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Vamos CA, Foti TR, Reyes Martinez E, Pointer Z, Detman LA, Sappenfield WM. Identification of Clinician Training Techniques as an Implementation Strategy to Improve Maternal Health: A Scoping Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6003. [PMID: 37297607 PMCID: PMC10252379 DOI: 10.3390/ijerph20116003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 05/23/2023] [Accepted: 05/25/2023] [Indexed: 06/12/2023]
Abstract
Training is a key implementation strategy used in healthcare settings. This study aimed to identify a range of clinician training techniques that facilitate guideline implementation, promote clinician behavior change, optimize clinical outcomes, and address implicit biases to promote high-quality maternal and child health (MCH) care. A scoping review was conducted within PubMed, CINAHL, PsycInfo, and Cochrane databases using iterative searches related to (provider OR clinician) AND (education OR training). A total of 152 articles met the inclusion/exclusion criteria. The training involved multiple clinician types (e.g., physicians, nurses) and was predominantly implemented in hospitals (63%). Topics focused on maternal/fetal morbidity/mortality (26%), teamwork and communication (14%), and screening, assessment, and testing (12%). Common techniques included didactic (65%), simulation (39%), hands-on (e.g., scenario, role play) (28%), and discussion (27%). Under half (42%) of the reported training was based on guidelines or evidence-based practices. A minority of articles reported evaluating change in clinician knowledge (39%), confidence (37%), or clinical outcomes (31%). A secondary review identified 22 articles related to implicit bias training, which used other reflective approaches (e.g., implicit bias tests, role play, and patient observations). Although many training techniques were identified, future research is needed to ascertain the most effective training techniques, ultimately improving patient-centered care and outcomes.
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Affiliation(s)
- Cheryl A. Vamos
- USF’s Center of Excellence in Maternal and Child Health Education, Science & Practice, The Chiles Center, College of Public Health, University of South Florida, Tampa, FL 33612, USA
| | - Tara R. Foti
- College of Public Health, University of South Florida, Tampa, FL 33612, USA; (T.R.F.); (Z.P.)
| | - Estefanny Reyes Martinez
- College of Public Health, Florida Perinatal Quality Collaborative, University of South Florida, Tampa, FL 33612, USA;
| | - Zoe Pointer
- College of Public Health, University of South Florida, Tampa, FL 33612, USA; (T.R.F.); (Z.P.)
| | - Linda A. Detman
- The Chiles Center, College of Public Health, Florida Perinatal Quality Collaborative, University of South Florida, Tampa, FL 33612, USA; (L.A.D.); (W.M.S.)
| | - William M. Sappenfield
- The Chiles Center, College of Public Health, Florida Perinatal Quality Collaborative, University of South Florida, Tampa, FL 33612, USA; (L.A.D.); (W.M.S.)
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Renwick S, Hookes S, Draycott T, Dey M, Hodge F, Storey J, Winter C, Sengupta N, Benjamin F. PROMPT Wales project: national scaling of an evidence-based intervention to improve safety and training in maternity. BMJ Open Qual 2021; 10:e001280. [PMID: 34675036 PMCID: PMC8532559 DOI: 10.1136/bmjoq-2020-001280] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 07/03/2021] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND In healthcare, there is increasing recognition of the importance of developing and testing strategies to scale effective interventions. The NHS long-term plan (2019) acknowledges that often a gold standard approach to a problem already exists somewhere within the NHS, however, it has not been replicated widely across the system. METHODS We describe the approach and process measures for national scaling of PROMPT (Practical Obstetric Multi-Professional Training) across 12 obstetric-led maternity units in Wales. PROMPT is an evidence-based training package for local maternity staff, previously associated with improvements in maternal and neonatal outcomes, reduction in litigation related to preventable harm and improved safety culture. PROMPT has previously been disseminated internationally using a train-the-trainer model. However, this has been associated with variations in uptake, fidelity and impact. In Wales, the project was supported by Welsh Government, and a structured scaling plan was developed, encompassing ongoing implementation support from a multi-professional team. RESULTS PROMPT was successfully implemented in all obstetric led units in Wales, with 326 local PROMPT facilitators trained, and 82.5%-100% of maternity staff attended a local PROMPT course in the first 15 months of the project (January 2019-March 2020). All training courses included evidence-based authentic elements, and 93% of courses in the first year (100/107) were supported by a national implementation team, providing coaching, implementation support and quality assurance. CONCLUSIONS Authentically scaling up complex interventions is a significant challenge. To replicate the improved outcomes demonstrated by PROMPT, intervention reach and fidelity must first be demonstrated.In this national scaling project, our scaling methodology led to the successful implementation of PROMPT across all health boards in Wales. Additionally, we demonstrated reduced variation in adoption, reach, timescale and intervention fidelity between maternity units with varying readiness for change, which had been difficult in two previous large-scale PROMPT implementation projects.
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Affiliation(s)
- Sophie Renwick
- Faculty of Medicine, University of Bristol, Bristol, UK
- PROMPT Maternity Foundation, Bristol, UK
| | - Sarah Hookes
- NHS Wales Shared Services Partnership Legal and Risk Services, Cardiff, UK
| | | | - Madhuchanda Dey
- Department of Obstetrics and Gynaecology, Singleton Hospital, Swansea, UK
| | - Frances Hodge
- Department of Obstetrics and Gynaecology, Singleton Hospital, Swansea, UK
| | | | | | - Niladri Sengupta
- Department of Obstetrics and Gynaecology, Betsi Cadwaladr University Health Board, Bodelwyddan, UK
| | - Fiona Benjamin
- Department of Obstetrics and Gynaecology, Princess of Wales Hospital, Bridgend, UK
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Relph S, Elstad M, Coker B, Vieira MC, Moitt N, Gutierrez WM, Khalil A, Sandall J, Copas A, Lawlor DA, Pasupathy D. Using electronic patient records to assess the effect of a complex antenatal intervention in a cluster randomised controlled trial-data management experience from the DESiGN Trial team. Trials 2021; 22:195. [PMID: 33685512 PMCID: PMC7941939 DOI: 10.1186/s13063-021-05141-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 02/19/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The use of electronic patient records for assessing outcomes in clinical trials is a methodological strategy intended to drive faster and more cost-efficient acquisition of results. The aim of this manuscript was to outline the data collection and management considerations of a maternity and perinatal clinical trial using data from electronic patient records, exemplifying the DESiGN Trial as a case study. METHODS The DESiGN Trial is a cluster randomised control trial assessing the effect of a complex intervention versus standard care for identifying small for gestational age foetuses. Data on maternal/perinatal characteristics and outcomes including infants admitted to neonatal care, parameters from foetal ultrasound and details of hospital activity for health-economic evaluation were collected at two time points from four types of electronic patient records held in 22 different electronic record systems at the 13 research clusters. Data were pseudonymised on site using a bespoke Microsoft Excel macro and securely transferred to the central data store. Data quality checks were undertaken. Rules for data harmonisation of the raw data were developed and a data dictionary produced, along with rules and assumptions for data linkage of the datasets. The dictionary included descriptions of the rationale and assumptions for data harmonisation and quality checks. RESULTS Data were collected on 182,052 babies from 178,350 pregnancies in 165,397 unique women. Data availability and completeness varied across research sites; each of eight variables which were key to calculation of the primary outcome were completely missing in median 3 (range 1-4) clusters at the time of the first data download. This improved by the second data download following clarification of instructions to the research sites (each of the eight key variables were completely missing in median 1 (range 0-1) cluster at the second time point). Common data management challenges were harmonising a single variable from multiple sources and categorising free-text data, solutions were developed for this trial. CONCLUSIONS Conduct of clinical trials which use electronic patient records for the assessment of outcomes can be time and cost-effective but still requires appropriate time and resources to maximise data quality. A difficulty for pregnancy and perinatal research in the UK is the wide variety of different systems used to collect patient data across maternity units. In this manuscript, we describe how we managed this and provide a detailed data dictionary covering the harmonisation of variable names and values that will be helpful for other researchers working with these data. TRIAL REGISTRATION Primary registry and trial identifying number: ISRCTN 67698474 . Registered on 02/11/16.
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Affiliation(s)
- Sophie Relph
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, 10th Floor North Wing, St. Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK.
| | - Maria Elstad
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, 4th Floor, Addison House, Guy's Campus, London, SE1 1UL, UK
| | - Bolaji Coker
- Division of Health and Social Care Research, King's College London, London, UK.,NIHR Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust and King's College London, Guy's Hospital, London, UK
| | - Matias C Vieira
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, 10th Floor North Wing, St. Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK.,Department of Obstetrics and Gynaecology, University of Campinas (UNICAMP), School of Medical Sciences, 101 Alexander Fleming St, Cidade Universitaria, Campinas, SP, Brazil
| | - Natalie Moitt
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, 10th Floor North Wing, St. Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
| | - Walter Muruet Gutierrez
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, 10th Floor North Wing, St. Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
| | - Asma Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, UK.,Molecular & Clinical Sciences Research Institute, St George's, University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Jane Sandall
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, 10th Floor North Wing, St. Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
| | - Andrew Copas
- Centre for Pragmatic Global Health Trials, Institute for Global Health, University College London, Gower Street, London, WC1E 6BT, UK
| | - Deborah A Lawlor
- Population Health Science, Bristol Medical School, University of Bristol, Bristol, BS8 2BL, UK.,Bristol NIHR Biomedical Research Centre, Bristol, BS8 2BL, UK.,MRC Integrative Epidemiology Unit at the University of Bristol, Bristol, BS8 2BL, UK
| | - Dharmintra Pasupathy
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, 10th Floor North Wing, St. Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK.,Speciality of Obstetrics, Gynaecology and Neonatology, Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
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Fransen AF, van de Ven J, Banga FR, Mol BWJ, Oei SG. Multi-professional simulation-based team training in obstetric emergencies for improving patient outcomes and trainees' performance. Cochrane Database Syst Rev 2020; 12:CD011545. [PMID: 33325570 PMCID: PMC8094450 DOI: 10.1002/14651858.cd011545.pub2] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Simulation-based obstetric team training focuses on building a system that will anticipate errors, improve patient outcomes and the performance of clinical care teams. Simulation-based obstetric team training has been proposed as a tool to improve the overall outcome of obstetric health care. OBJECTIVES To assess the effects of simulation-based obstetric team training on patient outcomes, performance of obstetric care teams in practice and educational settings, and trainees' experience. SEARCH METHODS The Cochrane Pregnancy and Childbirth Group's Trials Register, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) were searched (14 April 2020), together with references checking and hand searching the available proceedings of 2 international conferences. SELECTION CRITERIA We included randomised controlled trials (RCTs) (including cluster-randomised trials) comparing simulation-based obstetric team training with no, or other type of training. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane, to identify articles, assess methodological quality and extract data. Data from three cluster-randomised trials could be used to perform generic inverse variance meta-analyses. The meta-analyses were based on risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs). We used the GRADE approach to rate the certainty of the evidence. We used Kirkpatrick's model of training evaluation to categorise the outcomes of interest; we chose Level 3 (behavioural change) and Level 4 (patient outcome) to categorise the primary outcomes. MAIN RESULTS We included eight RCTs, six of which were cluster-randomised trials, involving more than 1000 training participants and more than 200,000 pregnancies/births. Four studies reported on outcome measures on Kirkpatrick level 4 (patient outcome), three studies on Kirkpatrick level 3 (performance in practice), two studies on Kitkpatrick level 2 (performance in educational settings), and none on Kirkpatrick level 1 (trainees' experience). The included studies were from Mexico, the Netherlands, the UK and the USA, all middle- and high-income countries. Kirkpatrick level 4 (patient outcome) Simulation-based obstetric team training may make little or no difference for composite outcomes of maternal and/or perinatal adverse events compared with no training (3 studies; n = 28,731, low-certainty evidence, data not pooled due to different composite outcome definitions). We are uncertain whether simulation-based obstetric team training affects maternal mortality compared with no training (2 studies; 79,246 women; very low-certainty evidence). However, it may reduce neonatal mortality (RR 0.70, 95% CI 0.48 to 1.01; 2 studies, 79,246 pregnancies/births, low-certainty evidence). Simulation-based obstetric team training may have little to no effect on low Apgar score compared with no training (RR 0.99, 95% 0.85 to 1.15; 2 studies; 115,171 infants; low-certainty evidence), but it probably reduces trauma after shoulder dystocia (RR 0.50, 95% CI 0.25 to 0.99; 1 study; moderate-certainty evidence) and probably slightly reduces the number of caesarean deliveries (RR 0.79, 95% CI 0.67 to 0.93; 1 study; n = 50,589; moderate-certainty evidence) Kirkpatrick level 3 (performance in practice) We found that simulation-based obstetric team training probably improves the performance of the obstetric teams in practice, compared with no training (3 studies; 2398 obstetric staff members, moderate-certainty evidence, data not pooled due to different outcome definitions). AUTHORS' CONCLUSIONS Simulation-based obstetric team training may help to improve team performance of obstetric teams, and it might contribute to improvement of specific maternal and perinatal outcomes, compared with no training. However, high-certainty evidence is lacking due to serious risk of bias and imprecision, and the effect cannot be generalised for all outcomes. Future studies investigating simulation-based obstetric team training compared to training courses with a different instructional design should carefully consider how and when to measure outcomes. Particular attention should be paid to effect measurement at the level of patient outcome, taking into consideration the low incidence of adverse maternal and perinatal events.
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Affiliation(s)
- Annemarie F Fransen
- Department of Obstetrics and Gynaecology, Máxima Medical Centre, Veldhoven, Netherlands
| | - Joost van de Ven
- Department of Obstetrics and Gynaecology, Elkerliek Hospital, Helmond, Netherlands
| | - Franyke R Banga
- Department of Obstetrics and Gynaecology, Máxima Medical Centre, Veldhoven, Netherlands
| | - Ben Willem J Mol
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Australia
| | - S Guid Oei
- Department of Obstetrics and Gynaecology; Department of Electrical Engineering (University of Technology, Eindhoven), Máxima Medical Centre, Veldhoven, Netherlands
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Myers LC, Gartland RM, Skillings J, Heard L, Bittner EA, Einbinder J, Metlay JP, Mort E. An Examination of Medical Malpractice Claims Involving Physician Trainees. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2020; 95:1215-1222. [PMID: 31833853 DOI: 10.1097/acm.0000000000003117] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
PURPOSE To identify patient-, provider-, and claim-related factors of medical malpractice claims in which physician trainees were directly involved in the harm events. METHOD The authors performed a case-control study using medical malpractice claims closed between 2012-2016 and contributed to the Comparative Benchmarking System database by teaching hospitals. Using the service extender flag, they classified claims as cases if physician trainees were directly involved in the harm events. They classified claims as controls if they were from the same facilities, but trainees were not directly involved in the harm events. They performed multivariable regression with predictor variables being patient and provider characteristics. The outcome was physician trainee involvement in harm events. RESULTS From the original pool of 30,973 claims, there were 581 cases and 2,610 controls. The majority of cases involved residents (471, 81%). Cases had a statistically significant higher rate of having a trainee named as defendants than controls (184, 32% vs 233, 9%; P < .001). The most common final diagnosis for cases was puncture or laceration during surgery (62, 11%). Inadequate supervision was a contributing factor in 140 (24%) cases overall, with the majority (104, 74%) of these claims being procedure related. Multivariable regression analysis revealed that trainees were most likely to be involved in harm events in specialties such as oral surgery/dentistry and obstetrics-gynecology (OR = 7.99, 95% CI 2.93, 21.83 and OR = 1.85, 95% CI 1.24, 2.66, respectively), when performing procedures (OR = 1.58, 95% CI 1.27, 1.96), or when delivering care in the emergency room (OR = 1.65, 95% CI 1.43, 1.91). CONCLUSIONS Among claims involving physician trainees, procedures were common and often associated with inadequate supervision. Training directors of surgical specialties can use this information to improve resident supervision policies. The goal is to reduce the likelihood of future harm events.
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Affiliation(s)
- Laura C Myers
- L.C. Myers is a research fellow, Division of Pulmonary and Critical Care, Massachusetts General Hospital, Boston, Massachusetts; ORCID: http://orcid.org/0000-0002-2872-3388
| | - Rajshri M Gartland
- R.M. Gartland is a surgical resident, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Jillian Skillings
- J. Skillings is data analyst, Controlled Risk Insurance Company, Boston, Massachusetts
| | - Lisa Heard
- L. Heard is senior program director, Patient Safety and Education, Controlled Risk Insurance Company, Boston, Massachusetts
| | - Edward A Bittner
- E.A. Bittner is associate professor of anesthesia, Harvard Medical School, and program director, Critical Care Anesthesiology Fellowship, Department of Anesthesia, Massachusetts General Hospital, Boston, Massachusetts
| | - Jonathan Einbinder
- J. Einbinder is instructor of medicine, Harvard Medical School, member, Division of General Internal Medicine, Brigham and Women's Hospital, and assistant vice president, Advanced Data Analytics and Coding, Controlled Risk Insurance Company, Boston, Massachusetts
| | - Joshua P Metlay
- J.P. Metlay is professor, Department of Medicine, Harvard Medical School, professor of health policy and management, Harvard School of Public Health, and chief, General Internal Medicine Division, Massachusetts General Hospital, Boston, Massachusetts
| | - Elizabeth Mort
- E. Mort is assistant professor in health care policy, Harvard Medical School, member, Division of General Internal Medicine, and chief quality officer, Massachusetts General Hospital, Boston, Massachusetts
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Myers LC, Sawicki D, Heard L, Camargo CA, Mort E. A description of medical malpractice claims involving advanced practice providers. J Healthc Risk Manag 2020; 40:8-16. [PMID: 32362078 DOI: 10.1002/jhrm.21412] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 03/18/2020] [Accepted: 03/30/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND The number of physician assistants (PAs) and advanced practice registered nurses (APRNs), together known as advanced practice providers (APPs), has risen dramatically. The goal is identifying characteristics of paid medical malpractice claims, in which APPs are defendants. METHODS Retrospective cohort study using Harvard's malpractice insurer's national database. Closed claims (2007-2016) with PAs, APRNs, or physicians as defendants. The primary analysis compared claims by role group by patient-, provider-, and claim-level characteristics. Supplemental analyses compared claims naming APPs with and without physicians. Multivariable logistic regression identified variables associated with claim payment. RESULTS Of 54,772 claims, PAs were defendants without APRNs or physicians in 26 claims; APRNs were defendants without PAs or physicians in 63; physicians were defendants without PAs or APRNs in 37,354. Approximately 75% of claims naming APPs co-named physicians. More claims naming PAs and APRNs were paid on behalf of the hospital/practice (38% and 32%, respectively) compared with physicians (8%, P < 0.001). Payment was less likely for inpatient care (OR 0.89, 95% CI 0.85-0.93, P < 0.001) but higher when APRNs were defendants (1.82, 1.09-3.03), when procedure-related (1.31, 1.25-1.38, P < 0.001) or patients died (1.09, 1.03-1.16, P = 0.003). CONCLUSIONS These results can inform patient safety initiatives to prevent future harms. The target is outpatient airway procedures performed by APRNs.
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Affiliation(s)
| | | | - Lisa Heard
- Massachusetts College of Pharmacy and Health Sciences, Boston, MA
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Merriel A, Ficquet J, Barnard K, Kunutsor SK, Soar J, Lenguerrand E, Caldwell DM, Burden C, Winter C, Draycott T, Siassakos D. The effects of interactive training of healthcare providers on the management of life-threatening emergencies in hospital. Cochrane Database Syst Rev 2019; 9:CD012177. [PMID: 31549741 PMCID: PMC6757513 DOI: 10.1002/14651858.cd012177.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Preparing healthcare providers to manage relatively rare life-threatening emergency situations effectively is a challenge. Training sessions enable staff to rehearse for these events and are recommended by several reports and guidelines. In this review we have focused on interactive training, this includes any element where the training is not solely didactic but provides opportunity for discussions, rehearsals, or interaction with faculty or technology. It is important to understand the effective methods and essential elements for successful emergency training so that resources can be appropriately targeted to improve outcomes. OBJECTIVES To assess the effects of interactive training of healthcare providers on the management of life-threatening emergencies in hospital on patient outcomes, clinical care practices, or organisational practices, and to identify essential components of effective interactive emergency training programmes. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL and ERIC and two trials registers up to 11 March 2019. We searched references of included studies, conference proceedings, and contacted study authors. SELECTION CRITERIA We included randomised trials and cluster-randomised trials comparing interactive training for emergency situations with standard/no training. We defined emergency situations as those in which immediate lifesaving action is required, for example cardiac arrests and major haemorrhage. We included all studies where healthcare workers involved in providing direct clinical care were participants. We excluded studies outside of a hospital setting or where the intervention was not targeted at practicing healthcare workers. We included trials irrespective of publication status, date, and language. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane and Cochrane Effective Practice and Organisation of Care (EPOC) Group. Two review authors independently extracted data and assessed the risk of bias of each included trial. Due to the small number of studies and the heterogeneity in outcome measures, we were unable to perform the planned meta-analysis. We provide a structured synthesis for the following outcomes: survival to hospital discharge, morbidity rate, protocol or guideline adherence, patient outcomes, clinical practice outcomes, and organisation-of-care outcomes. We used the GRADE approach to rate the certainty of the evidence and the strength of recommendations for each outcome. MAIN RESULTS We included 11 studies that reported on 2000 healthcare providers and over 300,000 patients; one study did not report the number of participants. Seven were cluster randomised trials and four were single centre studies. Four studies focused on obstetric training, three on obstetric and neonatal care, two on neonatal training, one on trauma and one on general resuscitations. The studies were spread across high-, middle- and low-income settings.Interactive training may make little or no difference in survival to hospital discharge for patients requiring resuscitation (1 study; 30 participants; 98 events; low-certainty evidence). We are uncertain if emergency training changes morbidity rate, as the certainty of the evidence is very low (3 studies; 1778 participants; 57,193 patients, when reported). We are uncertain if training alters healthcare providers' adherence to clinical protocols or guidelines, as the certainty of the evidence is very low (3 studies; 156 participants; 558 patients). We are uncertain if there were improvements in patient outcomes following interactive training for emergency situations, as we assessed the evidence as very low-certainty (5 studies, 951 participants; 314,055 patients). We are uncertain if training for emergency situations improves clinical practice outcomes as the certainty of the evidence is very low (4 studies; 1417 participants; 28,676 patients, when reported). Two studies reported organisation-of-care outcomes, we are uncertain if interactive emergency training has any effect on this outcome as the certainty of the evidence is very low (634 participants; 179,400 patient population).We examined prespecified subgroups and found no clear commonalities in effect of multidisciplinary training, location of training, duration of the course, or duration of follow-up. We also examined areas arising from the studies including focus of training, proportion of staff trained, leadership of intervention, and incentive/trigger to participate, and again identified no clear mediating factors. The sources of funding for the studies were governmental, local organisations, or philanthropic donors. AUTHORS' CONCLUSIONS We are uncertain if there are any benefits of interactive training of healthcare providers on the management of life-threatening emergencies in hospital as the certainty of the evidence is very low. We were unable to identify any factors that may have allowed us to identify an essential element of these interactive training courses.We found a lack of consistent reporting, which contributed to the inability to meta-analyse across specialities. More trials are required to build the evidence base for the optimum way to prepare healthcare providers for rare life-threatening emergency events. These trials need to be conducted with attention to outcomes important to patients, healthcare providers, and policymakers. It is vitally important to develop high-quality studies adequately powered and with attention to minimising the risk of bias.
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Affiliation(s)
- Abi Merriel
- University of BristolPopulation Health Sciences, Bristol Medical SchoolDepartment of Women's and Children's HealthThe ChilternsBristolUKBS10 5NB
| | - Jo Ficquet
- Royal United Hospital NHS Foundation TrustWomen and Children's DivisionCoombe ParkBathUKBA1 3NG
| | - Katie Barnard
- North Bristol TrustLearning and Research, Southmead HospitalBristolUKBS10 5NB
| | - Setor K Kunutsor
- University of BristolTranslational Health Sciences, Bristol Medical SchoolBristolUK
| | - Jasmeet Soar
- North Bristol NHS Trust, Southmead HospitalAnaesthetic DepartmentBristolUKBS10 5NB
| | - Erik Lenguerrand
- University of BristolTranslational Health Sciences, Bristol Medical SchoolBristolUK
| | - Deborah M Caldwell
- University of BristolPopulation Health Sciences, Bristol Medical SchoolDepartment of Women's and Children's HealthThe ChilternsBristolUKBS10 5NB
| | - Christy Burden
- University of BristolPopulation Health Sciences, Bristol Medical SchoolDepartment of Women's and Children's HealthThe ChilternsBristolUKBS10 5NB
| | - Cathy Winter
- North Bristol NHS TrustDepartment of Women's HealthBristolUK
| | - Tim Draycott
- North Bristol NHS TrustDepartment of Women's HealthBristolUK
| | - Dimitrios Siassakos
- University College LondonUCL EGA Institute for Women's Health86‐96 Chenies MewsBloomsburyLondonUKWC1E 6HX
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Lenguerrand E, Winter C, Siassakos D, MacLennan G, Innes K, Lynch P, Cameron A, Crofts J, McDonald A, McCormack K, Forrest M, Norrie J, Bhattacharya S, Draycott T. Effect of hands-on interprofessional simulation training for local emergencies in Scotland: the THISTLE stepped-wedge design randomised controlled trial. BMJ Qual Saf 2019; 29:122-134. [PMID: 31302601 PMCID: PMC7045781 DOI: 10.1136/bmjqs-2018-008625] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 06/19/2019] [Accepted: 06/24/2019] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To assess whether the implementation of an intrapartum training package (PROMPT (PRactical Obstetric Multi-Professional Training)) across a health service reduced the proportion of term babies born with Apgar score <7 at 5 min (<75mins). DESIGN Stepped-wedge cluster randomised controlled trial. SETTING Twelve randomised maternity units with ≥900 births/year in Scotland. Three additional units were included in a supplementary analysis to assess the effect across Scotland. The intervention commenced in March 2014 with follow-up until September 2016. INTERVENTION The PROMPT training package (Second edition), with subsequent unit-level implementation of PROMPT courses for all maternity staff. MAIN OUTCOME MEASURES The primary outcome was the proportion of term babies with Apgar<75mins. RESULTS 87 204 eligible births (99.2% with an Apgar score), of which 1291 infants had an Apgar<75mins were delivered in the 12 randomised maternity units. Two units did not implement the intervention. The overall Apgar<75mins rate observed in the 12 randomised units was 1.49%, increasing from 1.32% preintervention to 1.59% postintervention. Once adjusted for a secular time trend, the 'intention-to-treat' analysis indicated a moderate but non-significant reduction in the rate of term babies with an Apgar scores <75mins following PROMPT training (OR=0.79 95%CI(0.63 to 1.01)). However, some units implemented the intervention earlier than their allocated step, whereas others delayed the intervention. The content and authenticity of the implemented intervention varied widely at unit level. When the actual date of implementation of the intervention in each unit was considered in the analysis, there was no evidence of improvement (OR=1.01 (0.84 to 1.22)). No intervention effect was detected by broadening the analysis to include all 15 large Scottish maternity units. Units with a history of higher rates of Apgar<75mins maintained higher Apgar rates during the study (OR=2.09 (1.28 to 3.41)) compared with units with pre-study rates aligned to the national rate. CONCLUSIONS PROMPT training, as implemented, had no effect on the rate of Apgar <75mins in Scotland during the study period. Local implementation at scale was found to be more difficult than anticipated. Further research is required to understand why the positive effects observed in other single-unit studies have not been replicated in Scottish maternity units, and how units can be best supported to locally implement the intervention authentically and effectively. TRIAL REGISTRATION NUMBER ISRCTN11640515.
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Affiliation(s)
- Erik Lenguerrand
- Translational Health Sciences, University of Bristol, Bristol, UK
| | - Cathy Winter
- Department of Women's Health and Children's Health, Southmead Hospital, North Bristol NHS Trust, Westbury on Trym, UK
| | | | - Graeme MacLennan
- Centre for Healthcare Randomised Trials, Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Karen Innes
- Centre for Healthcare Randomised Trials, Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Pauline Lynch
- Maternity Unit, Ninewells Hospital and Medical School, NHS Tayside, Dundee, UK
| | - Alan Cameron
- Ian Donald Fetal Medicine Centre, Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Joanna Crofts
- Department of Women's Health and Children's Health, Southmead Hospital, North Bristol NHS Trust, Westbury on Trym, UK
| | - Alison McDonald
- Centre for Healthcare Randomised Trials, Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Kirsty McCormack
- Centre for Healthcare Randomised Trials, Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Mark Forrest
- Centre for Healthcare Randomised Trials, Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - John Norrie
- Edinburgh Clinical Trials Unit, Centre for Population Health Sciences, Usher Institute, University of Edinburgh, Edinburgh, UK
| | | | - Tim Draycott
- Translational Health Sciences, University of Bristol, Bristol, UK
- Department of Women's Health and Children's Health, Southmead Hospital, North Bristol NHS Trust, Westbury on Trym, UK
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Medical Malpractice Involving Pulmonary/Critical Care Physicians. Chest 2019; 156:907-914. [PMID: 31102609 DOI: 10.1016/j.chest.2019.04.102] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 04/27/2019] [Accepted: 04/30/2019] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Medical malpractice data can be leveraged to understand specialty-specific risk. METHODS Malpractice claims were examined from the Comparative Benchmarking System (2007-2016), a national database containing > 30% of claims data in the United States. Claims were identified with either internal medicine or pulmonary/critical care (PCC) physicians as the primary provider involved in the harm. Claim characteristics were compared according to specialty and care setting (inpatient vs outpatient), and multiple regression analysis was performed to predict claim payment. RESULTS Claims involving PCC physicians differed from those involving internal medicine physicians in terms of harm severity, allegation, final diagnosis, procedure involvement, payment rate, and contributing factors. The majority of claims involving PCC physicians resulted from inpatient care (63%), of which only 26% occurred delivering intensive care. Eighty-one percent were from harm events that resulted in death/permanent injury. The most common diagnosis was laceration during a procedure for inpatient claims (6%) and lung cancer for outpatient claims (28%). Thirty-one percent of claims overall involved procedures. Although only 26% were paid, the median indemnity per paid claim of $285,769 ranked PCC as the twelfth highest of 69 specialties. The two variables associated with indemnity payment were outpatient care (OR, 1.70; 95% CI, 1.01-2.86) and temporary harm (OR, 0.36; 95% CI, 0.15-0.87). CONCLUSIONS Malpractice claims involving PCC physicians were distinct from claims involving internal medicine physicians. Although only one-quarter of claims was paid, the indemnity per claim was high among specialties. Specialty-specific prevention strategies must be developed to mitigate both patient harm and provider malpractice risk.
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