Surgical patient advocacy: role and value in surgery

Patient advocacy may be necessary during medical care in the home or office as well as during hospitalization in either private or public sector care. Patients may choose a relative, a close friend or a physician as their patient advocate. The patient advocate may provide physical assistance and usually accompanies the patient throughout the course of disease. By agreeing to the presence of a patient advocate during visits, the patient implicitly acknowledges that confidentiality may be breached. Patient advocates may be particularly useful for the patient in case of severe disease or poor prognosis. The advocate becomes an intermediary contact and, at the same time, provides educational, relational and psychological support for the patient. The patient advocate should be consulted when the patient is incapable of making his own decisions. The patient advocate is supposed to be able to express the wishes of the patient, when the latter is incapable of doing so. The patient should therefore choose someone who, in his judgment, is competent to voice the patient's opinion for him. When the patient advocate remains at the patient's side at the end of life, whether in the hospital or at the patient's home, the advocate can benefit from "family solidarity leave" and obtain a daily stipend if this interrupts his or her professional activity.     

Improving team structure and communication: a key to hospital efficiency

HYPOTHESIS: Improving team structure and heightening communication will help provide cost-effective and high-quality patient care for general surgery patients. DESIGN: This study surveys teamwork initiatives and their effects on specific variables related to patient care. PATIENTS: The study population comprised all patients admitted to the hospital's general surgery teams during 5 years 3 months. SETTING: Tertiary care hospital. INTERVENTIONS: A complete restructuring of the patient care team for general surgery patients admitted to the hospital. The intervention occurred midway through the study period. MAIN OUTCOME MEASURES: Mean length of stay for general surgery patients as a marker of team efficiency and a standardized patient satisfaction survey. RESULTS: The mean length of stay after initiation of the restructured care team was significantly shorter than before initiation. The significance was present despite a consistent patient acuity measure and was associated with a high patient satisfaction level. CONCLUSIONS: Restructuring the patient care team yielded a decreased mean length of stay while maintaining a high level of patient satisfaction. This analysis helps validate a hospital-wide initiative to maintain a high level of patient care while increasing patient volume.     

Patient‐to‐patient peer mentor support in dialysis: Improving the patient experience

Greater focus on patient‐reported outcome measures for dialysis patients and an increased patient engagement focus has highlighted a lack of formal patient‐generated strategies. Patient‐to‐patient peer mentoring is one approach that may improve the outcomes for people receiving dialysis. This review aims to synthesize quantitative and qualitative studies investigating dialysis‐associated patient‐to‐patient peer mentor support among adults with chronic kidney disease and end stage kidney disease. Research studies describe the benefits of peer mentor programs in dialysis to include: improved goal setting, decision‐making and increased self‐management. While a variety of program formats exist, a combination of face‐to‐face and telephone peer support models are recommended and formal training of mentors is required. In addition, the formal support of dialysis clinicians, nephrologists and administrators is vital for the success of a dialysis patient‐to‐patient peer mentor program.     

Telefonische Patientenaufkl?rung

Caution when using the telephone to provide patient information is definitely recommended. The advantage of this method of informing the patient is primarily found for the patients, who save time and money. In contrast, the physician carries the burden of proof when using the telephone that sufficient information was provided to the patient, if a patient later claims that the patient information via telephone was inadequate. The physician is responsible for the estimation of the operative risk as only simple procedures are eligible for this form of patient information. Thus, providing information to the patient by telephone should remain an exception. In cases involving minors, it is advisable that both parents participate in providing informed and written consent for a procedure.     

Post-radical retropubic prostatectomy inguinal hernia: an analysis of risk factors with special reference to preoperative inguinal hernia morbidity and pelvic lymph node dissection

PURPOSE: Inguinal hernia after radical retropubic prostatectomy has been reported to occur in 7% to 21% of patients. We analyzed the impact of simultaneous pelvic lymph node dissection, preoperative inguinal hernia morbidity, postoperative anastomotic stricture, duration of surgery and patient age. We also compared the detection rate of inguinal hernia events in a retrospective patient file survey to that in a prospective patient administered questionnaire. MATERIALS AND METHODS: A total of 498 patients underwent radical retropubic prostatectomy plus pelvic lymph node dissection and 166 underwent radical retropubic prostatectomy only. Mean followup was 40 months (median 37, range 3 to 85). All 664 patients were analyzed in the patient file survey. The patient administered questionnaire was mailed preoperatively, and after 3, 6, 12, 18, 24 and 36 months to 271 patients who underwent operation between 2001 and 2002. A total of 207 patients (76.4%) completed the preoperative questionnaire. RESULTS: The cumulative incidence of inguinal hernia after 24 months was 11.6% in the patient file survey and 15.7% in the patient administered questionnaire. In the patient file survey patient age was the only studied factor that significantly influenced risk. The patient file survey failed to detect half of the men with preoperative inguinal hernia morbidity and a third of post-radical retropubic prostatectomy inguinal hernias compared to the patient administered questionnaire. On patient administered questionnaire analysis preoperative inguinal hernia morbidity was a significant risk factor for postoperative inguinal hernia (log rank Mantel-Cox test p = 0.010). CONCLUSIONS: Previous inguinal hernia morbidity and age increase the risk of post-radical retropubic prostatectomy inguinal hernia. Simultaneous pelvic lymph node dissection, postoperative anastomotic stricture and duration of surgery were not significant risk factors in this study. The patient file survey is inferior to the patient administered questionnaire for detecting inguinal hernia events.     

Expanded Occupational Safety and Health Administration 300 log as metric for bariatric patient-handling staff injuries

BackgroundMobilization of morbidly obese patients poses significant physical challenges to healthcare providers. The purpose of this study was to examine the staff injuries associated with the patient handling of the obese, to describe a process for identifying injuries associated with their mobilization, and to report on the need for safer bariatric patient handling.MethodsWe performed our study at a 761-bed, level 1 trauma center affiliated with a U.S. medical school. The hospital's Occupational Safety and Health Administration (OSHA) 300 log was expanded to the “E-OSHA 300 log” to specifically identify injuries the staff attributed to bariatric patient handling. The 2007 E-OSHA 300 log was analyzed to identify and describe the frequency, severity, and nature of bariatric versus nonbariatric patient handling injuries.ResultsThe analyses revealed that during 2007, although patients with a body mass index of ≥35 kg/m² constituted <10% of our patient population, 29.8% of staff injuries related to patient handling were linked to working with a bariatric patient. Bariatric patient handling accounted for 27.9% of all lost workdays and 37.2% of all restricted workdays associated with patient handling. Registered nurses and nursing assistants accounted for 80% of the injuries related to bariatric patient handling. Turning and repositioning the patient in bed accounted for 31% of the injuries incurred. The E-OSHA 300 log narratives revealed that staff injuries associated with obese and nonobese patient handling were usually performed using biomechanics and not equipment.ConclusionManual mobilization of morbidly obese patients increases the risk of caregiver injury. A tracking indicator on the OSHA 300 logs for staff injury linked to a bariatric patient would provide the ability to compare obese and nonobese patient handling injuries. The E-OSHA 300 log provides a method to identify the frequency, severity, and nature of caregiver injury during mobilization of the obese. Understanding the heightened risk of injury associated with manual bariatric patient handling should help healthcare institutions identify deficiencies in their current injury prevention program and focus resources more precisely for safer, systems-based bariatric patient-handling solutions. Effective patient handling systems should also reduce the aura of fear that might be present in some caregivers when mobilizing a bariatric patient.     

Doctor-patient relationship. The consultation

This article deals primarily with the office consultation involving a new patient. The consultation lays the groundwork for the physician/patient relationship in a number of ways. The authors consider the objective and subjective assessments which take place between the doctor and the patient and offer advice on how to decide on a course of treatment with the patient.     

Intra-abdominal abscess due to patient non-compliance after construction of an ileal neobladder: Case report and review of the literature

PURPOSE: A case report of patient with an intra-abdominal abscess 8 weeks after radical cystectomy and construction of an ileal neobladder is presented. METHODS/RESULTS: The patient was admitted with nausea, vomiting and singultus. A perforation of the neobladder due to overdistension was assumed to be the underlying cause of the intra-abdominal abscess formation as the patient admitted infrequent voiding during the day and no emptying of the neobladder at night. The patient underwent explorative laparotomy and 4200 mL of pus was removed from the abdominal cavity. The patient made an uneventful recovery and was discharged from hospital after 5 weeks. Neobladder function remained stable and the patient was leading a normal life at 24 months follow-up. CONCLUSIONS: The present case demonstrates the need for careful patient selection prior to radical cystectomy with continent urinary diversion. Reduced compliance and mental disabilities of a patient can increase the complication rate.     

Patient Education Strategies in Dermatology: Part 2: Methods

Patient education is an important aspect of patient care in dermatology. Successful education increases patient satisfaction and results in improved outcomes and adherence. This article individually evaluates several patient-education strategies: verbal education, written information, group-based learning, audiotapes, videotapes, computer-assisted education, and the internet. The review presents the strengths and limitations of each strategy based on recognized barriers to effective patient education that were discussed in Part 1. Additionally, a summary of recommendations for effective patient education is provided.In Part 1 of this review of patient-education strategies in dermatology, the authors examined evidence supporting the use of patient education to benefit patient care. Additionally, they analyzed barriers, such as illiteracy, information overload, and physician time, which can hinder effective patient education. Successful education is ultimately dependent on choosing an effective method of education that is appropriate for the given patient. Therefore, in Part 2 of this review, the authors focus on individual patient-education strategies and their inherent strengths and weaknesses. In evaluating and discussing the different methods of patient education, the authors hope to create a better understanding of what generates optimal patient education.     

Avoiding and correcting complications in facial plastic surgery: patient selection

Far from being simply a cursory step, the initial consultation between the patient and plastic surgeon, when patient selection usually occurs, can be complicated. Proper patient selection is the key first step toward a successful outcome from a proposed procedure. Not only must the physical and health status of the patient be understood, but the surgeon quickly must determine whether the emotional and psychological attributes and expectations of a particular patient are up to the rigors of the particular surgery being discussed. The concepts of expectations and satisfaction, personality types, and the difficult patient will be discussed. Yes, predicting the future is part of the surgeon's valued armamentaria. But even experienced and astute physicians cannot always make perfect decisions.     

Safety, quality, and the National Surgical Quality Improvement Program

The Institute of Medicine 1999 publication, To Err is Human, focused attention on preventable provider errors in surgery, and prompted numerous new national initiatives to improve patient safety. It is uncertain whether these initiatives have actually improved patient safety, mainly because of the lack of a quantitative metric for the assessment of patient safety in surgery. A 15-year experience with the National Surgical Quality Improvement Program, which originated in the Veteran's Administration in 1991 and was recently made available to the private sector, prompts the surgical community to place patient safety in surgery within a much larger conceptual framework than that of the Institute of Medicine report, and provides a quantitative metric for the assessment of patient safety initiatives. This conceptual framework defines patient safety in surgery as safety from all adverse outcomes (not only preventable errors and sentinel events); regards safety as an integral part of quality of surgical care; recognizes that adverse outcomes, and hence patient safety, are primarily determined by quality of systems of care; and uses comparative risk-adjusted outcome data as a metric for the identification of system problems and for the assessment and improvement of patient safety from adverse outcomes.     

Radial keratotomy in a patient with keratoconus

A 33-year-old patient had radial keratotomy performed on both eyes for relief of longstanding myopia. Minimal reduction of myopia was obtained, and the patient underwent a second radial keratotomy in both eyes. Best corrected visual acuity decreased, and the patient had a marked, irregular astigmatism postoperatively. Careful ophthalmologic evaluation revealed that the patient had keratoconus bilaterally. Following a failed trial of contact lens wear, the patient underwent a penetrating keratoplasty of the right eye. Pathologic evaluation revealed findings of keratoconus, as well as radial keratotomy scars. This case report illustrates the importance of a complete ophthalmologic examination possibly including videokeratography, prior to keratorefractive surgery.     

无缝式手术患者转运交接系统的研发及应用

目的研发手术患者转运交接系统,优化交接流程,实现无缝式交接。方法 2019年4~7月使用传统的电话沟通、口头传达方式进行手术患者转运交接;2020年4~7月研发并应用无缝式手术患者转运交接系统,通过信息化管理手段优化手术患者交接,信息同步推送,扫码识别患者身份,全流程监测患者路径信息。结果系统应用后,工勤人员接入患者用时、连台手术间隔时间、手术患者转运交接不良事件发生率显著低于应用前,护士及工勤人员满意度显著提升(均P<0.01)。结论手术患者转运交接系统的应用,优化了交接流程,确保各环节标准化、精细化、高效化。     

Informed consent

The origins of informed consent come from philosophy, medical experimentation, the law, and contemporary trends in doctor and patient relationships. Every surgical patient signs an informed consent form but the literature would suggest that many times there is incomplete information conveyed by the physicians or understood by the patient. Informed consent should be considered as an expression of respect for patient autonomy and the patient education necessary for a truly informed consent should be considered a surgical virtue.     

Consent: assessing and communicating risk

The consent process is a cornerstone of the patient–doctor relationship. It can be a complex process presenting challenges to both doctor and patients due to the interaction of multiple different factors, including ethical and legal considerations. Ensuring the patient has informed consent requires a through understanding of the risks of an intervention for a particular patient; therefore risk assessment is of fundamental importance. Accurate risk assessment can be done through assessment of individual patient factors and the proposed procedure combined with population data. Communication of this risk to the patient is key and the surgeon should use clear language to avoid bias or misunderstanding. Use of adjuncts such as visual aids, examples from other areas of life, with avoidance of statistical data and vague terms may help the patient understand the risks more completely.     

Patient delay from onset of chest pain suggesting acute coronary syndrome to hospital admission

OBJECTIVE: The aim of the study was to examine patient delay (time from onset of chest pain to patient seeking medical care) among patients who were admitted to hospital with suspected acute coronary syndrome (ACS). DESIGN AND RESULTS: For 337 patients acutely admitted to the Cardiology Department, Odense University Hospital, during a 3-month period in 1998 with suspected ACS, patient delay and the total pre-hospital delay were registered. In addition, information on patient characteristics, patient behaviour and symptom perception was obtained. The median patient delay was 2.85 h (range 0.2-91 h), of this the "silent" patient delay represented 1 h (range 1 min-11.3 h). The total pre-hospital delay was median 3.88 h. Thirty-one per cent of the patients had confirmed acute myocardial infarction (AMI), and this patient group had a significantly shorter patient delay compared with the group without AMI, 2.05 h vs 3.12 h, p = 0.01. Patient delay of more than 2 h was associated with the factors "self-medication" and "wanted to wait and see if the symptoms went away". A smaller than average risk of patient delay was found in the case of "suspicion of heart attack" and "suspicion of a serious condition". CONCLUSION: Patient delay is considered to be a serious impediment to markedly improving the prognosis in the case of ACS.     

Extracorporeal shock wave lithotripsy in the prone position: treatment of stones in the distal ureter or anomalous kidney

A total of 15 patients underwent ESWL using the Dornier HM3 lithotriptor with the patient in the prone position. The stones were in the distal ureter over the sacroiliac joint in 10 patients, 8 of whom had undergone unsuccessful ureteroscopic manipulation. Two patients had horseshoe kidneys with stones that were too anterior to permit accurate targeting with the patient in the standard supine position. One patient had a solitary stone in a pelvic kidney and 1 had an obstructing ureteropelvic junction stone in a crossed ectopic kidney. The final patient had a reconstructed lower urinary tract with a stone at 1 of the ureterointestinal anastomoses. Excellent pulverization was achieved in all patients after only 1 prone ESWL treatment. One patient required temporary percutaneous nephrostomy after ESWL and 1 may require retrograde manipulation of fragments at the ureterovesical junction. No patient had melena, and other than temporary ileus in 1 patient who had concurrent supine ESWL of renal calculi, no gastrointestinal complications were seen. All but 1 patient were free of stones 1 month after prone ESWL. Prone ESWL prevents blockage of shock wave energy by the bony pelvis, because the shock waves enter anteriorly and exit posteriorly. ESWL with the patient in the prone position is a safe and effective treatment of calculi in the distal ureter or anomalous kidney.     

Iatrogenic left ventricular pseudoaneurysm

A case of iatrogenic left ventricular pseudoaneurysm in a male patient, with a diagnosis of pericarditis, is presented. The patient developed severe complications after an attempted diagnostic and therapeutic pericardiocentesis. Six months later, after corrective surgery, the pseudoaneurysm recurred. The patient had a second operation and two connections to the left ventricle were found. One year later the patient is well.     

Results of surgical treatment of synchronous multiple primary lung carcinomas

Four male patients with synchronous multiple lung carcinoma were operated on. In one patient both tumours were adenocarcinomas; both were bronchioloalveolar carcinomas in a second patient. In a third patient the tumours were adenocarcinoma and bronchioloalveolar carcinoma while in the fourth patient an adenocarcinoma and a squamous cell carcinoma were present. One patient was asymptomatic and free from carcinoma at follow-up examination 11 years and 7 months after the operation. The other three died of pulmonary carcinoma 11 months, 1 year 3 months and 9 years 8 months postoperatively.     

Improvement in clinical outcomes after dry needling in a patient with occipital neuralgia

The primary purpose of this case report is to outline the diagnosis, intervention and clinical outcome of a patient presenting with occipital neuralgia. Upon initial presentation, the patient described a four-year history of stabbing neck pain and headaches. After providing informed consent, the patient underwent a total of four dry needling (DN) sessions over a two-week duration. During each of the treatment sessions, needles were inserted into the trapezii and suboccipital muscles. Post-intervention, the patient reported a 32-point change in her neck disability index score along with a 28-point change in her headache disability index score. Thus, it appears that subsequent four sessions of DN over two weeks, our patient experienced meaningful improvement in her neck pain and headaches. To the best of our knowledge, this is the first case report describing DN to successfully improve clinical outcomes in a patient diagnosed with occipital neuralgia.