Gibbons C , Connolly M, Callanan
Surgical time out is a recent addition to pre-operative protocols worldwide. This audit was carried out to investigate whether the guidelines and regulations relating to surgical time out are being comprehensively followed in SVPH, so that there are less preventable errors in the operating room.
The results of the audit were obtained through the observation of 30-40 surgical cases, by one observer (CG), randomly chosen over a period of 5 working days. The tool used was a sphinx survey, which consisted of a number of tick-the-box questions.
This audit was focused on whether the entire surgical team played an active role in time out both by listening and stopping what they were doing and the role of the patient in time out. Time out was carried out in 39/40(97.5%) of the cases observed. Time out was initiated by the nurse the majority of the time, 37/40(92.5%) times.
In all cases the patients’ details were confirmed from the chart with the wrist band on the patient. All members of the team stopped what they were doing completely 23/40(57.5%) times. Time out was interrupted in 11 out of the 40 cases (27.5%). The patient was anaesthetised prior to time out in 100% (32/32) of the general anaesthetic cases.
From the results of this audit, it can be seen that the fundamentals of surgical time out are carried out well in SVPH but there are some aspects of the time out procedure, which could be improved upon. Primarily, ensuring that every member of the surgical team completely stop what they are doing and pause during time out to ensure complete staff compliance and that each team member is actively listening and, thus, actively involved.
Stress is mental, emotional or physical strain which can have a huge effect on an individual’s wellbeing and, in the case of doctors, can have a detrimental effect on work performance and subsequent patient care1. A literature review by Prins and colleagues published in 2007 showed the rates of burnout within an intern population (first postgraduate year) ranged from 18% to 82%, that there was a paucity of good quality studies on intern stress internationally and that most of these studies had been done in the US2.
This study examines stress from quantitative and qualitative perspectives reported by interns in an Irish Intern Network, with a particular focus on interns who have completed General Practice rotations.
A mixed methods approach was used. Firstly an on-line quantitative survey (incorporating 3 components: the General Health Questionnaire (GHQ); questions pertaining to situational / professional / personal stressors identified from the literature; and questions about work-life balance) was distributed electronically to all interns (101 interns) in the Mid Leinster Intern Network. Secondly, two focus groups were convened involving a group of interns who had completed a General Practice rotation (six interns) and another group who had not (eight interns).
The focus groups were audio-recorded, transcribed and then thematic analysis was used to carry out the analysis.
There was a 46% response rate to the on-line survey. Using the Goldberg analysis of the GHQ-12 taking a score of four out of 12 to signify significant levels of stress, 22 of the 46 interns (48%) scored four or higher. Female interns had a higher average score of 4.0 compared to male interns whose mean score was 3.74 (although not a statistically significant difference). There was a statistically significant difference in the ‘older interns’ being more stressed in that those over 28 years old had an average GHQ-12 value of 6.3 compared to 3.4 for those interns aged under 28 (p=0.03). 78% of interns felt there was a conflict between their work-life balance.
Being ‘on call’ and ‘conflict with nurses’ were the two biggest stressors identified from the quantitative survey. These two themes were also the commonest stress inducing themes to emerge from the focus group. However, lack of support and leadership from consultants and not feeling part of a team also featured strongly in the focus groups. It also emerged that there was of lack of undergraduate training in coping skills to deal with the death of patients.
The interns found their General Practice placements to be more supportive and educationally beneficial than their hospital placements. The General Practice interns found that dealing with phone calls and laboratory results about patients they had not met stressful and one group found their lack of a defined role caused them stress.
Almost half of the interns in this study reported scores consistent with pathological levels of stress with interns over aged 28 being significantly more stressed than those under 28. High levels of stress in doctors have been linked to adverse patient outcomes and increased malpractice claims. Interns reported stress in their relationships with nurses; more work needs to be done on this area so that changes can be made to address the problem.
On-call commitments are stressful for all doctors but policies could be put in place to reduce the stress load. The relationship with consultants is complex, but team building, leadership and clearer intern roles could improve intern morale More training in medical school for how to deal with the death of patients is something the interns feel would be very helpful. This study has shown that high levels of stress are an issue for many Irish interns. Given the effect this has on the mental health of the interns and patient safety it is an issue that should be addressed
The available literature suggests that comprehension may be sub-optimal in patients undergoing surgical procedures. We performed a pilot study to assess comprehension following standard verbal consent in patients undergoing laparoscopic cholecystectomy.
35 consecutive patients undergoing elective laparoscopic cholecystectomy were recruited. All patients were subjected to a standardised consent discussion and received an information leaflet pertaining to the procedure. A validated questionnaire (1) was used to assess patient understanding of the indication for surgery, the nature of the proposed surgery, the treatment alternatives, and the potential risks of the surgery.
35 patients were recruited all of whom agreed to complete a questionnaire. The overall mean patient comprehension score was 45%. Patients scored highly (>85% correct) in relation the type of procedure, the indication for surgery, the operative technique (laparoscopic), and certain complications (bile duct injury, conversion to open surgery). Patients scored poorly (<40%) in relation to certain other complications, alternative treatment options to surgery, and the potential for involvement of trainees in their procedure. All feedback from patients on the consent process was positive.
Deficiencies exist in the level of following verbal consent in patients undergoing laparoscopic cholecystectomy. Strategies that may improve understanding in patients consenting to surgical intervention warrant further investigation.
Nasogastric enteral tube (NGT) placement is associated with adverse clinical outcomes in physicians lacking relevant competency(a). The Professional Completion Module (PCM) for UCD final year medical students (Final Meds) incorporates intern shadowing (sub-internship).
A pilot was undertaken whereby interested Final Med sub-interns were asked to have completed an external e-learning module on NGT placement and then joined hospital interns, who had not been asked to undertake the prior e-learning module, during a Clinical Nutrition Seminar, for a Radiologist-delivered Powerpoint tutorial and optional multiple choice competency assessment based on X-ray images of NGTs.
De-identified scores among participants in the competency assessment were analysed using non-parametric statistical tests in SPSSv18.
A total of 36 sub-interns and interns completed the competency assessment (26 UCD Final Med sub-interns and 10 interns). For the a priori actual/required pass mark minimum threshold of 9/10 correct answers, there was a non-statistically significant trend towards a superior pass rate among those participants asked to undertake the NGT placement e-learning in advance of the Seminar, i.e. sub-interns (n=17, 65%) compared to interns (n=3 passed, 30%) (Fisher’s Exact p=0.07).
For the subset of sub-interns, there was no significant correlation of the NGT competency test pass rate with subsequent student performance in the summative PCM assessment (Pearson correlation 0.01, p=0.69), with the strongest, albeit weak, correlation being observed among NGT test result and the student’s prior Surgery examination grade (Pearson correlation 0.26, p=0.21). NGT test pass rates were not associated with graduate vs undergraduate entry student status (Fisher’s Exact p=1.0). When the NGT exam pass mark was notionally set at a minimum threshold of 8/10 correct MCQ answers, the trend towards superior pass rate among sub-interns attained statistical significance (sub-interns n=25, 96%) over interns (n=6, 60%; Fisher’s Exact p=0.015).
The NGT placement competency test performance among seminar participants, which overall was very satisfactory, was better for UCD sub-interns, who had been asked to undertake a relevant e-learning module in advance of the seminar and its competency test, compared to interns who had not received the e-learning opportunity. Blended teaching/learning for NGT placement outperforms more traditional instruction methods.
Burnout is 'a syndrome of emotional exhaustion, depersonalisation, and reduced personal accomplishment that can occur among individuals who work with people in some capacity'. The condition is prevalent (10 -71%) among postgraduate medical trainees. This study aims to quantify levels of burnout among postgraduate medical trainees in the ROI using a validated burnout inventory. Burnout among healthcare providers carries implications for patient safety and quality of care. It also adversely affects retention of NCHDs and contributes to higher rates of alcohol and substance abuse, depression, and suicide compared with other professions.
The population included NCHDs working both in acute hospitals and in the community. The data collection was based on cross sectional probability sampling. 260 NCHDs responded to the survey. Burnout was measured using the Copenhagen Burnout Inventory (CBI). The CBI comprises three scales assessing personal, work related, and patient related burnout, each assessed on a 5–point Likert scale. Scores were individually calculated out of 100 for each respondent.
Beyond a total average score of 50 points the person was defined as being exposed to burnout. A subgroup analysis for each NCHD grade was also performed. Continuous data was expressed as mean ± standard deviation. Categorical variables were expressed as frequencies and percentages. Statistical calculations were performed using IBM SPSS Version 21.0 (IBM Corporation, New York, USA).
A total of 260 NCHDs responded. Each NCHD grade reported scores reflecting high degrees of personal (mean 60, SD 17) and workplace related (mean 60 SD 19.1) burnout. Rates of client related burnout were low (mean 32 SD 18.3).
Self–reported rates of personal and work-related burnout among NCHDs were high, with comparatively low rates of client related burnout. Further studies are required to identify contributory factors to personal- and work-related burnout and to establish comparative rates of burnout among the different postgraduate specialties and subspecialties.