Dealing with Difficult Patients: Do Customer Service Initiatives Improve Patient Satisfaction at an Interdisciplinary Pain Center?

Chronic pain patients can be difficult to manage due to complicated medical and psychiatric comorbidities. This study focused on strategies designed to improve patient treatment satisfaction within a tertiary urban hospital‐based pain management center. Information was obtained of monthly patient satisfaction and Press Ganey scores in 2009 based on patient perceptions of staff and telephone access, frequency of returned phone calls, staff empathy and responsiveness, and overall patient experience with their pain treatment. Information was also obtained of the number of formal complaints made to the Patient Relations Department of the hospital. A customer service program designed to target patient's phone access, response to phone calls, improved patient experiences, and service friendliness was initiated in March 2010. Six hundred eleven patients (n = 611) were randomly surveyed 3 months after their treatment between 2009 and 2012 and rates of formal patient complaints were monitored. Thirty‐three (n = 33) staff members were encouraged to attend monthly 1.5‐hour customer service meetings and participate in specialized work teams between March 2010 and December 2012. Patient satisfaction scores rose from a low of 80.3 (average of 83.5%) in 2009 to a high of 91.2 (average 88.9%) in 2012. Annual formal complaints to Patient Relations decreased by 40.5% over 4 years (112 in 2009 to 30 in 2012). Phone abandonment rates also decreased by 20% and the center scored 12% higher than average total practice scores in patient satisfaction based on secret shopper ratings. This study demonstrates that customer service initiatives that engage staff participation and that are designed to target specific improvements in patient satisfaction can effectively change the way pain patients perceive treatment at an interdisciplinary anesthesia‐based pain center.     

Using Reference Databases of Genetic Variation to Evaluate the Potential Pathogenicity of Candidate Disease Variants

The potential pathogenicity of genetic variants identified in disease‐based resequencing studies is often overlooked where variants have previously been reported in dbSNP, the 1000 genomes project, or the National Heart, Lung and Blood Institute Exome Sequencing Project (ESP). In this work, we estimate that collectively, these databases capture ～52% of mutations (dbSNP 50.4%; 1000 genomes 4.8%; and ESP 10.2%) reported as disease causing within phenotype‐based locus‐specific databases (LSDBs). To investigate whether these mutations may simply represent benign population variants, we evaluated whether the carrier frequencies associated with mutations implicated in amyotrophic lateral sclerosis were higher than what could be accounted for by high‐penetrance disease models. In doing so, we have questioned the veracity of 51 mutations, but also demonstrated that each of the three databases included credible disease variants. Our results demonstrate the benefits of using databases such as dbSNP, the 1000 genomes project, and the ESP to evaluate the pathogenicity of putative disease variants, and suggest that many disease mutations reported across LSDBs may not actually be pathogenic. However, they also demonstrate that even in the context of rare Mendelian disorders, the potential pathogenicity of variants reported by these databases should not be overlooked without proper evaluation.     

Partial heat acclimation of athletes with spinal cord lesion

Heat acclimation (HA) can improve thermoregulatory stability in able-bodied athletes in part by an enhanced sweat response. Athletes with spinal cord lesion are unable to sweat below the lesion and it is unknown if they can HA. Five paralympic shooting athletes with spinal cord lesion completed seven consecutive days HA in hot conditions (33.4 ± 0.6 °C, 64.8 ± 3.7 %rh). Each HA session consisted of 20 min arm crank exercise at 50 % $ \dot{V}{\text{O}}_{{ 2 {\text{peak}}}} $ followed by 40 min rest, or simulated shooting. Aural temperature (T _aur) was recorded throughout. Body mass was assessed before and after each session and a sweat collection swab was fixed to T12 of the spine. Fingertip whole blood was sampled at rest on days 1 and 7 for estimation of the change in plasma volume. Resting T _aur declined from 36.3 ± 0.2 °C on day 1 to 36.0 ± 0.2 °C by day 6 (P < 0.05). During the HA sessions mean, T _aur declined from 37.2 ± 0.2 °C on day 1, to 36.7 ± 0.3 °C on day 7 (P < 0.05). Plasma volume increased from day 1 by 1.5 ± 0.6 % on day 7 (P < 0.05). No sweat secretion was detected or changes in body mass observed from any participant. Repeated hyperthermia combined with limited evaporative heat loss was sufficient to increase plasma volume, probably by alterations in fluid regulatory hormones. In conclusion, we found that although no sweat response was observed, athletes with spinal cord lesion could partially HA.     

Attachment security and parenting quality predict children's problem-solving,attributions, and loneliness with peers

The influence of early relational experience on later social understanding has evoked rich theoretical discussion but relatively little empirical inquiry. Enlisting data from the NICHD Study of Early Child Care and Youth Development, measures of the security of attachment in infancy, toddlerhood, and early childhood, together with measures of parenting quality (maternal sensitivity and depressive symptoms) gathered longitudinally throughout infancy and early childhood, were used to predict differences in children's thoughts and feelings about peers (i.e., social problem solving, negative attributional biases, aggressive solutions to ambiguous social situations, and self-reported loneliness) when children were 54 months and in first grade. Relational experiences, especially before 36 months, were significantly predictive of later peer-related representations. Attachment security at 24 and 36 months was associated with enhanced social problem-solving skills and less loneliness, but security of attachment at 15 months was nonpredictive. Early maternal sensitivity was positively associated with later social problem-solving and negatively with aggressive responses, and early maternal depressive symptoms were positively associated with children's negative attributions. Concurrent parenting quality was also associated with children's thoughts and feelings about peers, but less consistently. These findings shed new light on how early relational experiences may contribute to social information processing with peers at the end of the preschool years, and that the timing of relational influences may be crucial.     

Place of death in haematological malignancy: variations by disease sub-type and time from diagnosis to death

Background

The reasons patients with haematological malignancies die in hospital more often than those with other cancers is the subject of much speculation. We examined variations in place of death by disease sub-type and time from diagnosis to death, to identify groups of ‘at-risk’ patients.

Methods

The study is based in the United Kingdom within the infrastructure of the Haematological Malignancy Research Network (HMRN), a large on-going population-based cohort including all patients newly diagnosed with haematological malignancies in the north of England. Diagnostic, demographic, prognostic, treatment and outcome data are collected for each patient and individuals are ‘flagged’ for death. This study includes all adults (≥18 years) diagnosed 1st September 2004 to 31st August 2010 (n?=?10,325), focussing on those who died on/before 31st August 2012 (n?=?4829).

Results

Most deaths occurred in hospital (65.9%), followed by home (15.6%), nursing home (11%) and hospice (7.5%) and there was little variation by diagnostic sub-type overall. Differences in place of death were, however, observed by time from diagnosis to death, and this was closely related to sub-type; 87.7% of deaths within a month of diagnosis happened in hospital and these largely occurred in patients with acute myeloid leukaemia, diffuse large B-cell lymphoma and myeloma. Patients surviving longer, and particularly beyond 1 year, were less likely to die in hospital and this corresponded with an increase in the proportion of home deaths.

Conclusions

Time from diagnosis to death was clearly a major determinant of place of death and many patients that died within three months of diagnosis did so in hospital. This was closely related to disease sub-type, with early deaths occurring most notable in the more aggressive diseases. This is likely to be due to a combination of factors including acute presentation, rapid disease progression without transition to a palliative approach to care and complications of treatment. Nonetheless, hospital deaths also occurred frequently in indolent diseases, suggesting that other factors were likely to contribute to the large proportion of hospital deaths overall. More evidence is needed to fully understand these complex cancers.

     

Hyperoxia in patients with cardiogenic shock after myocardial infarction supported with venoarterial extracorporeal membrane oxygenation

BackgroundVenoarterial extracorporeal membrane oxygenation (V-A ECMO) improves perfusion and oxygenation in patients with cardiogenic shock. However, it can also result in supranormal oxygen exposure. Recent evidence suggests hyperoxia may be harmful, particularly in critically ill patients. The aim of this study was to describe oxygen exposure in patients receiving V-A ECMO after acute myocardial infarction and to investigate the association between hyperoxia and in-hospital mortality.Methods and designWe conducted a retrospective, cohort study of consecutive patients receiving V-A ECMO at a single tertiary level ECMO centre. We compared the mean and peak arterial oxygen tensions over the first 72 h after V-A ECMO initiation (n = 30) with those from a convenience sample of patients treated with an intra-aortic balloon pump (IABP) (n = 30) for cardiogenic shock.ResultsSixty patients admitted between January 2012 and March 2018 were included in the study. Patients on V-A ECMO had significantly higher arterial oxygen tensions during the first three days than those with an IABP, at 0–24 h; V-A ECMO: 286.51 mmHg (135.76) vs IABP: 103.48 mmHg (15.22), p < 0.01.Thirteen of 30 (44.8%) patients in the V-A ECMO cohort manifested extreme hyperoxia (PaO₂ ≥300 mmHg) in the first 24 hrs, compared with none in the IABP population. Within the V-A ECMO group, there was no significant association between extreme hyperoxia and in-hospital mortality (P = 0.19), duration of mechanical ventilation (P = 0.63), or troponin levels (P = 0.16) in the first 24 hrs.ConclusionSevere hyperoxia is common in patients receiving V-A ECMO after acute myocardial infarction, and this continues for at least 72 h. We found no association between extreme hyperoxia and clinical outcomes.     

Systematic review of pressure injury prevalence in Australian and New Zealand hospitals

BackgroundPressure injuries have a major impact on patients and healthcare organisations. The complications of pressure injuries increase morbidity and mortality rates and are costly to individuals and healthcare systems. The total prevalence rate of pressure injuries within acute care hospitals in Australia and New Zealand is unknown, and despite a focus on prevention, pressure injuries still occur within these hospital settings.AimTo report the prevalence of pressure injuries within acute care settings in Australian and New Zealand hospitals and to identify the stage and location of pressure injuries and analyse the methods used to conduct pressure injury point prevalence studies.MethodsA systematic review of studies published in CINAHL, MEDLINE and Cochrane databases and a two-part grey literature search, including a customised Google search and a targeted website search, was undertaken up to July 2019. The systematic review was prospectively registered with PROSPERO (CRD42018105566).FindingsThe overall prevalence of pressure injuries in acute-care hospitals in Australia and New Zealand is 12.9% (95% CI, 9.5%–16.8%) and the hospital-acquired pressure injury prevalence is 7.9% (95% CI, 5.7%–10.3%). Stage I and stage II are the most common pressure injuries. The most frequent locations for pressure injuries are the sacrum/buttock/coccyx area (41%) and the heels (31%). The reporting of details about methodology varies considerably between studies.DiscussionPressure injuries remain a significant problem within acute-care hospital settings. Total prevalence rates are decreasing over time with the numbers of stage I and II pressure injuries decreasing faster than other pressure injuries.ConclusionThe findings from this study can be used to set performance benchmarks within acute-care hospitals in Australia and New Zealand. Pressure injuries are preventable and pressure injury prevalence studies can be used to monitor the effectiveness of nursing care processes to improve patient outcomes.