42 research outputs found
Barriers to seeking emergency care during the COVID-19 pandemic may lead to higher morbidity and mortality â a retrospective study from a Swiss university hospital
AIMS OF THE STUDY
While COVID-19 significantly overburdens emergency rooms (ERs) and hospitals in affected areas, ERs elsewhere report a marked decrease in patient numbers. This study aimed to investigate the assumption that patients with urgent problems currently avoid the ER.
METHODS
Electronic health records from the ER of a large Swiss university hospital were extracted for three periods: first, the awareness phase (ap) from the publication of the national governmentâs initiative âHow to protect ourselvesâ on 1 March 2020 to the lockdown of the country on 16 March; second, the mitigation phase (mp) from 16â30 March; finally, patients presenting in March 2019 were used as a control group. We compared parameters including a critical illness as the discharge diagnosis (e.g., myocardial infarction, stroke, sepsis and ER death) using logistic and linear regression, as well as 15-day bootstrapped means and 95% confidence intervals for the control group.
RESULTS
In the three periods, a total of 7143 patients were treated. We found a 24.9% (42.5%) significant decline in the number of patients presenting during the ap (mp). Patients presenting during the mp were more likely to be critically ill. There was an increase of 233% and 367% (ap and mp, respectively) of ER deaths (none related to COVID-19) compared to the control period. Apart from polytrauma (increase of 5% in the mp), all other critical illnesses as discharge diagnosis showed a lower incidence in descriptive analysis. Significantly more patients died in the ER in both the ap and mp.
CONCLUSIONS
Barriers to seeking emergency care during COVID-19 pandemic may lead to higher morbidity and mortality. Healthcare authorities and hospitals must ensure low barriers to treatment and business as usual for all patients
Exploring objective measures for assessing team performance in healthcare: an interview study.
INTRODUCTION
Effective teamwork plays a critical role in achieving high-performance outcomes in healthcare. Consequently, conducting a comprehensive assessment of team performance is essential for providing meaningful feedback during team trainings and enabling comparisons in scientific studies. However, traditional methods like self-reports or behavior observations have limitations such as susceptibility to bias or being resource consuming. To overcome these limitations and gain a more comprehensive understanding of team processes and performance, the assessment of objective measures, such as physiological parameters, can be valuable. These objective measures can complement traditional methods and provide a more holistic view of team performance. The aim of this study was to explore the potential of the use of objective measures for evaluating team performance for research and training purposes. For this, experts in the field of research and medical simulation training were interviewed to gather their opinions, ideas, and concerns regarding this novel approach.
METHODS
A total of 34 medical and research experts participated in this exploratory qualitative study, engaging in semi-structured interviews. During the interview, experts were asked for (a) their opinion on measuring team performance with objective measures, (b) their ideas concerning potential objective measures suitable for measuring team performance of healthcare teams, and (c) their concerns regarding the use of objective measures for evaluating team performance. During data analysis responses were categorized per question.
RESULTS
The findings from the 34 interviews revealed a predominantly positive reception of the idea of utilizing objective measures for evaluating team performance. However, the experts reported limited experience in actively incorporating objective measures into their training and research. Nevertheless, they identified various potential objective measures, including acoustical, visual, physiological, and endocrinological measures and a time layer. Concerns were raised regarding feasibility, complexity, cost, and privacy issues associated with the use of objective measures.
DISCUSSION
The study highlights the opportunities and challenges associated with employing objective measures to assess healthcare team performance. It particularly emphasizes the concerns expressed by medical simulation experts and team researchers, providing valuable insights for developers, trainers, researchers, and healthcare professionals involved in the design, planning or utilization of objective measures in team training or research
Is language an issue? Accuracy of the German computerized diagnostic decision support system ISABEL and cross-validation with the English counterpart.
OBJECTIVES
Existing computerized diagnostic decision support tools (CDDS) accurately return possible differential diagnoses (DDx) based on the clinical information provided. The German versions of the CDDS tools for clinicians (Isabel Pro) and patients (Isabel Symptom Checker) from ISABEL Healthcare have not been validated yet.
METHODS
We entered clinical features of 50 patient vignettes taken from an emergency medical text book and 50 real cases with a confirmed diagnosis derived from the electronic health record (EHR) of a large academic Swiss emergency room into the German versions of Isabel Pro and Isabel Symptom Checker. We analysed the proportion of DDx lists that included the correct diagnosis.
RESULTS
Isabel Pro and Symptom Checker provided the correct diagnosis in 82 and 71âŻ% of the cases, respectively. Overall, the correct diagnosis was ranked in 71âŻ, 61 and 37âŻ% of the cases within the top 20, 10 and 3 of the provided DDx when using Isabel Pro. In general, accuracy was higher with vignettes than ED cases, i.e. listed the correct diagnosis more often (non-significant) and ranked the diagnosis significantly more often within the top 20, 10 and 3. On average, 38 ± 4.5 DDx were provided by Isabel Pro and Symptom Checker.
CONCLUSIONS
The German versions of Isabel achieved a somewhat lower accuracy compared to previous studies of the English version. The accuracy decreases substantially when the position in the suggested DDx list is taken into account. Whether Isabel Pro is accurate enough to improve diagnostic quality in clinical ED routine needs further investigation
Use of epinephrine in anaphylaxis: a retrospective cohort study at a Swiss university emergency department.
AIMS OF THE STUDY
Anaphylaxis is a medical emergency and requires prompt treatment to prevent life-threatening conditions. Epinephrine, considered as the first-line drug, is often not administered. We aimed first to analyse the use of epinephrine in patients with anaphylaxis in the emergency department of a university hospital and secondly to identify factors that influence the use of epinephrine.
METHODS
We performed a retrospective analysis of all patients admitted with moderate or severe anaphylaxis to the emergency department between 1 January 2013 and 31 December 2018. Patient characteristics and treatment information were extracted from the electronic medical database of the emergency department.
RESULTS
A total of 531 (0.2%) patients with moderate or severe anaphylaxis out of 260,485 patients admitted to the emergency department were included. Epinephrine was administered in 252 patients (47.3%). In a multivariate logistic regression, cardiovascular (Odds Ratio [OR] = 2.94, CI 1.96-4.46, p <0.001) and respiratory symptoms (OR = 3.14, CI 1.95-5.14, p<0.001) were associated with increased likelihood of epinephrine administration, in contrast to integumentary symptoms (OR = 0.98, CI 0.54-1.81, p = 0.961) and gastrointestinal symptoms (OR = 0.62, CI 0.39-1.00, p = 0.053).
CONCLUSIONS
Less than half of the patients with moderate and severe anaphylaxis received epinephrine according to guidelines. In particular, gastrointestinal symptoms seem to be misrecognised as serious symptoms of anaphylaxis. Training of the emergency medical services and emergency department medical staff and further awareness are crucial to increase the administration rate of epinephrine in anaphylaxis
a prospective observational study
Introduction Emergency rooms (ERs) generally assign a preliminary diagnosis to
patients, who are then hospitalised and may subsequently experience a change
in their lead diagnosis (cDx). In ERs, the cDx rate varies from around 15% to
more than 50%. Among the most frequent reasons for diagnostic errors are
cognitive slips, which mostly result from faulty data synthesis. Furthermore,
physicians have been repeatedly found to be poor self-assessors and to be
overconfident in the quality of their diagnosis, which limits their ability to
improve. Therefore, some of the clinically most relevant research questions
concern how diagnostic decisions are made, what determines their quality and
what can be done to improve them. Research that addresses these questions is,
however, still rare. In particular, field studies that allow for generalising
findings from controlled experimental settings are lacking. The ER, with its
high throughput and its many simultaneous visits, is perfectly suited for the
study of factors contributing to diagnostic error. With this study, we aim to
identify factors that allow prediction of an ER's diagnostic performance.
Knowledge of these factors as well as of their relative importance allows for
the development of organisational, medical and educational strategies to
improve the diagnostic performance of ERs. Methods and analysis We will
conduct a field study by collecting diagnostic decision data, physician
confidence and a number of influencing factors in a real-world setting to
model real-world diagnostic decisions and investigate the adequacy, validity
and informativeness of physician confidence in these decisions. We will
specifically collect data on patient, physician and encounter factors as
predictors of the dependent variables. Statistical methods will include
analysis of variance and a linear mixed-effects model. Ethics and
dissemination The Bern ethics committee approved the study under KEK Number
197/15. Results will be published in peer-reviewed scientific medical
journals. Authorship will be determined according to ICMJE guidelines. Trial
registration number The study protocol Version 1.0 from 17 May 2015 is
registered in the Inselspital Research Database Information System (IRDIS) and
with the IRB (âKantonale Ethikkomissionâ) Bern under KEK Number 197/15
On the role of biomedical knowledge in the aquisition of clinical knowledge
Die universitĂ€re Ausbildung von Ărztinnen und Ărzten ist einem deutlichen
Wandel unterworfen. Die damit einhergehenden Umstrukturierungen der
humanmedizinischen StudiengÀnge betreffen auch die Rolle der sogenannten
âvorklinischenâ, also grundlagenwissenschaftlichen FĂ€cher wie der Anatomie,
der Biochemie oder der Physiologie. So legen internationale Studien nahe, dass
die EinfĂŒhrung von reformierten StudiengĂ€ngen mit einer Verminderung des
Unterrichtsvolumens von FĂ€chern wie der Anatomie einherging. Parallell zu
diesen VerÀnderungen etablierte sich eine bis heute andauernde Diskussion um
die Funktion vorklinischen Wissens fĂŒr den Aufbau und Erhalt von klinischem
Wissen und Denken. Auch wenn keinesfalls der Wert der Grundlagenwissenschaften
insgesamt angezweifelt wurde, gibt es verschiedene Standpunkte zur Relevanz
dieser grundlagenwissenschaftlichen Inhalte in der Wissensentwicklung von
Studierenden der Humanmedizin. Die hier vorgelegte Arbeit greift die zuvor
skizzierte Diskussion auf, und setzt sich mit der Frage auseinander, in
wieweit vorklinisches Wissen mit der Entwicklung klinischen Wissens in
Verbindung steht. In einer prospektiven LĂ€ngsschnittstudie wurden
Leistungsdaten von 598 Studierenden eines traditionellen Studiengangs
(âRegelstudiengangâ) analysiert. Die hier ausgewerteten Daten wurden ĂŒber zwei
Jahre verteilt an vier Messzeitpunkten erhoben. Untersucht wurde die
Entwicklung zwischen dem ersten und dem vierten klinischen Semester. Zur
Modellierung der Wechselbeziehung zwischen Leistungen im
grundlagenwissenschaftlichen Bereich einerseits und Entwicklung und Aufbau von
klinischen Inhalten andererseits, wurden lineare Strukturgleichungsmodelle
(\textit{Dual Change Score Models}) verwendet. Deskriptiv zeigen die Daten,
beginnend mit dem ersten klinischen Semester, einen Abfall der Leistungen im
vorklinischen Bereich und einen Zuwachs an Leistungen im klinischen Bereich.
Der statistische Vergleich verschiedener Strukturgleichungsmodelle legen den
Schluss nahe, dass ein Modell die Daten am besten beschreibt, in dem frĂŒhere
Niveaus im vorklinischen Bereich mit LeistungsverÀnderung im klinischen
Bereich assoziiert sind. Allerdings ist dieser Zusammenhang negativ
ausgeprÀgt: Bessere Leistungen im vorklinischen Bereich sind mit geringeren
ZuwĂ€chsen im klinischen Bereich verknĂŒpft. Auch wenn diese Analysen eine
negative Beziehung zeigen, so sind diese aufgrund des korrelativen Charakters
der Untersuchung nicht als kausale Wechselwirkungen interpretierbar. Dennoch
lieĂe sich dieses Beziehungsmuster auch mit Befunden aus der
lernpsychologischen Forschung, in etwa solcher zu negativem Transfer,
erklĂ€ren. AbschlieĂend lĂ€sst sich sagen, dass die vorgelegten Befunde auf die
Notwendigkeit zur weiterfĂŒhrenden Auseinandersetzung mit der Integration von
grundlagenwissenschaftlichen Inhalten und ihrer klinischer Anwendung
hindeuten.Basic science education in undergraduate medical education faces several
challenges. One prominent discussion is focused on the relevance of biomedical
knowledge for the development and integration of clinical knowledge. Although
the value of basic science knowledge is generally emphasized, several
theoretical positions differ on the relative role of this knowledge and the
optimal approach for its instruction. In the present paper we address the
specific question whether and to which extent biomedical knowledge is related
to the development of clinical knowledge. We analyse repeated measure data of
performances on basic science and clinical knowledge assessments. A sample of
N=598 medical students from a traditional curriculum participated in the
study. Overall a developmental phase of 2 years of medical education was
covered. Structural equation modelling was used to analyse the temporal
relation between biomedical knowledge and the acquisition of clinical
knowledge. At the end of formal basic science education and the beginning of
the clinical phase, students show the highest levels of biomedical knowledge.
Our data suggests a decline in basic science knowledge which is complemented
by a growth of clinical knowledge. Statistical comparison of several
structural equation models revealed that a model specifying unidirectional
relations from earlier states of biomedical knowledge to subsequent changes in
clinical knowledge explained the data best. However, the parameter estimates
indicate that this association is negative. Our analysis suggests a negative
relation between earlier levels of basic science knowledge and subsequent
gains in clinical knowledge. We discuss limitations of our study such as the
given educational context and the non-experimental nature. Although our
results do not necessarily contradict the relevance of basic sciences we
speculate on mechanisms that might be related to our findings. We conclude
that our results hint at possibly critical issues in basic science education
that have been rarely addressed thus far
A validity argument for progress testing: Examining the relation between growth trajectories obtained by progress tests and national licensing examinations using a latent growth curve approach
Background: Progress testing is a longitudinal assessment that aims at tracking students' development of knowledge. This approach is used in many medical schools internationally. Although progress tests are longitudinal in nature, and their focus and use of developmental aspects is a key advantage, individual students' learning trajectories themselves play, to date, only a minor role in the use of the information obtained through progress testing. Methods: We investigate in how far between-person differences in initial levels of performance and within-person rate of growth can be regarded as distinct components of students' development and analyze the extent to which these two components are related to performances on national licensing examinations using a latent growth curve model. Results: Both, higher initial levels of performances and steepness of growth are positively related to long-term outcomes as measured by performance on national licensing examinations. We interpret these findings as evidence for progress tests' suitability to monitor students' growth of knowledge across the course of medical training. Conclusions: This study indicates that individual development as obtained by formative progress tests is related to performance in high-stakes assessments. Future studies may put more focus on the use of between-persons differences in growth of knowledge
How sure can we be that a student really failed? On the measurement precision of individual pass-fail decisions from the perspective of Item Response Theory
Background
In high-stakes assessments in medical education, the decision to let a particular participant pass or fail has far-reaching consequences. Reliability coefficients are usually used to support the trustworthiness of assessments and their accompanying decisions. However, coefficients such as Cronbachâs Alpha do not indicate the precision with which an individualâs performance was measured.
Objective
Since estimates of precision need to be aligned with the level on which inferences are made, we illustrate how to adequately report the precision of pass-fail decisions for single individuals.
Method
We show how to calculate the precision of individual pass-fail decisions using Item Response Theory and illustrate that approach using a real exam. In total, 70 students sat this exam (110 items). Reliability coefficients were above recommendations for high stakes test (> 0.80). At the same time, pass-fail decisions around the cut score were expected to show low accuracy.
Conclusions
Our results illustrate that the most important decisionsâi.e. those based on scores near the pass-fail cut-scoreâare often ambiguous, and that reporting a traditional reliability coefficient is not an adequate description of the uncertainty encountered on an individual level
No knowledge gap in human physiology after remote teaching for second year medical students throughout the Covid-19 pandemic
Abstract The COVID-19 pandemic had a disruptive effect on higher education. A critical question is whether these changes affected studentsâ learning outcomes. Knowledge gaps have consequences for future learning and mayâin health professionals' educationâalso pose a threat to patient safety. Current research has shortcomings and does not allow for clear-cut interpretation. Our context is instruction in human physiology in an undergraduate medical program from high stakes end of term examinations. The sequence of imposed measures to slow the COVID-19 pandemic created a natural experiment, allowing for comparisons in performance during in-person versus remote instruction. In a two-factorial design, mode of instruction (in-person vs. remote) and mode of assessment (in-person vs. remote) were analyzed using both basic (non-parametric statistics, T-tests) and advanced statistical methods (linear mixed-effects model; resampling techniques). Test results from a total of Nâ=â1095Â s-year medical students were included in the study. We did not find empirical evidence of knowledge gaps; rather, students received comparable or higher scores during remote teaching. We interpret these findings as empirical evidence that both students and teachers adapted to pandemic disruption in a way that did not lead to knowledge gaps. We conclude that highly motivated students had no reduction in academic achievement. Moreover, we have developed an accessible digital exam system for secure, fair, and effective assessments which is sufficiently defensible for making pass/fail decisions