Doctor's assistants--do we need them?

OBJECTIVE: To investigate the potential for the doctor's assistant role within an accident and emergency (A&E) department in relation to consultant workload. METHODS: A time and motion evaluation of the activities of four A&E consultants before and after a doctor's assistant was established as a team member within our department. A review of the literature was undertaken to allow comparisons with the American model of the physician assistant within the emergency department. RESULTS: The initial evaluation indicated that over 20% of the consultant's time could have been saved if an assistant were available to perform a variety of non-medical tasks. The restudy performed once the assistant was in post indicated less time was spent by the doctors in "medical" clerical duties (6.7% v 11.5% time), telephone use (5.6% v 7.7%), and venepuncture/cannula insertion (0.4% v 2.1%), and more time was spent on consultation over cases (15.3% v 11.3%) and supervision of other staff (9.3% v 4.1%). These five areas changed significantly (p = 0.005 by paired t test). CONCLUSIONS: The doctor's assistant may have a role in reprofiling the workload of senior doctors in A&E departments in the UK. They may also have a role in reducing the pressure on junior doctors, though this effect was not evaluated.     

Nursing handovers: do we really need them?

AIM: This study attempts to address the content of nursing handover when compared with formal documentation sources. BACKGROUND: The nursing handover has attracted criticism in the literature in relation to its continuing role in modern nursing. Criticisms include those related to time expenditure, content, accuracy and the derogatory terms in which patients are sometimes being discussed. METHODS: Twenty-three handovers, covering all shifts, from one general medical ward were audio-taped. Their content was analysed and classified according to where, within a ward's documentation systems, the information conveyed could be located. FINDINGS: Results showed that almost 84.6% of information discussed could be located within existing ward documentation structures and 9.5% of information discussed was not relevant to ongoing patient care. Only 5.9% of handover content involved discussions related to ongoing care or ward management issues that could not be recorded in an existing documentation source. LIMITATIONS: The results of this study are representative of only one ward in one Australian Hospital. Specific documentation sources were also not checked to determine their content. CONCLUSION: Streamlining the nursing handover may improve the quality of the information presented and reduce the amount of time spent in handover.     

Do we need new guidelines?

Early on in our medical training, we were told that experience is more important than knowledge in the medical field and that medicine is therefore not an exact science but an art. We were encouraged to become medical artists. Although this statement has proven to be largely correct, we perceived it as a provocation. The scientific nature of our profession of choice was being called into question. We had spent day and night cramming our heads full of knowledge and even after more than 30 years in the field were still trying to increase our knowledge on a daily basis, but this was apparently not highly valued. Based on the demands, the statement was justified and we are in fact shaped by medicine and the daily routine. In many critical situations intuition and experience, not learned data, determine what is right for a patient. It's not surprising that the terms "guidelines" and "quality control" set off mental warning bells in many colleagues who view medicine as an art. The reactions to new guidelines can be expected to range from an inexpressible feeling of discomfort to clear verbal rejection. The tem "total quality management" as specially developed and practiced in the Japanese auto industry will unavoidably be met with simple refusal. It is important for us to occasionally address quality assurance issues, and we must not avoid the necessary socio-economic discussion by hiding behind humanitarian and ethical arguments. One of the goals of the European Federation for Ultrasound in Medicine and Biology (EFSUMB) is quality assurance for ultrasound diagnostics [1]. As a result, the first guidelines for using ultrasound contrast agents were published in 2004 in Ultraschall in der Medizin/European Journal of Ultrasound, the official publication of EFSUMB [2]. An updated and enhanced version of these guidelines will be published in this issue [3]. These two publications are compatible with earlier publications regarding standardization [4-10], training [11-22]and continuing education [23-28].     

You know what we need?

I've listened to many of you moan about the current flat NIH budgets, lack of funding, and the frustration of being a scientist in the current depressed economy. Instead of complaining to only ourselves in the scientific community, we need to make ourselves heard by politicians and the public at large. We need a pundit.     

Are we measuring what we need to measure?

Optimal treatment for patients with chronic pain remains elusive. A growing international consensus advocates evidence-based practice with assessment of clinical outcomes to improve the process and outcome of care. Clinical decision making about treatment options for an individual patient should include the patient's clinical presentation, available evidence, and patient preferences. Treatment should then be monitored and outcomes of treatment assessed. Although the placement of clinical decision making on a scientific, often quantitative basis as opposed to a subjective, impressionistic approach makes intuitive sense, the question is whether we have been measuring what we need to measure to practice evidence-based practice when we consider the current available evidence on pain management? The methods of synthesis of available evidence are still in development. Much of the evidence, although having internal validity, has limited external validity and is difficult to apply to the individual patient. Patients with chronic pain are a heterogeneous group, and different interventions may be indicated for different subgroups of patients. Various methods are being developed to better match patients with treatment. Little information exists on patient preferences, or how best to measure these. Information on how health care providers make clinical decisions is also scarce. Outcome measurement has come a long way and core domains to be measured have been established. Establishing normative data is a next main goal. Important methodologic and practical challenges remain to formulate evidence that can be applied to the individual patient with chronic pain.     

Single donor platelets: can we afford to use them? Can we afford not to use them?

One of the strategies to reduce the risk of harming a patient by transfusion therapy is to limit the overall risk of transfusion-transmitted disease. Central to this approach is minimizing the number of allogeneic blood products with which a patient is transfused. The usual dose of platelets for an adult patient is either six to 10 random donor platelets vs. one unit of platelets, pheresis (so-called single donor apheresis platelets). Consequently, the transfusion services at the University of Southern California Health Sciences Campus (USC University Hospital, the Norris Cancer Hospital, and Los Angeles County + USC Medical Center) routinely use single donor apheresis platelets (SDPs) rather than random donor platelets (RDPs) in an effort to minimize allogeneic platelet transfusions, and thereby reduce risk of transfusion-transmitted infection. Although there are other compelling medical, technical, and medical-legal reasons to use SDPs instead of RDPs, the authors believe that a decrease in allogeneic donor exposures alone is sufficient reason to make SDPs the platelet component of choice at their institutions.     

Children's voices: can we hear them?

This article addresses an important but often neglected notion in the care of children--the notion of voice. Recognizing that a crucial role for pediatric nurses is that of advocate for the child, this article poses the questions of how children's voices can be heard and how nurses know whose voice they represent when they act in an advocacy capacity. Drawing on contributions from psychology, sociology, and feminist studies, the analysis narrows our focus to the special challenge created for pediatric nurses when they recognize the importance of voice in caring for children, and examines the complexities inherent in attending to voice in pediatric nursing practice.     

Endosurgery: what do we need?

A paradigm shift in therapeutic endoscopy occurred with the advent of mucosectomy for the treatment of mucosal neoplasms and suture plication for gastroesophageal reflux disease. The objectives changed from finding simple, easy, and quick alternatives to surgery to reproducing surgical results. A radical version of flexible endoscopy has emerged to meet new goals of full-thickness resections, creation of anastomoses, and lumen reconfiguration. This will require a new generation of endosurgical tools that cut, stitch, and staple with added dimensions of multiaxis orientation and triangulation.     

Do we need the overtube for push-enteroscopy?

BACKGROUND AND AIMS: Push-enteroscopy is well established in many gastroenterological departments. There is no agreement about whether the use of an overtube is helpful to optimize the depth of insertion. In this prospective and randomized study we investigated the effect of the overtube for push-type enteroscopy. PATIENTS AND METHODS: Between August 1999 and August 2000, 80 patients (47 male, 33 female; age 63.1, range 20 - 90 years), who underwent investigation by push-enteroscopy were randomly allocated to two groups. Group T underwent investigation with the Olympus push-enteroscope SIF 100 with an overtube and group NT without an overtube. The length of insertion was estimated by fluoroscopy, by counting the folds of the small bowel and by insertion length in centimeters, while the scope was drawn back to the pylorus. The number of pathological findings was documented and patient comfort was measured by means of a standard questionnaire completed after enteroscopy. RESULTS: Both groups were comparable with regard to age, gender, indication for enteroscopy and pathological findings. There was a highly significant correlation between the length of insertion measured in centimeters and the counted folds in both groups (correlation 0.57, P < 0.001 in group T; 0.80, P < 0.001 in group NT). The length of insertion estimated by means of fluoroscopy was not reliable in determination of the exact length of insertion. There was a significant difference (P < 0.05) in the insertion depth between group T (mean values: insertion length 72.4 cm, counted folds 99.3) and group NT (mean values: insertion length 60.8 cm, counted folds 74.1). CONCLUSIONS: The use of an overtube in push-enteroscopy is advantageous with respect to the depth of insertion (significant difference between group T and NT in counted folds and the insertion depth in centimeters). At this time, this gain of insertion length did not result in a higher rate of pathological findings. Nevertheless, we would recommend the use of an overtube in performing push-type enteroscopy in order to increase the number of pathological findings.