Identifying physical therapists' attitudes, beliefs, and barriers toward diagnostic imaging referral: a mixed-methods study.

OBJECTIVE: Ten states, including the District of Columbia, have laws that currently permit physical therapists (PTs) to directly order diagnostic imaging (DI) in the United States. Military and civilian PTs order DI judiciously and appropriately demonstrating optimal patient outcomes and satisfaction when compared to other medical professionals. However, no studies have explored perceived attitudes, beliefs, and barriers to PT DI referral specific to North Dakota (ND). Therefore, the purpose of this mixed-methods study was to identify ND PTs' attitudes, beliefs, and barriers toward DI referral. METHODS: A total of 147 participants completed an online survey with a subset of 17 participants agreeing to an interview. Frequency counts of demographic data and perceived barriers were completed. A binary logistic regression was run on demographic data. One-on-one interviews were conducted with a thematic coding process completed within a qualitative analysis. RESULTS: Seventy-four percent of PTs reported not currently referring for DI, although 71% felt that it would improve their patient outcomes. PTs with post-professional training (OR = 4.59), a doctorate degree (OR = 3.84), practicing in an orthopaedic or sports setting (OR = 3.55), and practicing within an urban setting of ND (OR = 3.01) were more likely to refer for DI. The main barriers identified in the survey included: (1) the logistics of performing a DI referral, (2) DI referrals only privileged to other medical providers, (3) provider/work relationship dynamics, (4) the cost of continuing education (CE), (5) and the inability to identify CE. One-on-one interviews further identified five main themes related to DI referral. DISCUSSION/CONCLUSION: Several barriers identified resulted in 74.1% of PTs not directly referring for DI, although certain characteristics (post-professional training, doctorate degree, orthopaedic/sports setting, practicing in an urban area in ND) were more likely to refer for DI. This study may help improve future adoption and implementation of DI referral in current and future states.

Intubation drug pack containing pre-filled syringes reduces the time to endotracheal intubation in a simulated paediatric emergency.

To determine if an intubation drugs pack containing pre-filled syringes can reduce the time to endotracheal intubation compared with standard care during a simulated paediatric emergency. Twenty doctors (10 consultants and 10 registrars) who worked in the paediatric intensive care unit or anaesthetic department of a tertiary paediatric hospital were asked to participate in an in situ simulated emergency paediatric intubation scenario. The participants were instructed to prepare and administer intubation medications. They were randomised to either an intubation drug pack, containing pre-filled syringes or to standard care where each of the drugs had to be individually drawn-up. The mean time to intubation when using the pre-filled syringes of 159.5 s was over three times faster than with standard care of 497.5 s (p<0.001), allowing intubation to occur on average 5 min and 38 s earlier. Utilising an intubation drug pack containing pre-filled syringes significantly reduced the time from decision to intubate to intubation in a simulated paediatric emergency. This applied irrespective of clinical experience with registrars utilising the pre-filled syringes outperforming consultant anaesthetists when they used standard care.

Simulation-based Education and Human Factors Training in Postgraduate Medical Education: A Northern Ireland Perspective.

With their potential to improve patient safety, simulation based education (SBE) and human factors training are gaining momentum across the spectrum of medical education. There are ever increasing drivers for their integration, in particular within the postgraduate arena. This article aims to provide an overview of both simulation based education and human factors training. The breadth of terminology can be bewildering and our target audience is novice or developing practitioners and policymakers. We focus particularly on a regional setting where the Northern Ireland Simulation and Human Factors Network (NISHFN) is working to advance the field.

Developing leadership as a trainee- opportunities, barriers and potential improvements.

The General Medical Council explicitly state that doctors completing training should demonstrate capabilities in leadership and teamwork.1 However, most trainees receive little formal training in leadership. In March 2017, at the Faculty of Medical Leadership and Management (FMLM) Northern Ireland Regional Conference, a workshop on developing leadership skills as a trainee was hosted and the views of doctors in training regarding current opportunities, potential barriers and improvements were sought. In Northern Ireland presently there are a number of opportunities available for trainees to gain experience in leadership - both by learning through observation and learning through experience. These range from informal activities which do not require significant time commitment to focused, immersive leadership experiences such as ADEPT (Achieve Develop Explore Programme for Trainees)2, and the Royal College of Physicians' Chief Registrar scheme.3 Several barriers to developing leadership have been identified, including limited understanding of what constitutes leadership, a lack of senior support and little formal recognition for trainees leading teams. Time pressures, frequently rotating jobs, limited resources and difficulty upscaling can also undermine the sustainability of improvement and other leadership projects. Incorporating awareness of and training in leadership skills, as well as greater engagement with senior leaders and managers, at an early stage in training could promote understanding and encourage trainees. Formalising leadership roles within training posts may improve experience. Deaneries and Trusts can also enable leadership opportunities by facilitating study leave, raising awareness amongst supervisors, and providing career enhancing incentives for interested trainees.

Safety of reassessment-and-release practice for mental health patients boarded in the emergency department.

OBJECTIVES: Among emergency department (ED) mental health and substance abuse (MHSA) patients, we sought to compare mortality and healthcare utilization by ED discharge disposition and inpatient bed request status. METHODS: A retrospective cohort study of 492 patients was conducted at a single University ED. We reviewed three groups of MHSA patients including ED patients that were admitted, ED patients with a bed request that were discharged from the ED, and ED patients with no bed request that were discharged from the ED. We identified main outcomes as ED return visit, re-hospitalization and mortality within 12months based on chart review and reference from the National Death Index. RESULTS: The average age of patients presenting was 30.5 (SD16.4) years and 251 (51.0%) were female patients. Of these patients, 216 (43.9%) presented with mood disorder and 93 (18.9%) with self-harm. The most common reason for discharge from the ED after an admission request was placed was from stabilization of the patient (n=138). An ED revisit within 12months was significantly higher among patients discharged who had a bed request in place prior to departure (54.0%, p<0.001), than those discharged from the ED (40.9%) or admitted to inpatient care (30.5%). The rate of suicide attempt and death did not show statistical significance (p=0.55 and p=0.88). CONCLUSION: MHSA patients who were discharged from ED after bed requests were placed were at greater risk for return visits to the ED. This implicates that these patients require outpatient planning to prevent further avoidable healthcare utilization.

Improving paediatric prescribing practice in a district general hospital through implementation of a quality improvement programme.

Prescribing errors are a well recognised cause of adverse incidents and have a direct effect on patients.[1] This impacts on the doctor-family relationship and results in breakdown of trust and communication.[2] This quality improvement project was carried out in the paediatric ward of a district general hospital in Northern Ireland. A retrospective analysis of paediatric prescribing errors between January and December 2013 identified two errors that were felt to be secondary to under-reporting. A baseline audit was subsequently performed that highlighted 32 errors across 12 drug charts. A driver diagram identified three components contributing to prescribing errors and relevant tests of change were developed. The three primary drivers included: education and communication, practical prescribing changes, and medicine reconciliation. Seven interventions were implemented sequentially over a six month period and their effectiveness assessed by a prospective drug chart audit. Ten drug charts were selected at random by the staff nurse allocated to medications on the day of audit. The charts were audited using a predesigned proforma and the total number of errors counted. These were subcategorised and results displayed in graphical format after each intervention. Seven audit cycles were completed in total after each intervention was put into practice. The number of errors (including percentage change following each intervention) is as follows: intervention 1: 32 (+19%); Intervention 2: 31 (+15%); Intervention 3: 17 (-37%); Intervention 4: 12 (-56%); Intervention 5: 15 (-44%); Intervention 6: 7 (-74%); Intervention 7: 10 (-63%). In conclusion, permanent and successful measures are needed to reduce prescribing errors in order to minimise the impact of staff changeover and knowledge deficits.

Validation of the Saskatoon Falls Prevention Consortium's Falls Screening and Referral Algorithm.

PURPOSE: To investigate the concurrent validity of the Saskatoon Falls Prevention Consortium's Falls Screening and Referral Algorithm (FSRA). METHOD: A total of 29 older adults (mean age 77.7 [SD 4.0] y) residing in an independent-living senior's complex who met inclusion criteria completed a demographic questionnaire and the components of the FSRA and Berg Balance Scale (BBS). The FSRA consists of the Elderly Fall Screening Test (EFST) and the Multi-factor Falls Questionnaire (MFQ); it is designed to categorize individuals into low, moderate, or high fall-risk categories to determine appropriate management pathways. A predictive model for probability of fall risk, based on previous research, was used to determine concurrent validity of the FSRI. RESULTS: The FSRA placed 79% of participants into the low-risk category, whereas the predictive model found the probability of fall risk to range from 0.04 to 0.74, with a mean of 0.35 (SD 0.25). No statistically significant correlation was found between the FSRA and the predictive model for probability of fall risk (Spearman's ρ=0.35, p=0.06). CONCLUSION: The FSRA lacks concurrent validity relative to to a previously established model of fall risk and appears to over-categorize individuals into the low-risk group. Further research on the FSRA as an adequate tool to screen community-dwelling older adults for fall risk is recommended.

Objectif : Étudier la validité concurrente de l'algorithme de dépistage des risques de chute et de renvoi en consultation (Falls Screening and Referral Algorithm, FSRA) du Saskatoon Falls Prevention Consortium. Méthode : Vingt-neuf personnes âgées (moyenne d'âge [ET] de 77,7 ans [4,0]) vivant dans une résidence pour personnes âgées autonomes satisfaisaient les critères d'inclusion; elles ont rempli un questionnaire démographique et ont été soumises à certaines composantes du FSRA et du test d'équilibre de l'échelle de Berg (EEB). Le FSRA comprend un test de dépistage des risques de chute (Elderly Fall Screening Test, EFST) et le questionnaire multifactoriel en matière de chutes (Multi-Factor Falls Questionnaire, MFQ). Il est conçu pour classer les individus dans trois catégories ­ risque de chute élevé, modéré ou faible ­ afin d'établir les approches de gestion appropriées. Un modèle prédictif de probabilité des risques de chute basé sur une étude antérieure a été utilisé pour établir la validité concurrente du FRSA. Résultats : Au total, 79 % des participants ont été classés dans la catégorie à faible risque du FSRA, puisque le modèle prédictif a permis d'établir la probabilité des risques de chute dans leur cas entre 0,04 et 0,74, avec une moyenne de 0,35 (ET=0,25). On n'a pu établir aucune corrélation significative sur le plan statistique entre le FSRA et le modèle prédictif de la probabilité des risques de chute (ρ de Spearman=0,35, p=0,06). Conclusion : Le FSRA manque de validité concurrente si on le compare à un modèle de risques de chute préalablement établi et semble « surclasser ¼ les individus dans le segment à faible risque. D'autres études sur le FSRA en tant qu'outil approprié de dépistage chez les aînés résidant dans la communauté sont recommandées.