Village doctors: a national telephone survey of Bangladesh's lay medical practitioners.

BACKGROUND: Bangladesh outperforms its Least Developed Country (LDC) status on a range of health measures including life expectancy. Its frontline medical practitioners, however, are not formally trained medical professionals, but instead lightly-trained 'village doctors' able to prescribe modern pharmaceuticals. This current study represents the most complete national survey of these practitioners and their informal 'clinics'. METHODS: The study is based on a national Computer Assisted Telephone Interviewing (CATI) of 1,000 informal practitioners. Participants were sampled from all eight divisions and all 64 districts of Bangladesh, including 682 participants chosen from the purposively recruited Refresher Training program conducted by the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B), supplemented with 318 additional participants recruited through snowball sampling. PRIMARY AND SECONDARY OUTCOME MEASURES: In addition to demographics, village doctors were asked about the characteristics of their 'clinics' including their equipment, their training, income and referral practices. RESULTS: Three quarters of the wholly male sample had not completed an undergraduate program, and none of the sample had received any bachelor-level university training in medicine. Medical training was confined to a range of short-course offerings. Village doctor 'clinics' are highly dependent on the sale of pharmaceuticals, with few charging a consultation fee. Income was not related to degree of short-course uptake but was related positively to degree of formal education. Finally, practitioners showed a strong tendency to refer patients to the professional medical care system. CONCLUSIONS: Bangladesh's village doctor sector provides an important pathway to professional, trained medical care, and provides some level of care to those who cannot afford or otherwise access the nation's established healthcare system. However, the degree to which relatively untrained paramedical practitioners are prescribing conventional medicines has concerning health implications.

Characterising the nature of clinical incidents reported across a tertiary health service: a retrospective audit.

Objective Reducing the number of adverse patient safety incidents (PSIs) requires careful monitoring and active management processes. However, there is limited information about the association between hospital settings and the type of PSI. The aims of this study were to describe the severity, nature and characteristics of PSIs from an analysis of their incidence and to assess the relationships between the type of PSI and its setting. Methods A retrospective audit of a clinical incident management system database was conducted for a tertiary health service in Australia with 620000 residents. Records of PSIs reported for patients between 1 July 2017 and 30 June 2018 with Safety Assessment Codes (SAC) of PSIs were extracted from the clinical incident management system and analysed using descriptive and inferential statistics. PSIs involving paediatrics, mental health and primary care were excluded. Results In all, 4385 eligible PSIs were analysed: 24 SAC1, 107 SAC2 and 4254 SAC3 incidents. Across reported PSIs, the most common incidents related to skin injury (28.6%), medication (23.2%), falls (19.9%) and clinical process (8.5%). Falls were reported significantly more often in the medical division (χ2=43.85, P<0.001), whereas skin injury incidents were reported significantly more often in the surgical division (χ2=22.56, P<0.001). Conclusions A better understanding of the nature of PSIs and where they occur may lead to more targeted quality improvement strategies. What is known about this topic? Improving patient safety requires effective safety learning systems, which include incident reporting and management processes. Although incident reporting systems typically underestimate the incidence of iatrogenic harm, they do provide valuable opportunities to improve the future safety of health care. What does this paper add? This study reports the extent and severity of different types of PSIs that typically occur in a large tertiary hospital in Australia. The most common types of incidents are skin injury, falls, medication errors and clinical process. There are empirical associations between the type of PSI and clinical division (medical, surgical). What are the implications for practitioners? A greater understanding of the types of PSI and the settings in which they occur may inform the development of more targeted quality improvement strategies that potentially reduce their incidence.

The quality and clinical applicability of recommendations in pressure injury guidelines: A systematic review of clinical practice guidelines.

BACKGROUND: Pressure injuries are one of the most frequently occurring, yet preventable hospital-acquired adverse events. Given there are many clinical practice guidelines available on the prevention and treatment of pressure injuries, it is useful to understand the quality of these guidelines and the clinical application of their recommendations. OBJECTIVE: To critically evaluate the quality and applicability of the recommendations in pressure injury prevention and treatment clinical practice guidelines. DESIGN: Systematic review, reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. DATA SOURCES: We systematically searched the literature published from 2005 to 2020 using MEDLINE, EMBASE, CINAHL, the Cochrane Library, ProQuest and PubMed electronic databases, and nine guideline repositories. REVIEW METHODS: We assessed overall quality using the validated Appraisal of Guidelines for Research and Evaluation II (AGREE II) and AGREE Recommendation Excellence (AGREE-REX) tools. Overall % mean scores across AGREE II and AGREE-REX domains were calculated for each guideline. Clinical practice guidelines were then ranked in tertiles based on "high", "moderate" or "low" quality. The review protocol was registered in the International Prospective Register of Systematic Reviews. RESULTS: Initial combined database and repository searches yielded 3247 documents. Of these,73 full text documents were reviewed. The final analysis included 12 complete guidelines and 14 related documents. Overall AGREE II scores ranged from 32% to 96% while AGREE-REX scores were generally lower ranging from 10% to 75%. Combined % mean scores across AGREE II and AGREE-REX criteria suggest that four guidelines were ranked as "high" (range 69% to 85%) and are recommended without modification. These included; the 2019 International Guideline, the 2016 Canadian Guideline, the 2014 NICE Guideline, and the 2013 Belgian Guideline. CONCLUSIONS: There is disparity in the quality of the included guidelines, however four high quality guidelines are available. These guidelines could ideally be implemented in daily practice and adapted to local policies.

Identifying barriers and facilitators to recognition and response to patient clinical deterioration by clinicians using a behaviour change approach: A qualitative study.

BACKGROUND: Failure of clinicians to recognise and respond to patient clinical deterioration is associated with increased hospital mortality. Emergency response teams are implemented throughout hospitals to support direct-care clinicians in managing patient deterioration, but patient clinical deterioration is often not identified or acted upon by clinicians in ward settings. To date, no studies have used an integrative theoretical framework in multiple sites to examine why clinicians' delay identification and action on patients' clinical deterioration. AIM: To identify barriers and facilitators that influence clinicians' absent or delayed response to patient clinical deterioration using the Theoretical Domains Framework. METHODS: The Theoretical Domains Framework guided: (a) semi-structured interviews with clinicians, health consumers and family members undertaken at two sites; (b) deductive analyses of inductive themes to identify barriers and facilitators to optimal care. This study complied with the COREQ research guidelines. FINDINGS: Seven themes identified: (a) information transfer; (b) ownership of patient care; (c) confidence to respond; (d) knowledge and skills; (e) culture; (f) emotion; and (g) environmental context and resources. DISCUSSION: The Theoretical Domains Framework identified traditional social and professional hierarchies and limitations due to environmental contexts and resources as contributors to diminished interprofessional recognition and impediments to the development of effective relationships between professional groups. Communication processes were impacted by these restraints and further confounded by inadequate policy development and limited access to regular effective team-based training. As a result, patient safety was compromised, and clinicians frustrated. CONCLUSIONS: These results inform the development, implementation and evaluation of a behaviour change intervention and increase knowledge about barriers and facilitators to timely response to patient clinical deterioration. RELEVANCE TO CLINICAL PRACTICE: Results contribute to understanding of why clinicians delay responding to patient clinical deterioration and suggest key recommendations to identify and challenge traditional hierarchies and practices that prevent interdisciplinary collaboration and decision-making.

The Impact of Robotic-Assisted Surgery on Team Performance: A Systematic Mixed Studies Review.

OBJECTIVE: The aim of this study is to describe the impact of robotic-assisted surgery on team performance in the operating room. BACKGROUND: The introduction of surgical robots has improved the technical performance of surgical procedures but has also contributed to unexpected interactions in surgical teams, leading to new types of errors. METHOD: A systematic literature search of Cumulative Index to Nursing and Allied Health Literature, PubMed, ProQuest, Cochrane, Web of Science, PsycINFO, and Scopus databases using key words and MeSH terms was conducted. Screening identified studies employing qualitative and quantitative methods published between January 2000 and September 2019. Two reviewers independently appraised the methodological quality of the articles using the Mixed Methods Appraisal Tool (2018). Discussions were held among authors to examine quality scores of the studies and emergent themes, and agreement was reached through consensus. Themes were derived using inductive content analysis. RESULTS: Combined searches identified 1,065 citations. Of these, 19 articles, 16 quantitative and 3 qualitative, were included. Robotic-assisted surgeries included urology, gynecology, cardiac, and general procedures involving surgeons, anesthetists, nurses, and technicians. Three themes emerged: Negotiating the altered physical environs and adapting team communications to manage task and technology; managing the robotic system to optimize workflow efficiency; and technical proficiency depends on experience, team familiarity, and case complexity. CONCLUSION: Inclusion of a robot as a team member adds further complexity to the work of surgery. APPLICATION: These review findings will inform training programs specifically designed to optimize teamwork, workflow efficiency, and learning needs.

Empathy in pregnant women and new mothers: a systematic literature review.

OBJECTIVE: This systematic review explores changes in perinatal empathy and influence on maternal behaviours and child development. BACKGROUND: The well-being and development of infants are commonly linked to their mothers' capacity for empathy. However, characteristic changes during pregnancy and childbirth including sleep deprivation, mood and cognitive difficulties may disrupt empathic processing. METHODS: Original research papers (n = 7413) published in English language peer-reviewed academic journals were obtained by searching four electronic databases PsycINFO, PubMed, Scopus and CINAHL. Inclusion criteria were studies reporting empathy of women in the period from pregnancy to 12 months postpartum. Empathy was operationalised as a general tendency of empathic emotional responding and cognitive perspective taking. Thirteen studies were systematically assessed using the Critical Appraisal Skills Programme criteria. RESULTS: Impaired empathy in mothers, due most notably to high personal distress, was associated with risk of neglect or maltreatment of children and was partially explained by mothers' aversive response to infant crying. CONCLUSION: Few studies present empathy as a central theme. There is a paucity of definitional parameters and theoretical linkages and over-reliance on brief self-report indices of empathy. Future studies need to be theory based, incorporate experimental approaches, and provide greater sampling diversity toadvance our understanding of empathy in perinatal women.

Childbirth and criteria for traumatic events.

OBJECTIVE: for some women childbirth is physically and psychologically traumatic and meets Criterion A1 (threat) and A2 (intense emotional response) for Posttraumatic Stress Disorder of the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV).This study differentiates Criterion A1 and A2 to explore their individual relationship to prevalence rates for posttraumatic stress, each other, and associated factors for childbirth trauma. DESIGN AND SETTING: women were recruited at three hospitals from October 2008 to October 2009. Questionnaires were completed at recruitment and at 14 days post partum. PARTICIPANTS: women in the third trimester of pregnancy (n=890) were recruited by a research midwife while waiting for their antenatal clinic appointment. Participants were over 17 years of age, expected to give birth to a live infant, not undergoing psychological treatment, and able to complete questionnaires in English. FINDINGS: this study found 14.3% of women met criteria for a traumatic childbirth. When the condition of A2 was removed, the prevalence rate doubled to 29.4%. Approximately half the women who perceived threat in childbirth did not have an intense negative emotional response. Predictors of finding childbirth traumatic were pre-existing psychiatric morbidity, being a first time mother and experiencing an emergency caesarean section. KEY CONCLUSIONS: the fear response is an important diagnostic criterion for assessing psychologically traumatic childbirth. The identification of risk factors may inform maternity service delivery to prevent traumatic birth and postpartum approaches to care to address long-term negative consequences. IMPLICATIONS FOR PRACTICE: prevention and treatment of traumatic childbirth are improved through knowledge of potential risk factors and understanding the woman's subjective experience.