Policies for Mandatory Ethics Consultations at U.S. Academic Teaching Hospitals: A Multisite Survey Study.

OBJECTIVES: To determine the number of top-ranked U.S. academic institutions that require ethics consultation for specific adult clinical circumstances (e.g., family requests for potentially inappropriate treatment) and to detail those circumstances and the specific clinical scenarios for which consultations are mandated. DESIGN: Cross-sectional survey study, conducted online or over the phone between July 2016 and October 2017. SETTING: We identified the top 50 research medical schools through the 2016 U.S. News and World Report rankings. The primary teaching hospital for each medical school was included. SUBJECTS: The chair/director of each hospital's adult clinical ethics committee, or a suitable alternate representative familiar with ethics consultation services, was identified for study recruitment. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A representative from the adult ethics consultation service at each of the 50 target hospitals was identified. Thirty-six of 50 sites (72%) consented to participate in the study, and 18 (50%) reported having at least one current mandatory consultation policy. Of the 17 sites that completed the survey and listed their triggers for mandatory ethics consultations, 20 trigger scenarios were provided, with three sites listing two distinct clinical situations. The majority of these triggers addressed family requests for potentially inappropriate treatment (9/20, 45%) or medical decision-making for unrepresented patients lacking decision-making capacity (7/20, 35%). Other triggers included organ donation after circulatory death, initiation of extracorporeal membrane oxygenation, denial of valve replacement in patients with subacute bacterial endocarditis, and posthumous donation of sperm. Twelve (67%) of the 18 sites with mandatory policies reported that their protocol(s) was formally documented in writing. CONCLUSIONS: Among top-ranked academic medical centers, the existence and content of official policies regarding situations that mandate ethics consultations are variable. This finding suggests that, despite recent critical care consensus guidelines recommending institutional review as standard practice in particular scenarios, formal adoption of such policies has yet to become widespread and uniform.

States Move to Ban Pelvic Exams on Unconscious Women.

Despite long-standing ethical concerns, the practice has persisted.

Inadequate conflict of interest policies at most French teaching hospitals: A survey and website analysis.

BACKGROUND: There are 32 teaching hospitals in France, including 30 University hospitals and two Regional teaching hospitals. Teaching hospitals have three roles: health care provision, training of healthcare professionals, and medical research. These roles lead to frequent interactions with pharmaceutical and medical device companies, inevitably raising risks of conflicts of interests. Therefore, policies to manage conflict of interests (COI) are crucial. This study aims to examine COI policies in French teaching hospitals. METHODS: All French teaching hospitals (n = 32) were included in this study. All hospitals websites were screened for institutional COI policies and curriculum on COI, using standardized keyword searches. More data were collected through a questionnaire addressed to each chief executive officer (CEO) of the teaching hospital. We used predefined criteria (n = 20) inspired by similar surveys on COI policies in French, US and Canadian medical schools, with some additions to reflect the local hospital context. A global score for each hospital, ranging from 0 to 60 (higher scores denoting stronger policies) was calculated by summing points obtained for each criterion. RESULTS: All 32 hospitals had websites; 21 hospitals listed policies or regulations on their websites or provided them on request. In December 2017, 17 (53.1%) had rules and regulations for some items only, four of which (12.5%) have considered implementing a policy, and only two (6.3%) have begun implementation. 15 (46.9%) had no evidence of COI policies and a null score. The maximum score was 24 out of 60. CONCLUSION: This is the first systematic assessment of COI policies in teaching hospitals in France. Such policies are needed to protect patients, clinicians and students from undue commercial influence. Despite public and political pressure for better management of COI, few teaching hospitals have implemented comprehensive and protective policies, and some hospitals lacked policies altogether. These results highlight the need for greater attention to management of COI within teaching hospitals. One potential solution would be to integrate COI policies into hospital accreditation procedures, in order to ensure a baseline of management at all teaching hospitals.

Frequency of Ethical Issues on a Hospitalist Teaching Service at an Urban, Tertiary Care Center.

Little is known about the daily ethical conflicts encountered by hospitalists that do not prompt a formal clinical ethics consultation. We describe the frequencies of ethical issues identified during daily rounds on hospitalist teaching services at a metropolitan, tertiary-care, teaching hospital. Data were collected from September 2017 through May 2018 by two attending hospitalists from the ethics committee who were embedded on rounds. A total of 270 patients were evaluated and 113 ethical issues were identified in 77 of those patients. These issues most frequently involved discussions about goals of care, treatment refusals, decision-making capacity, discharge planning, cardiopulmonary resuscitation status, and pain management. Only five formal consults were brought to the Hospital Ethics Committee for these 270 patients. Our data are the first prospective description of ethical issues arising on academic hospitalist teaching services and are an important step in the development of a targeted ethics curriculum for hospitalists.

How to optimize the prescription of laboratory tests? Success and failures in an academic hospital.

In the context of the flat-rate reimbursements in healthcare, we reviewed physicians' behavior towards laboratory test ordering. We demonstrated how it could be improved when a specific stage of the patient management is considered. We took a multi-step approach to analyze the laboratory test orders in the context of planned laparoscopic cholecystectomy in a general teaching hospital. A reference order set was defined through a collaborative analysis between clinicians and laboratory physicians. The clinical and financial impacts were then evaluated over a period of 24 months. After the introduction of the reference order set, the number of laboratory tests per order decreased significantly for patients with cholecystitis of low severity. Above the monitoring of repeated orderings during a single stay, the major impacts were achieved by a drastic reduction of inappropriate orders, particularly in the field of bacteriology. The main effects of the order set were maintained throughout a follow-up period of 24 months. Our study demonstrated that, when considering laboratory test ordering optimization, reference order sets could achieve high levels of efficiency. To ensure high compliance to reference order sets, extensive collaboration between clinicians and laboratory physician is mandatory even if very sophisticated information systems are available.

Ethical issues in knowledge, perceptions, and exposure to hospital hazards by patient relatives in a tertiary institution in North Western Nigeria.

INTRODUCTION: Patient relatives are a significant part of the health care team in any hospital setting. This study determines their knowledge, perceptions, and factors responsible for their exposure to health hazards at the Ahmadu Bello University Teaching Hospital (ABUTH), Zaria, Kaduna State. The outcome of this study is intended to help the hospital managers to have a reference to make plans for the patient relatives' welfare and also address the ethical issues regarding patients' relatives safety while in the hospital. MATERIALS AND METHODS: This is a cross-sectional descriptive study involving 100 participants selected by systematic random sampling technique from the ten admission wards of the ABUTH. The data were analyzed using the Statistical Package for Social Sciences IBM 20 and STATA SE12. RESULTS: The mean age of the respondents was 35 years. They were mainly Hausa (58%), female (79%), and Muslims (76%). About 21%, 25%, and 54% of the respondents have poor, fair, and good knowledge, respectively, with a mean knowledge score of 33.3% while 24% perceived that blood urine and feces from patient relatives are safe to handle. Sexual harassment (13.3%), abusive insults from health care workers, (13.3%) and aggression from other patients were reported. Being the sole caregiver, type of illness, handling of patients' blood and feces, and length of hospital stay were significantly associated with exposure to hospital hazards (P < 0.05, χ2 > 1, odds ratio >1). CONCLUSION: The participants' knowledge and perception of hospital hazard were poor. Abusive insults by health workers, sexual harassment, and indiscriminate handling of patients' specimen constitute major ethical challenges in this setting. The hospital management should have a guideline specifying the roles and responsibilities of patients and their relatives. There is a need for the health care workers' ethics education and safe accommodation for patient relatives.

Ethical implications and decision making in care education process.

OBJECTIVE: To determine ethical implications for nursing practice at the point of decision making by nursing professors in practice area. METHODOLOGY: A qualitative method was adopted, with use of semistructured interviews with sixteen nursing professors who delivered care at a teaching hospital in Salvador, Bahia, from May to June 2011. The methodological reference used was the discourse of the collective subject (DCS) by Lefévre and Lefévre. RESULTS: . In response to DCSs, the following subjects appeared: "Ethics is fundamental and of vital importance in the decision making process," "searching for knowledge and research to identify problems and solutions, including alternatives and support for decisions," and "to act in the best way." CONCLUSION: Professors who provide education about patient care also delivered care. They have the responsibility to consider the ethical implications of decision making because they stimulate fundamental reflection and could positively influence future nursing professionals.

Shadows amid sunshine: regulating financial conflicts in medical research.

Under brand new rules implementing the Physician Payments Sunshine Act (Sunshine Act), a wide range of financial relationships, including many research-related payments, between industry, physicians, and teaching hospitals will be publicly disclosed through comprehensive, standardized payment reporting. The Sunshine Act represents the latest in a series of regulatory attempts to address financial conflicts of interest that may bias research conduct and threaten subject safety. This article summarizes the major aspects of the Sunshine Act affecting medical research, how it interacts with existing laws and policies, and identifies important unresolved issues and implementation challenges that still lie ahead with the rollout of the legislation underway. The Sunshine Act primarily depends on disclosure as a regulatory tool. As such, its long-term impact remains open to question. Disclosure in this context may have limited utility given, among other reasons, uncertainty about who the intended recipients are and their ability to use the information effectively. Apart from the insufficiency of transparency, this article further explores how proportionality, fairness, and accountability considerations make optimal regulation of financial conflicts in medical research quite challenging.

When money and principles clash: the ethics of a surgical teaching service.

During your preoperative visit, a very wealthy patient, Gill Bates, who donated a wing to the large teaching hospital in which you practice, has an unusual request: He does not want any residents involved with his care. He is scheduled for an open infrarenal aneurysmectomy. He explains that his decision is based on the experience of a relative many years ago who was harmed by a resident's error. You clarify that you will do the procedure but that this is a teaching hospital and residents provide excellent assistance and postoperative care. He is resolute in demanding that only grown-up surgeons provide his care.

The physician payments sunshine act: what the average radiologist and manager need to know.

The Physician Payments Sunshine Act (PPSA) was enacted in 2010 and requires applicable manufacturers of medical devices, drugs, biological material, or medical supplies to report payments or transfers of value that are provided to physicians or teaching hospitals. PPSA has value in creating greater transparency in the financial relationships between industry, physicians, and teaching hospitals, and in potentially reducing problematic conflicts of interest. PPSA requires that this data be published, in searchable form, on a public website. CMS has delayed the reporting under PPSA until after January 1, 2013, and has yet to issue its final rules for PPSA; however, Physician Payments data already exist in a publically searchable database. It is important to realize that names of individuals may appear in the PPSA public database, even if those individuals did not actually receive a transfer of value. As with all broad-stroke legislation, consequences not anticipated or not considered sufficiently important for our government leaders may well present a problem for individuals. It behooves all physicians and healthcare managers to carefully follow the CMS PPSA regulations. In advance of meeting or interacting with any PPSA-applicable manufacturer, obtain a clear and mutual understanding regarding what reportable value, if any, will be prepared for and provided by the applicable manufacturer. In this, as in all situations in which government regulations are at play, "knowledge is strength."

Mortality and morbidity meetings: an untapped resource for improving the governance of patient safety?

INTRODUCTION: National Health Service hospitals and government agencies are increasingly using mortality rates to monitor the quality of inpatient care. Mortality and Morbidity (M&M) meetings, established to review deaths as part of professional learning, have the potential to provide hospital boards with the assurance that patients are not dying as a consequence of unsafe clinical practices. This paper examines whether and how these meetings can contribute to the governance of patient safety. METHODS: To understand the arrangement and role of M&M meetings in an English hospital, non-participant observations of meetings (n=9) and semistructured interviews with meeting chairs (n=19) were carried out. Following this, a structured mortality review process was codesigned and introduced into three clinical specialties over 12 months. A qualitative approach of observations (n=30) and interviews (n=40) was used to examine the impact on meetings and on frontline clinicians, managers and board members. FINDINGS: The initial study of M&M meetings showed a considerable variation in the way deaths were reviewed and a lack of integration of these meetings into the hospital's governance framework. The introduction of the standardised mortality review process strengthened these processes. Clinicians supported its inclusion into M&M meetings and managers and board members saw that a standardised trust-wide process offered greater levels of assurance. CONCLUSION: M&M meetings already exist in many healthcare organisations and provide a governance resource that is underutilised. They can improve accountability of mortality data and support quality improvement without compromising professional learning, especially when facilitated by a standardised mortality review process.

Prenatal screening for sickle cell anemia: awareness among health professionals and medical students at the Lagos University Teaching Hospital and the concept of prevention by termination.

Nigeria has the highest population of sickle cell anemia (SCA) patients in the whole world. This condition manifests with frequent episodes of aches and pains, recurrent infections, and frequent hospitalization. Prenatal screening is one of the methods of reducing the prevalence of this disease. The study aimed to determine the awareness and acceptability of prenatal screening for SCA among health professionals and students at the Lagos University Teaching Hospital. It was a descriptive and cross-sectional study carried out between August and September 2006, involving 403 health professionals and students using structured questionnaires. The study revealed that 91.3% of the respondents had heard about prenatal screening for SCA, whereas 8.7% of the respondents had not. In addition, the majority of the respondents (75.3%) knew that SCA can be prevented by prenatal screening for SCA, whereas 13.7% and 11.3% were not aware or not sure, respectively. Up to 48.2% of the respondents were not aware that prenatal screening for SCA is available in Nigeria with the nurses being the least aware (χ=11.9, P=0.00). 42.1% of the respondents will not allow preventive termination of pregnancy if prenatal screening confirms SCA. For those who will not allow preventive termination, up to 79% of them decided on the basis of their religious beliefs. There is a poor level of awareness of the availability of prenatal screening services in Nigeria among health workers in Lagos, and religion is a major factor militating against its acceptability.

Análisis de la suspensión de cirugía en un hospital docente / Análise da suspensão de cirurgias em um hospital de ensino

En busca de los índices de mejor calidad, la suspensión de las cirugías han sido examinadas por los servicios y recibido la atención de los investigadores en el campo de la salud. Las altas tasas de cancelación revelan un manejo inadecuado que tienen efectos negativos en el equipo de salud y en la vida del paciente y su familia. Este estúdio retrospectivo y descriptivo tuvo como objetivo identificar el tipo de suspensión quirúrgica y las razones de este procedimiento en un hospital público de enseñanza. Los datos fueron recolectados de los archivos del Archivo de la Unidad Quirúrgica y Servicio de Archivo Médico y Estadístico del referido hospital. Hubo una tasa de anulación quirúrgica de 14.14% y para 1402 (63,78%) cirugías canceladas no había constancia de la justificación de la suspensión. Las razones para la suspensión de las cirugías fueron: 194 (8,82%) por la no hospitalización de los pacientes, 182 (8,30%) por las condiciones clínicas inadecuadas, 179 (8,14%) debido a problemas administrativos, 94 (4,27%) por asuntos de asistencia para el cuidados de la salud, 61 (2,77%) por problemas estructurales, 40 (1,82%) por ausencia del pacientes y 46 (2.10%) por otras razones. Estos resultados señalan a la necesidad de adoptar medidas para garantizar la seguridad del paciente y la calidad del servicio ofrecido (AU)

In the search for better quality indices, the suspensions of surgeries have been examined by and received attention from researchers in the field of health. High cancellation rates reveal an inadequate management that impacts negatively on the health team iself and the patient's life and and that of his or her family. This retrospective descriptive study aim to identify the rate of surgical suspension and the reasons for this procedure in a public teaching hospital. Data were collected from the Surgical Center Archive and Medical Archive Service Statistics. There was a rate of 14.14% surgical cancellations and in 1,402 (63.78%) occasions no records were found that justify the suspension of the surgeries. The results showed the following justifications for the suspensions of the surgery: 194 (8.82%) were non hospitalized patients; 182 (8.30%) for inadequate clinical conditions;, 179 (8.14%) due to administrative problems;, 94 (4.27%) for welfare issues;, 61 (2.77%) for structural issues; 40 (1.82%) for lack of patients and 46 (2.10%) for other reasons. These findings point to the need to adopt measures that will ensure patient safety and quality of service offered (AU)