BMJ quality & safety
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BMJ quality & safety · Oct 2021
Randomized Controlled TrialEffectiveness of a multifaceted intervention to improve emergency department care of low back pain: a stepped-wedge, cluster-randomised trial.
Overuse of lumbar imaging is common in the emergency department (ED). Few trials have examined interventions to address this. We evaluated the effectiveness of a multifaceted intervention to implement guideline recommendations for low back pain in the emergency department. ⋯ It is uncertain if a multifaceted intervention to implement guideline recommendations for low back pain care decreased lumbar imaging in the ED; however, it did reduce opioid prescriptions without adversely affecting patient outcomes. Trial registration number ACTRN12617001160325.
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BMJ quality & safety · Sep 2021
Randomized Controlled TrialMedical crisis checklists in the emergency department: a simulation-based multi-institutional randomised controlled trial.
Studies carried out in simulated environments suggest that checklists improve the management of surgical and intensive care crises. Whether checklists improve the management of medical crises simulated in actual emergency departments (EDs) is unknown. ⋯ In this multi-institution study, checklists markedly improved local resuscitation teams' management of medical crises simulated in situ, and most personnel reported that they would use the checklists if they had a similar case in reality.
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BMJ quality & safety · Sep 2019
Randomized Controlled TrialElectronic health record-based clinical decision support alert for severe sepsis: a randomised evaluation.
Sepsis remains the top cause of morbidity and mortality of hospitalised patients despite concerted efforts. Clinical decision support for sepsis has shown mixed results reflecting heterogeneous populations, methodologies and interventions. ⋯ An EHR-based severe sepsis alert did not result in a statistically significant improvement in several sepsis treatment performance measures.
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BMJ quality & safety · Sep 2019
Randomized Controlled Trial Multicenter StudyExposure to incivility hinders clinical performance in a simulated operative crisis.
Why is this important?
Medical crises are high stress, and do not always bring out optimal behaviour in clinical teams. Although progress has been made to improve operating room cultures, the specific consequences of ‘incivil’ behaviour in anaesthesiology have not been previously defined.
Katz and team set out to identify the effect of incivility on performance during a simulated operating room crisis (intraoperative haemorrhage), noting that multiple surveys show the ubiquity of incivility in surgical and anaesthetic environments.
“Incivility is a potential source of interpersonal conflict and a latent threat to effective communication...” – Katz et al.
What did they do?
Across three institutions, 76 anaesthesiology residents were randomised to crisis simulation encounters with or without incivility (“rude, dismissive or aggressive behaviour”), expressed by the simulated surgeon through scripted dialogue and demeanour.
“The experimental group’s surgeon was portrayed as impatient, but not overtly intimidating (ie, actors were instructed not to use inappropriate language, become physically intimidating or scream). The control group’s surgeon was courteous and the interactions straightforward.”
Participant performance was independently assessed in three ways:
- Completion of checklist items expected for the crisis.
- Ratings for vigilance, decision-making, teamwork and communication.
- Whether performance was consistent with level expected of anaesthesiology resident.
Exposure to incivility lowered performance across every metric
Also notable, exposed participants believed that the environment negatively effected performance, even though self-reported performance assessment was comparable between groups.
91% of the control group were rated as performing at their expected level, but only 64% of the incivility-exposed group. Quality of decision making was particularly vulnerable to incivility, as were vigilance, communication and teamwork.
Take-home message
Professional conduct and civil behaviour is another important non-technical skill, consequential to crisis performance. We should already appreciate that incivility has no place in the high-stakes environment of an operating theatre, if for no other reason than it’s not civil.
Anaesthesiologists should also be aware of how their behaviour may effect the performance of their colleagues.
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BMJ quality & safety · Sep 2018
Randomized Controlled TrialNext-generation audit and feedback for inpatient quality improvement using electronic health record data: a cluster randomised controlled trial.
Audit and feedback improves clinical care by highlighting the gap between current and ideal practice. We combined best practices of audit and feedback with continuously generated electronic health record data to improve performance on quality metrics in an inpatient setting. ⋯ The trial was registered with ClinicalTrials.gov (NCT02593253).