Perceptions of conflicting information about long-term medications: a qualitative in-depth interview study of patients with chronic diseases in the Swiss ambulatory care system.

OBJECTIVE: Patients with multiple long-term conditions visit various healthcare professionals and are exposed to medication information from various sources causing an increased risk of patients perceiving contradictory medication information. The aims of this study are to: (1) characterise conflicting medication information perceived by patients with long-term conditions, (2) better understand the related impact on patients' medication self-management and healthcare system navigation and (3) explore ways in which such events could be prevented. DESIGN: This study was conducted through qualitative semistructured interviews. Data were analysed using thematic analysis. SETTING: Community pharmacies and medical centres in Geneva, Switzerland. PARTICIPANTS: This study included outpatients from April 2019 to February 2020. Patients were included after participating in a quantitative survey of perceived conflicting information about medications for long-term diseases. METHODS: Semistructured audiotaped interviews of 20 to 60 min following a pre-established interview guide to explore participants' perceptions of conflicting information. Interviews were transcribed verbatim, and a thematic analysis was conducted with inductive and deductive coding using MAXQDA (2018, Release 18.2.3). RESULTS: Twenty-two patients were interviewed, until data saturation, mentioning indication or need for a medication as the main topic of conflicting information between two healthcare professionals. Perceived conflicting information often resulted from insufficient information provided and poor communication leading to confusion, doubts and medication non-adherence. Patients expected more information and more interprofessional communication on their medications. As a result of conflicting information, most participants learnt or were learning to take an active role and become partners of the healthcare providers. CONCLUSION: The need to strengthen and improve communication and interprofessional collaborative practice among healthcare professionals and with the patient is emerging to increase the quality and consistency of information about medications, and consequently, to ensure better use and experience of medications.

Patients' perceptions of conflicting information on chronic medications: a prospective survey in Switzerland.

OBJECTIVE: The number of patients with chronic diseases and subsequent visits to various healthcare professionals has been rising over the past decades, exposing patients to potential risks of receiving conflicting medication information. This study aims to investigate the prevalence of conflicting information on medications perceived by chronic patients in Switzerland and to understand its impact on patients' medication self-management and navigation in the healthcare system. PARTICIPANTS: This cross-sectional study included adult patients taking at least one prescribed medication for at least 6 months, who had visited at least two physicians in the past 3 months. MAIN OUTCOME MEASURES: Data on patients' perceptions of conflicting information were collected in person through a 17-item questionnaire available on paper and electronically with four domains: (1) whether the patient had perceived any conflicting information, (2) categories of conflicting information, (3) impact and (4) sources involved in the conflicting information. RESULTS: Of the 405 included patients, 47% perceived conflicting information related to one or more medication topics including indication, schedule, dosage, risk, severity or duration of side effects. Patients who perceived conflicting information were prescribed more drugs than those perceiving no conflicting information (p<0.01). Consequently, 65% of the participants modified their navigation of the healthcare system and 34% reported medication non-adherence. General practitioners (82%), specialist physicians (74%) and pharmacists (49%) were the healthcare professionals most often involved in conflicting information. Experience with the medication, its package insert and significant others were more frequently involved in conflicting information than internet or social media. CONCLUSION: Nearly half the patients in our study perceived conflicting information in the outpatient healthcare system, which can decrease medication effectiveness and pose safety issues. This issue is widely overlooked and unaddressed. Consistency of information among healthcare providers in partnership with patients should be reinforced through guidelines and new models of interprofessional care.

Interprofessional training: Start with the youngest! A program for undergraduate healthcare students in Geneva, Switzerland.

AIMS: Demography of patients and complexity in the management of multimorbid conditions has made collaborative practice a necessity for the future, also in Switzerland. Since 2012, the University of Applied Sciences (UAS) and its Healthcare School as well as the University of Geneva (UG) with its Medical Faculty have joined forces to implement a training program in collaborative practice, using simulation as one of the main learning/teaching process. METHODS: The actual program consists of three sequential modules and totalizes 300 h of teaching and learning for approximately 1400-1500 students from six tracks (nutritionists, physiotherapists, midwives, nurses, technologists in medical radiology, physicians); in 2019 another hundred pharmacists will also be included. The main issues addressed by the modules are Module 1: the Swiss healthcare system and collaborative tools. Module 2: roles and responsibilities of the different health professionals, basic tools acquisition in team working (situation monitoring, mutual support, communication). Module 3: the axis of quality and safety of care through different contexts and cases. CONCLUSIONS: A very first evaluation of the teaching and learning and particularly on the aspects of acquisition of collaborative tools shows positive attitudes of students towards the implementation of this new training program. Furthermore, a pre-post questionnaire on teamwork aspects reveals significant modifications.

SwissScoring--a nationwide survey of SAPS II assessing practices and its accuracy.

OBJECTIVE: The first description of the simplified acute physiology score (SAPS) II dates back to 1993, but little is known about its accuracy in daily practice. Our purpose was to evaluate the accuracy of scoring and the factors that affect it in a nationwide survey. METHODS: Twenty clinical scenarios, covering a broad range of illness severities, were randomly assigned to a convenience sample of physicians or nurses in Swiss adult intensive care units (ICUs), who were asked to assess the SAPS II score for a single scenario. These data were compared to a reference that was defined by five experienced researchers. The results were cross-matched with demographic characteristics and data on the training and quality control for the scoring, structural and organisational properties of each participating ICU. RESULTS: A total of 345 caregivers from 53 adult ICU providers completed the SAPS II evaluation of one clinical scenario. The mean SAPS II scoring was 42.6 ± 23.4, with a bias of +5.74 (95%CI 2.0-9.5) compared to the reference score. There was no evidence of bias variation according to the case severity, ICU size, linguistic area, profession (physician vs. nurse), experience, initial SAPS II training, or presence of a quality control system. CONCLUSION: This nationwide survey revealed substantial variability in the SAPS II scoring results. On average, SAPS II scoring was overestimated by more than 13%, irrespective of the profession or experience of the scorer or of the structural characteristics of the ICUs.

Needs assessment for training in interprofessional skills in Swiss primary care: a Delphi study.

Despite the importance of appropriate interprofessional collaboration in health care, it is still insufficiently taught in health professions education. The aim of the study was to conduct a needs assessment among health professionals on the themes and skills to be taught during interprofessional education programs in the context of Swiss primary care. A three round Delphi electronic survey was carried out in order to identify priority themes and skills to be included in such a program. Participants comprised 12 categories of health professionals. Seventy-two participated in the first, 41 in the second and 43 in the third round. Patient communication, case management of chronic conditions, therapeutic patient education, health promotion and prevention, ethics and medication were the most important themes identified. The most important skill was regarded as "to define and then share tasks and responsibilities between professionals". Sub-analysis revealed that both priority themes and skills chosen differed between health professional categories.

The predictive validity of the aptitude test for the performance of students starting a medical curriculum.

INTRODUCTION: Selection of medical students varies between German- and French-speaking Swiss faculties. Geneva introduced an aptitude test in 2010, aimed at helping decision making among students. The test was compulsory: it had to be taken by those who intended to register for medical studies. But it was not selective: there was no performance threshold under which registration would have been denied. METHODS: We followed 353 students who took the test in 2010, checked whether they confirmed their registration for medical studies and studied their performance during year 1 (selective year). RESULTS: The correlation between the aptitude test result and the academic performance during year 1 was 0.47 (n = 191), and weakened to 0.38 (n = 214) when including repetition of year 1. The failure to pass in year 2 or success were associated with the aptitude test results (p <0.001). Overall, 20% of the students succeeded after one year, 26% after a repeated year 1, and 53% failed and could not follow further medical studies. CONCLUSION: Though there was a clear association between the aptitude test and academic performance, students did not appear to take into account when making their career decisions the ability of the test (as implemented in Geneva, that is, compulsory but not selective) to predict their future performance in the medical programme. The test was withdrawn after the 2012 session, but a number of issues regarding the medical selection procedure remain to be addressed.

Harmonisation of anaesthesiology training in Europe.

The last 20 years has seen many changes in medical education, with reforms taking place in undergraduate health-care studies with the application of the Bologna principles and also transfer of the same educational principles to postgraduate medical specialty training. It is the aim of this article to grossly sketch and contextualise these reforms in the rapidly evolving European Union, before defining harmonisation of the medical postgraduate training and the bodies involved in this process; thereafter, the authors try to present the potential consensus points that can make the process of harmonisation in anaesthesiology postgraduate training in Europe become a reality. Finally, a brief outline of the potential challenges concludes the paper.

Education, teaching & training in patient safety.

Patient Safety is not a side-effect of good patient care by skilled clinicians. Patient safety is a subject on its own, which was traditionally not taught to medical personnel. This must and will dramatically change in the future. The 2010 Helsinki Declaration for Patient Safety in Anaesthesiology states accordingly "Education has a key role to play in improving patient safety, and we fully support the development, dissemination and delivery of patient safety training". Patient safety training is a multidisciplinary topic and enterprise, which requires us to cooperate with safety experts from different fields (e.g. psychologists, educators, human factor experts). Anaesthesiology has been a model for the patient safety movement and its European organisations like ESA and EBA have pioneered the field up to now: Helsinki Patient Safety Declaration and the European Patient Safety Course are the newest establishments. But Anaesthesiology must continue in its efforts in order to stay at the top of the patient safety movement, as many other disciplines gain speed in this topic. We should strive to fulfill the Helsinki Declaration and move even beyond that. As the European Council states: "Education for patient-safety should be introduced at all levels within health-care systems"

Low-dose sufentanil does not potentiate intrathecal morphine for perioperative analgesia after major colorectal surgery.

PURPOSE: Both intrathecal sufentanil (ITS) and intrathecal morphine (ITM) improve analgesia in obstetrical or cardiac procedures. From a pharmacokinetic standpoint, combining these two opioids may improve perioperative analgesia. We performed a prospective randomized double-blind study to compare the analgesic efficacy of ITM alone vs a mixture of a low dose of ITS plus ITM for perioperative pain relief in colorectal surgery. METHODS: Eighty adult patients undergoing colorectal surgery were randomly allocated to receive either 0.4 mg ITM alone or 10 microg ITS plus 0.4 mg ITM before general anesthesia. Intraoperative intravenous sufentanil consumption, postoperative morphine consumption delivered with a patient controlled analgesia device, pain scores, patient satisfaction and adverse effects were recorded for the first 48 hr postoperatively. RESULTS: No differences were observed between groups with respect to intraoperative sufentanil consumption (39 +/- 23 microg in group ITM and 40 +/- 25 microg in group ITS plus ITM, P = 0.85) and in postoperative morphine consumption in postanesthesia care unit (6 +/- 5 mg vs 6 +/- 5 mg, P = 0.59), at 24 hr (26 +/- 17 vs 24 +/- 15 mg, P = 0.59) and at 48 hr (47 +/- 31 vs 44 +/- 22 mg, P = 0.58). Similarly, no differences were observed in regards to pain relief, patient satisfaction and incidence of adverse effects. CONCLUSIONS: These results do not support the addition of 10 microg ITS to 0.4 mg ITM for colorectal surgery, as low dose sufentanil does not improve intraoperative and postoperative analgesia in this setting.

Non-invasive ventilation in the recovery room for postoperative respiratory failure: a feasibility study.

BACKGROUND: Non-invasive ventilation (NIV) has become a standard of care in acute respiratory failure. However, little data is available on its usefulness in recovery ward patients after general surgery. The present study aimed to document the feasibility of implementing NIV in this setting, and its impact on lung function. METHODS: During a 12-month period, all adult patients who underwent elective general surgical procedures under general anaesthesia during weekdays, were transferred to the recovery ward after extubation, and those who required NIV were included in this prospective observational study. NIV was applied with a bilevel device (VPAP II ST, ResMed, North Ryde, Australia). RESULTS: 4622 patients were admitted to the recovery ward, 83 of whom needed NIV. NIV increased pH (7.38 +/- .06 vs 7.30 +/- .05), reduced PaCO2 (7.38 +/- .06 vs 7.30 +/- .05) in hypercapnic patients (44 +/- 9 vs 55 +/- 10 mm Hg), and increased PaO2 in non-hypercapnic patients (80 +/- 10 vs 70 +/- 11 mm Hg). No complications attributable to NIV occurred. Most patients improved after 1-2 NIV trials, and all were transferred to the ward the same day. CONCLUSIONS: In recovery ward patients after general surgery, NIV is seldom required. When applied, NIV seems to exert favourable effects on lung function. NIV can be safely implemented with a bilevel device in a recovery ward not accustomed to the use of ICU ventilators. The cost-effectiveness of its systematic use in this setting should be assessed.

Development of clinical reasoning from the basic sciences to the clerkships: a longitudinal assessment of medical students' needs and self-perception after a transitional learning unit.

BACKGROUND: To facilitate students' transition from basic, science-oriented, problem-based learning (PBL) to clinical reasoning-oriented PBL, the University of Geneva School of Medicine introduced a 12-week unit of Introduction to Clinical Reasoning (ICR) at the beginning of its fourth or clerkship year. PURPOSE: The aims of the present study were to determine, after 12 weeks in the ICR unit, to what extent students had: (1) identified the learning content set by the faculty while adapting to the hypothetico-deductive reasoning approach; (2) familiarised themselves with the clinical reasoning-oriented learning process, and (3) transferred and further developed this process during the clinical years. METHOD: Students' derived objectives from the problems were compared to the objectives preset by the faculty to determine acquisition of intended learning content. To assess their adaptation to the clinical reasoning-oriented PBL approach, students (n = 124) were asked to list and freely comment on aspects of the unit they felt most at ease with or had difficulty with, and to complete a questionnaire on the clinical reasoning process (CRP). The same questionnaire was administered 6 and 12 months later to assess the evolution of the students' self-perception during clerkships. RESULTS: On average, student objectives matched 62% of faculty objectives. Half of the missed (38%) objectives were in basic sciences. Students generated 16% additional objectives, also predominantly in the basic sciences category (41%). Free comments indicated that the difficulties perceived by students were very similar to those previously reported in studies on reasoning and errors, such as difficulty in gathering, interpreting and weighting relevant data, synthesising information, and organising it hierarchically. These results were confirmed with the CRP questionnaire administered at the end of the unit. For most of the competencies assessed on the CRP questionnaire, a gradual improvement was seen to have occurred by 6 and 12 months after the unit. CONCLUSIONS: To ease students' transition from the preclinical to clinical years, a learning unit should give them the opportunity to train their clinical reasoning processes on standardised and prototypical problems, before encountering real patients with more ill-structured problems during clerkships. Such a transitional structure should particularly emphasise a developed repertoire of problem representations, recognition of key findings and a hierarchical classification of working hypotheses. It should foster the creation of links between the acquired basic clinical knowledge and the diagnostic, management and therapy steps of problem solving.

Isobaric versus hypobaric spinal bupivacaine for total hip arthroplasty in the lateral position.

UNLABELLED: Total hip arthroplasty (THA) is frequently performed under spinal anesthesia using either isobaric or hypobaric anesthetic solution. However, these two solutions have never been compared under similar surgical conditions. In the present study, we compared the anesthetic and hemodynamic effects of isobaric and hypobaric bupivacaine in 40 ASA physical status I-II patients undergoing THA in the lateral decubitus position under spinal anesthesia. With operative side up, patients randomly received, in a double-blinded manner, a spinal injection of 3.5 mL (17.5 mg) of plain bupivacaine mixed with either 1.5 mL of normal saline (isobaric group) or 1.5 mL of distilled water (hypobaric group). Sensory level and degree of motor block were evaluated on the nondependent and dependent sides until regression to L2 and total motor recovery. Hemodynamic changes during the first 45 min after spinal injection, and the time between spinal administration and first analgesic for a pain score >3 (on a 0-10 scale) were noted. Demographic characteristics of both groups were comparable. Upper sensory level and maximal degree of motor block were comparable between the operative and nonoperative sides in each group and between corresponding sides in both groups. Compared with the isobaric group, in the hypobaric group there was a prolonged time to sensory regression to L2 on the operative side (287 +/- 51 versus 242 +/- 36 min, P < 0.004) and a prolonged time to first analgesic (290 +/- 46 versus 237 +/- 39 min, P < 0.001). No difference in quality of motor block was noted at the end of surgery. Hemodynamic changes were comparable. We conclude that for THA in the lateral position, spinal hypobaric bupivacaine seems to be superior to isobaric in that it prolongs the sensory block on the operative side and delays the use of analgesics after surgery without further compromising hemodynamic stability. IMPLICATIONS: For total hip arthroplasty in the lateral position, spinal hypobaric bupivacaine compared with isobaric prolonged sensory block at the operative side and delayed the time to first analgesic.

Cerebrospinal fluid density influences extent of plain bupivacaine spinal anesthesia.

BACKGROUND: The attempts to explain the unpredictability of extent of spinal block provided by plain local anesthetic solutions have resulted in many clinical reports; however, causes of this uncertainty are as yet unknown. Recently, normal values of the human cerebrospinal fluid densities have been studied showing important interindividual variations, especially between females and males. The current study was designed to evaluate as primary endpoint the influence of cerebrospinal fluid density values on the extent of spinal block with plain bupivacaine. The ancillary endpoints were search of factors explaining the interindividual differences in cerebrospinal fluid density values reported and determination of the relation between upper extent and regression of spinal anesthesia. METHODS: Sixty-four consecutive patients undergoing peripheral orthopedic surgery with spinal block were enrolled. Spinal anesthesia was performed in the lateral decubitus position with the operated side upward. Two milliliters of cerebrospinal fluid was sampled before injection of 3 ml plain bupivacaine 0.5%. The patient was immediately turned supine and remained in the horizontal position until the end of the study. Maximal sensory block level and time to sensory regression to L4 were determined for each patient enrolled. Cerebrospinal fluid and bupivacaine densities as well as cerebrospinal proteins, glucose, sodium, and chloride concentrations were measured. RESULTS: A highly significant correlation between cerebrospinal fluid density and maximal sensory block level was found (P = 0.0004). However, this correlation was poorly predictive (R(2) = 0.37). Cerebrospinal fluid density, proteins, and glucose concentrations were significantly higher in men than in women: 1.000567 +/- 0.000091 versus 1.000501 +/- 0.000109 g/ml (P = 0.014), 0.46 +/- 0.18 versus 0.32 +/- 0.13 g/l (P = 0.001), and 3.27 +/- 0.7 versus 2.93 +/- 0.5 mM (P = 0.023), respectively. A highly significant (P = 0.0004) and predictive (R(2) = 0.73) inverse correlation was found between maximal upper sensory extent and sensory regression to L4. CONCLUSION: These findings indicate an influence of cerebrospinal fluid density on subarachnoid distribution of 3 ml plain bupivacaine 0.5% and show that with higher cerebrospinal fluid densities, a higher spinal block level can be expected.