites, which could be due to an increased need for vigilance in exposed grassland and the need to seek cover. In contrast, faeces from all disturbed sites in winter indicated a diet with more GSHR and less heather than faeces from less-disturbed sites. This could be due to a seasonal decline in recreation and increase in hunting activity reversing the disturbance levels at the different sites, since hunting is not normally carried out in areas used by the public for recreation. We conclude that there may be nutritional benefits to deer of reducing disturbance near open grassland

Datasheet1_Perceived potentially inappropriate treatment in the PICU: frequency, contributing factors and the distress it triggers.docx

BackgroundPotentially inappropriate treatment in critically ill adults is associated with healthcare provider distress and burnout. Knowledge regarding perceived potentially inappropriate treatment amongst pediatric healthcare providers is limited.ObjectivesDetermine the frequency and factors associated with potentially inappropriate treatment in critically ill children as perceived by providers, and describe the factors that providers report contribute to the distress they experience when providing treatment perceived as potentially inappropriate.MethodsProspective observational mixed-methods study in a single tertiary level PICU conducted between March 2 and September 14, 2018. Patients 0–17 years inclusive with: (1) ≥1 organ system dysfunction (2) moderate to severe mental and physical disabilities, or (3) baseline dependence on medical technology were enrolled if they remained admitted to the PICU for ≥48 h, and were not medically fit for transfer/discharge. The frequency of perceived potentially inappropriate treatment was stratified into three groups based on degree of consensus (1, 2 or 3 providers) regarding the appropriateness of ongoing active treatment per enrolled patient. Distress was self-reported using a 100-point scale.ResultsOf 374 patients admitted during the study, 133 satisfied the inclusion-exclusion criteria. Eighteen patients (unanimous - 3 patients, 2 providers - 7 patients; single provider - 8 patients) were perceived as receiving potentially inappropriate treatment; unanimous consensus was associated with 100% mortality on 3-month follow up post PICU discharge. Fifty-three percent of providers experienced distress secondary to providing treatment perceived as potentially inappropriate. Qualitative thematic analysis revealed five themes regarding factors associated with provider distress: (1) suffering including a sense of causing harm, (2) conflict, (3) quality of life, (4) resource utilization, and (5) uncertainty.ConclusionsWhile treatment perceived as potentially inappropriate was infrequent, provider distress was commonly observed. By identifying specific factor(s) contributing to perceived potentially inappropriate treatment and any associated provider distress, organizations can design, implement and assess targeted interventions.</p